Early one morning when I was an intern, a truck driver, a father of four in his 40s, came to the ER with a cough and a low-grade fever. Two hours later he was dead, from an overwhelming staph infection. The resident on duty thought it would be instructive for me to deliver this news to the man’s wife, who stood waiting in the hall, not suspecting that anything was seriously wrong. I stepped into the crowded corridor, found her, and said the first thing that came into my head, something I’d undoubtedly remembered from a B movie: “We lost him. There was nothing we could do.”
As the woman wailed, another patient’s relative, who happened to be walking by, sized up my performance: “Wow,” the man said, “That was cold.”
The thing is, I wasn’t cold. I was truly moved by the tragedy — who but a sociopath wouldn’t have been? But I’d never received any training in how to express myself in a way that might be helpful, or at least not unnecessarily hurtful, to my patient’s wife. I’d learned how to examine his lungs, interpret his chest X-ray, and initiate CPR when his heart stopped beating. But for the moment when my words would change a woman’s life forever, transform her instantly into a widow and single mother, I’d received zero preparation.
The assumption seems to have been that I would know instinctively how best to handle such an interaction, and that if I lacked the appropriate instincts, they couldn’t be taught.
In the last few years, medical and nursing schools have begun challenging this belief. Many offer sessions in which trainees practice speaking with “standardized patients,” people who volunteer or are paid to play the role of a patient or patient’s family member, with scripted questions and concerns.
I’ve served as a faculty evaluator in such sessions, observing medical students from behind a one-way mirror as they informed “patients” that their cancers had recurred. I graded the students based on whether they met a series of benchmarks outlined in a video they were assigned to watch before the session. These included allowing the patient time to react, remembering to address pain, and providing a follow-up plan.
Though it was clear to me that the students who watched the video were more likely to meet these benchmarks than those who hadn’t, I remained skeptical about whether the sessions really increased the students’ capacity for empathy. Can true feeling really be scripted? Can students rehearse empathy the way an actor rehearses a role?
I had a chance to reconsider these questions on a recent visit to the Program to Enhance Relational & Communication Skills (PERCS) at Boston Children’s Hospital. PERCS retains a repertory of a dozen or so professional actors, selected through auditions for their improvisational skills, to simulate difficult conversations with doctors, nurses, therapists, and other medical professionals.
The actors prepare for their roles as patients or family members as they might for any role: They study extensive back stories for their characters and immerse themselves in relevant information. An actor playing the mother of a child with cystic fibrosis might explore the Cystic Fibrosis Foundation website, visit families dealing with the disease, and spend time in the CAT scanners and pulmonary function labs that are such big parts of the lives of patients with CF.
The actors also help develop scenarios for the improv workshops. A workshop for staff who work in intensive care units might include a scenario in which they ask grieving parents to consider donating their child’s organs for transplant; neonatologists improvise conversations with actors playing parents of desperately ill preemies, and so forth.
The workshop I observed was geared to radiologists, who have a reputation, deserved or not, for preferring less direct contact with patients. But, as Stephen D. Brown, a radiologist and medical ethicist who co-directs this particular workshop, points out, these days it may be a radiologist who tells a parent that their child has a brain tumor, or informs a woman that she may have breast cancer.
In one scenario, a radiology trainee improvised a conversation with actors playing the parents of a 4-year-old whose liver cancer the trainee had missed on an ultrasound three months earlier. At one point, the young doctor averted her gaze from the couple.
Maintaining eye contact is usually on the checklist of things a doctor should do during a difficult encounter. But after the scene, the actor playing the child’s mother said that when the doctor lowered her eyes, she’d felt her shame most acutely.
Elaine C. Meyer, a nurse and psychologist who directs Children’s Institute for Professionalism and Ethical Practice, which produces the workshops, later told me that this was a good example of why PERCS has used professional improv actors — who are trained to be expecially sensitive to the words and body language of others —
But do we really want the person who tells us she botched our kid’s cancer diagnosis to be able to fake remorse more effectively? David M. Browning, a social worker who co-leads the radiology PERCS workshop, explains that learning to fake remorse and other emotions is not the point of the program. He tells participants in the improv session about acknowledging clinical errors: “We don’t want you to act sorry. We want you to be sorry.”
Psychiatrist Helen Riess, director of MGH’s Empathy and Relational Science Program, emphasizes that acting isn’t the same as faking. Riess says, “acting as if you care, with empathic facial expressions, posture, and tone of voice, can actually result in feeling that you care.” When Riess monitored heart rates, skin conductance, and other physiologic indicators of emotion on clinicians improvising difficult conversations with actors, she found that their emotional responses were genuine — and more likely to be so if they had rehearsed in advance.
It’s a shame I didn’t rehearse before my encounter with the truck driver’s wife.
I felt so badly for her. But sometimes feelings aren’t enough.Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog on Boston.com/Health. She can be reached at inpracticemd