Story telling and Simulation: What are you really saying?

By Ben Symon 

Let me start with a story.

“My son was born prematurely in a country that was not my own, and for the first month of his life I visited him once a day for the 10 – 20 minutes that hospital policy permitted me to be within the Neonatal Intensive Care.  I’d love to tell you that our first encounter was touching : a heart warming moment between a newborn son and the father who’d wanted a child for so long.  But the truth is that our first meeting was somewhat awkward. Stilted.  I didn’t know how to relate to him in that little humidicrib, this little undercooked infant chugging away with mild tachypnoea and an old man’s eyes.  I felt emotionally blank, a little in shock, and was unsure how to proceed. He looked like one of the many infants I’d looked after in the nursery back home, and I’d long ago taught myself not to form emotional connections with premature patients.  Their roads were far too rocky.  The emotional risks too great.

So I stroked his head and then awkwardly checked his femoral pulses.  As a paediatric emergency doctor I’d done hundreds of baby checks, and my clinician’s reflexes were faster and more evolved than my seemingly dormant paternal instincts.  The pulses were present, which made me relieved.  So I told him I loved him, and then sat and watched him for 10 minutes before being quietly gestured towards the door.

 

I then went back to my hastily booked apartment and counted down the 23 hours and 40 minutes to pass until I could see him again.

On the third day, he became more tachypnoeic.  His respiratory rate was 70, and had he been my patient I would have placed him on CPAP.  But he was not my patient, and this was not my country, and while the neonatologist looking after him respectfully listened to me voice my concerns, the CPAP was not started.  I did not make a fuss.  To do so might impact my son’s care.

I went back to my apartment, and stared at the wall.  Daniel had looked tired. Alone. And I was not there for him.  Unable to suppress my grief, I involuntarily let out a guttural moan.  I was not there for my son. He needed me, and I was not there.  I was not there for my son.”

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I recently found myself driving home from a Simulation Course, livid with rage.  I had been a candidate for a SIM that was designed to teach how to communicate with anxious parents.  I was excited to get to participate in, (rather than run), a simulation.  It had been awhile since I’d been on that side of the glass.

But as the confederate parents rolled in, howling and inconsolable, it became rapidly clear to me that this was a situation I could not win.  The faculty were enjoying their roles and the drama escalated despite my best attempts to calm them down.  I felt sabotaged and frustrated, my need to demonstrate my aptitude in resus neutered by a scenario design that made me feel pre-destined to fail.

The debrief was awkward, my participation somewhat cold and defensive, and as I drove home, I questioned the disproportionate intensity of my reaction.  Seemingly unbidden, the image of Daniel in that humidcrib rose from the depths of my memory.  And I realised why I was so angry.  I was a doctor, but I was also a parent. The designers of the Sim had felt that they could teach me how to ‘deal with parents’ by portraying a cartoonish stereotype.  They had meant some innocent fun, playing out our worst fears of what frustrating parents can be like, but they’d damaged their own learning objectives.  They hadn’t taught me compassion, they’d taught me that parents are awful, that they impede resuscitation, and that they cannot be reasoned with.  As the parent of a child who’d once needed medical help, it was not the representation of my experience I’d hoped to see painted.

I think we do this a lot in Sim.  We need scenarios that generate conflict, and we create it by introducing over the top stereotypes.   The arrogant surgeon.  The controlling intensivist.  The neurotic parent.  The overconfident junior doctor.

But stories are important.  It’s why I started this post with one.  I invited you in, I told you something about myself, a photo of my son.  I tried to connect with you from beyond my laptop screen even though we’ll likely never meet.  And in that connection I aimed to teach you a new perspective : the clinician who is also a parent, and what it might be like to be removed from your child’s bedside when they are unwell.

We tell stories to create impactful learning experiences.  We’ve done this for a very long time.  But don’t forget that the whole of the story matters.  If I create a sim that features an impossibly arrogant surgeon, my learners might learn about dealing with conflict, but they also learn another lesson : I don’t like surgeons, they’re arrogant and I have to defend my patients from them.

This is not my experience when dealing with surgeons.  They care about their patients, but they have a different frame than I do.  They’re also busy, and often tired, and I’m sometimes transferring emotional responsibility onto them. That’s where our conflicts come from.  If we want to break down tribes and improve interdisciplinary communication I think we need to create better characters in our Sims.  We should generate conflict not through boorish villains or shallow parodies but through creating clinical situations that inherently generate a difference in opinion.

Simulation with baby.jpg

The most artful Sim I’ve seen in this regard was a Sim for senior clinicians from PICU and Paediatrics.  A child is dying, the parents aren’t there, and the paediatricians wanted to continue resus till they arrive.  The inherent frames the family physicians and intensivists brought to the scenario create enough conflict on its own.  The paediatricians want the family to be able to say goodbye.  The intensivists know the consequences of this prolonged resus.  The threat of a catastrophic survival.  No villains were required, just a delicate talk about each other’s perspectives, and maybe a little empathy learned.

So when you’re writing a Scenario, or playing a confederate, think about the consequences of the story you’re telling.  Create characters with valid frames that can be explored, because it will teach your learners to hold the fundamental premise about their patients, and each other.  Ask yourself if there’s a subconscious curriculum you’ve accidentally hidden in your story, and if there is, does it contain lessons of value or does it perpetuate tribes?  Maybe there’s another way to tell your tale that teaches respect.  Because we can’t just hold the fundamental premise about our learners, we need to hold it for our colleagues, our patients and their families.  I think that’s where true connection lies.