My friends, it starts again woohoooooo!
National Blog Posting Month occurs every November, a 30 day daily blogging challenge apparently founded in 2006, inspired by National Novel Writing Month, or NaNoWriMo. I think this will be my fourth attempt, and it gets easier and more fun every year!
This year’s theme originates from a sense of both gratitude and anticipation. Increasingly I feel compelled to do more, contribute more, help more. When I look around I am consistently humbled by those who go before me, on whose broad and strong shoulders I stand. So I dedicate this month to all of you.
November 1: Role Play Makes Me Better.
I was converted to the Church of the Necessity of Role Play in 2003. I had previously belonged to Tribe of Full-Socket Eye Roll at Role Play. That year I had the privilege of attending a Stanford Faculty Development Program series. It was a 7 week clinical teaching program for physicians. Every week we practiced a specific teaching skill, on camera, then had to watch ourselves and critique our own and one another’s performance. Even though each ‘encounter’ was only a few minutes, and we were all pretending, it felt real enough to translate into concrete behavior changes in real life—for all of us.
Since then I have always employed role play when teaching motivational interviewing (MI) to medical students. At first I played the noncompliant or resistant patient, and had students take turns trying MI skils on me. When I noticed myself feeling defensive and belittled in that role, I realized what the students were missing, and how it could enhance their empathy. So I started having them take turns playing both patient and physician. That was an epiphany for us all. When I attended the Harvard Lifestyle Medicine Conference MI session in 2015, I experienced yet another layer of important experiential learning. In dyads, we not only took turns playing patient and physician, but we practiced both directive and MI styles of counseling. The contrast on both sides of each of those interactions solidified in both my cognitive and limbic brains why MI is a superior counseling method for behavior change.
This week at ICCH I innocently volunteered to play the physician in yet another role play. Little did I know what I was in for. I should have seen it coming, as the workshop title was “Teaching Medical Students How to Deal with Challenging Patient-Physician Encounters.” I, unknowingly, stepped into a scenario of recurrent asthma exacerbation brought on by stress, due to domestic violence. I felt anxious with a circle of international colleagues watching, and also confident that I could enter the play encounter the same as I aspire to enter a real one—present, open, grounded, kind, loving, and smart. The physician teacher who played my patient stayed solidly in character and immediately drew me in with her slumped posture, dejected facial expression, and barely perceptible voice. And she, like so many victims of violence, was not giving it up easily.
I had to conduct a medical interview as well as a psychological one, at times alternating between them. I wanted to get at what I suspected (first generalized stress, and then clearly violence at home), but we had just met, and she really wanted to get out of the hospital. Her fear was obvious; but she held its cause close to her chest, like the rest of her, until she could trust me. I approached with general words at first, “Anything else going on lately?” I kept my questioning as open ended as possible, and tried to leave space for her to answer. Nothing. Then I confessed my own inner dissonance: “I feel like there’s something else…” When that didn’t work, I continued with the general history. No other chronic medical problems, no surgeries; allergies that can trigger her asthma, but no recent exposures. You have 4 young kids, a full time job, a house to take care of. Are you partnered? Yes, married, to Bob. Pause; a breath. Then, “How does Bob treat you?” Pause. Why do you ask me that? “I’m asking about abuse.” And then it opened. How did you know? “I’ve been doing this a long time… And someone close to me was abused.” Do I look like her? “You remind me of her.”
She was mortified that I would tell anyone. How could I possibly help, then? There were longer silences as I, frantic on the inside and slow breathing on the outside, racked my brain for solutions. The harsh reality eventually settled on us both: Neither of us could do much about her situation in that moment, her asthma attack was resolved, and the longer I kept her away from her family the worse I might make everything for her in the near term. We agreed that I would look for ‘stress management’ resources, and I would give her my phone number. And I would discharge her later that day, back to her violent husband, who had promised he would never hit her again.
It was so real. I was almost able to forget about the audience. I was personally invested in the health and well-being of this one person in front of me. I imagined if she were a real patient. Would I actually give her my phone number in this moment? Absolutely I would. We had to start somewhere, and I was the only person who knew, who could connect her to resources for help.
After it ended, I felt pretty drained. We had both been tearful at times. I also felt proud to have gotten through—both the exercise and to my patient. I connected. And even though I had no immediate solutions, I had established a relationship that had hope for helping a person who really needed it.
I have not encountered this scenario in real life in a while—that I know of.
I hope I’m not missing something, somewhere, for somebody who needs me. Yikes.
Role play makes me better. It reminds me to always beware my blind spots, to keep practicing, and to remember the deep humanity of every person I meet.