Sunday, March 3, 2013

SIM Center: OSCE, Hospice, and Bad News

I recently tried to make a busy person retreat. I say "tried" because I showed up for direction the first two days: on the first day I wondered whether my directress thought Christ was an ascending savior and on the second day we mutually decided that I was actually too busy for a busy person retreat (this was when STEP 1 was really beginning to overwhelm me). I was glad of this because 1) I needed the time and 2) I wasn't really sure if I was on theologically sound ground. 

School is beginning to wind down: my last (fourth) preceptorship is in the SIM center, and the Palliative Care class had its culmination in a lab, also in the SIM center.


The preceptorship SIM center evaluation (OSCE) with a standardized patient was mixed. I missed the key finding because I forgot to do part of the physical exam. I definitely left with a feeling of "Achievement NOT Unlocked" because the red folder with the abnormal findings remained unopened. Normally, if part of the physical exam on the patient in the case would have resulted in a finding that the healthy actor can't simulate, the SP instructs the medical student to open the red folder if the student examined that (example: if you don't listen to the lungs, you don't get to open the folder and discover that you "heard" diffuse crackles). When she didn't give me that wonderful relief, I realized that I had missed something and I asked her, "Is there anything else I should know or any other questions?" She cheerily said after a little pause, "No, no other questions!" I felt like saying directly to her: "Uh-huh. I missed it, didn't I?" But of course, we were both in character, so I couldn't.


In the Palliative care lab yesterday, I was given the "chart" of an SP, took a brief history, and performed a physical exam. But it was different from the previous OSCE because my goal wasn't to diagnose the patient. Instead, I was to determine whether it was appropriate to refer them to hospice care. Speaking with the SP, I talked about her goals and her current life (bed-to-chair existence), and how hospice might help her life a little less tiring, boring, and depressing. It might help her husband worry less about her, it might help stop her rapid weight loss.

This stretched my limits. I like telling people "I know what's going on, and here's how we're going to work together to fix it," or "this isn't as bad as it seems," or "don't worry." But it's hard when I cannot say anything remotely resembling "this will all work out," and have to be realistic. There's a superadded challenge because I'm not sure whether I can talk about the true Source of hope, Who is never overcome by any dim future.

In addition to stretching my limits, my encounter brought out an interesting dimension of SIM centers and SPs. The SP I advised about hospice was the same SP I'd seen before for a prior OSCE. And I also saw her outside the SIM center between  the elevator to the parking lot, just a day before the Palliative Care lab. We chatted about her pet roosters and how they wake her up too early.


The Palliative Care lab also required us to give bad news to an SP.
Four cases were prepared and emailed to us (three death notifications and one terminal diagnosis) and we were told we'd work in pairs: one person leading, giving the patient the news, and the other supporting as needed. We were also given a schedule describing which cases we had and as we waited, my partner and I agreed which one we would take. We sat silently, staring at the brief paragraphs describing the case and searching for words to use to deliver the news. "I'm sorry, but while you were at home your son had a heart attack and, despite everything we could do, he died....?" "I know you were in remission and were doing everything the doctors told you, but your cancer is back...?"

I realized that one of the cases that my partner and I were assigned was telling a parent of the death of their tiny daughter. This was the case everyone said was "the worst." But I realized that my partner is currently pregnant with her first daughter, so I immediately claimed it. Before we filed into the hallway of the pretend doctor's office, we were coached well by a hospice-associated physician and a social worker.

When I walked into the hallway of rooms and looked at the paper posted on the door, I realized the case on the door did not match the case of the little girl that I'd prepared for. The paper on the door described a completely different situation! It was one of the four we'd received by email, so I'd thought about it a little, but this still came as an unwelcome surprise. Quickly, I tried to gather some thoughts together, and I prayed a little for myself and for the SPs, even though I knew they weren't truly receiving bad news. (I thought about setting a precedent for myself and my future practice, though. I wanted to start this in the right way.) And I walked in.

Once inside the room, I did what I was told--I got the names of everyone in the room (there were two SPs, pretending to be the decedent's mother and maternal aunt), introduced my partner, sat down and asked the SPs to sit down (maybe I should've done those in the reverse order?), and I asked what she already knew. I said a preparatory phrase like "I have bad news" or "I wish I had better news, but" and then told her that her adult son had died.

At first, she told me I had the wrong patient, then thought I was hiding her child somewhere. She stood up and cried and paced and the two SPs hugged (parenthetically, SPs are really amazing). And I was completely confused. I knew it was taboo to say "I understand..." or "I know..." and we were supposed to validate and normalize feelings, but all I could think to say was "I'm sorry" a lot. And I didn't talk much, I just sort of sat there. Once, I said something like, "I see this is completely overwhelming," and that sounded stupid. My partner passed her the tissues. I asked the SP if we should call her husband, and when she said he was out of town I said that this was something he should know about. And we should also contact his girlfriend....

"How am I going to do all this?" she moaned.

"It doesn't have to happen all at once," I said. "We can take this step by step."

She asked if she could see him, so I left her with a promise that I would go ask whether she could visit him right away. (We were told always to leave with a definite plan and a return time for follow-up, and to never give the person the idea we would abandon them.) My partner told me I'd done well after we left the room, and I think I at least didn't say anything hurtful.

I'll close with a few stories I heard afterwards:

  • The good: a really sensitive Christian friend had the little daughter case. And she said to the sobbing mother, "we'll take this minute by minute, hour by hour, day by day. And I'll stay with you, you won't be alone."
  • The bad: one of my future-ER-doc guys told me that he had the same case I did. While stumbling around for words, asked "do you have a preferred funeral home?"
I'm glad we got the chance to practice and go through the motions before actually having to deliver bad news!

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