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Acting like a Doctor.

In the beginning, there was acting. On our first day with real patients as third year medical students at Harlem Hospital, we were naturally kind to patients, but we had to pretend that we were competent. Everything was new then, every patient produced a fresh response in us, but we presented ourselves as more knowledgeable than we were. We had to pretend we knew how to talk on rounds, with patients, to nurses and families. My classmates and I had been coached, as a group, on how to present a case quickly (history, exam, lab testing, plan) in order to be of use to the senior doctors, the ones in the long white coats; our coats were shorter, the sign that we hadn't been doing this for as many years as they had. We did what our superiors told us to do,-we acted respectful, even to the bastards. But we couldn't wait to be on our own.

Within a week, we'd learned that what patients told us was often wrong, or quite different from what they would tell the next person who interviewed them. We'd take a history and then our professor would take the same history and gather completely different facts, as if we hadn't been listening, or couldn't reliably repeat the simple answers we'd heard. This reversal was a common embarrassment for us. We were surprised the first and second time it happened, but we only acted surprised by the third time. This was apprenticeship, and we were like actors researching our parts.

We were tired, and we didn't have time to eat or play or see friends after work. We acted as if we were not angry that we were indentured. We acted as if we could still function at a high level at home in the evening, when during the day we tied patients into restraints, and hurt some. We acted as if none of this bothered us. We learned to do what we had to do. Admit to a semi-private room, send for procedures, review results and diagnose, medicate, surgerize, plan for discharge. We started out idealistic and then we began to cut our losses, and only acted idealistic when we were talking to professors who rated us, or to our parents. We got used to being understudies who looked forward to performing well when the time came and we'd be given the lead. We hoped to know enough, to be confident enough, that our patients wouldn't know we were acting. But we began to question: if they knew, would they have cared?

Thirty years later, when I am with patients, I sometimes still feel as if I'm acting, that every consultation is a kind of theater. The patient has the sick role, what sociologist Talcott Parsons described as a temporary, medically sanctioned form of deviant behavior. Opposite them, I have to appear healthy (patients distrust doctors who are overweight or who smoke), caring, and involved, no matter how I feel, even if my son was suspended from school that morning, the cat escaped yesterday, my nephew's Marine unit was in a firefight last night, or my throat is sore. To be a doctor, to put on the long white coat, is to take on a role, to become a version of myself. Or many versions over the course of a clinical day. With one patient I must have a skeptical fury at a specialist's advice; with the next I try hard to be relentlessly positive despite an ominous biopsy result. I never feel that I disappear into each version or character like a Method actor, as much as perform as any professional would if hired for a single, recurring performance. But I sometimes wonder if the goal is to make the patient feel they've been given the attention they need, then is the best doctoring, the best communicating, a matter of force of personality, interest, and charisma, or can it be reflexive, practiced and mechanical?

"You, in this room, have a communication problem," Dr. Veri said to our group of thirty primary care doctors gathered in a basement conference space for a 7 AM meeting last month. In the past, early morning group meetings had generally dealt with hospital reorganization concerns, new documentation requirements, practice plan mergers, insurance company reimbursement declines, the annual update regarding the overall budget and financial health of the organization, in sum, the latest changes in an increasingly chaotic world of health care. Communication Quality, the subject of my email invitation, was a new and unusual topic.

Veri travelled the country helping doctors with what she called Being Clear. She was in her early forties, and her hair, parted in the center, reached her shoulders with an enthusiastic flip. Our hospital, she showed us in her first slide, was among the lowest 10 percent of hospitals nationwide in patient-doctor satisfaction scores; this finding was the reason Veri had come to town. The slide was filled with numbers; she knew that doctors are rarely convinced of anything without them. Since medical school, we compared and competed over scores; no one ever liked being in the bottom 10 percent. There was a rustle of discomfort. What were we doing wrong? Each one of us looked to the left and the right to identify the colleagues who were driving down our group score,-each of us presumed he or she alone was blameless.

Veri showed the brief satisfaction survey our practice plan asked patients to complete fourty-eight hours to six weeks after they left our offices, one produced and analyzed by a large consumer satisfaction conglomerate. She showed us the doctor-specific questions (there was a similar section regarding our nurses). There was a question about the doctor's attitude toward patient requests, one about friendliness and courtesy, another about skill. "How well were you kept informed about your condition and treatment?" "Please rate the time spent with you by the doctor, his/her concern for your questions and worries." "How well did the staff work together to care for you?" There was an overall "rating of care" question and a likelihood of recommending this office to others. And then there was the dreaded comments section, a few blank lines at the bottom of page two, where the happiest and least happy patients named names and left specifics.

"The presumption that every doctor provides services of consistently high quality is now being challenged," Veri said. "We are in a new era of identifying, measuring, reporting, and targeting health processes and outcomes. Difficulties with communication are the most common complaints made by patients.

"Most patients are pleased with care they receive," she continued. "But individual unhappy patients can skew the results dramatically."

I understood that if only ten or fifteen of my patients completed a survey (and this was the number that generated my data), I couldn't afford to make a single mistake.

The medical school where I teach instructs its students in how to behave in clinical settings by first sending them to see patients who aren't really patients but instead are paid medical actors, professionals hired to perform illness in staged classrooms. Wearing cotton gowns and presenting fictional lives and symptoms, these "standardized patients" know where it hurts and how to express it according to scripts they've been given--the single woman lawyer with seizures and a tranquilizer problem, the building manager with painless stomach ulcers and shortness of breath from anemia.

Playing along that these are real patients, the student goes on a diagnostic treasure hunt following a standard information-gathering script, an elaborate checklist of problems, practiced at home with classmates and friends. Organized to collect a reproducible narrative--why are you here, tell me the history of this complaint and your medical history more generally--the student script moves through the memorized catalog of symptoms--fatigue, fever, weakness, trouble sleeping, skin rash, hair or nail changes, etc.--a list of what can go wrong with a body, the same list I had thirty years ago. The student has fifteen minutes per patient, which enforces a galloping pace through the questions and a need to disguise the time-pressure as true interest.

The new student checklist prescribes certain actions--"Put the patient at ease," "Ensure patient readiness and comfort," "Comment on some personal quality or observation about the patient to elicit rapport"--that might already come naturally if they weren't on a checklist. These must have been added since my training because the latest generation of students wasn't doing them. In these simulation exercises with pseudo patients, the student must try to remember these fundamental skills of social interaction, which are sometimes forgotten in the nervousness of a first medical encounter--ask the patient for a name, sit down, make eye contact--at the same time as she or he hones diagnostic skills. They are reminders to be human, to be kind.

What's meant to be taught to the student through such encounters with mock patients is not only the branching symptom questions that lead to diagnosis, but also kindness. In the best case, the student must be mindful that his questions are intrusive while he creates an atmosphere that allows the vulnerable patient to tell the truth to a stranger. At the end of the interaction, the mock patient offers feedback to the student about how it felt to be examined, about the questions asked and the manner of asking, about helpful words and words that were awkward or constraining or rude. The exchange is videotaped through a one-way mirror, so that the student can later watch his or her performance. The actor-patient completes a scorecard and writes a report--a satisfaction survey, as it were.

What's primarily learned though, according to the doctors who run these simulation exercises, is that there is a right and a wrong diagnosis--he did have a pulmonary embolus--and an efficient way to get there. Since chemistry and organic chemistry, and all the prerequisites of medical school that allowed a student to get to be with a patient, are a matter of memorizing formulae, and the medical student's life is one long test, even with these first "patients," the diagnostic end trumps the manner in which the data were collected. Kindness, in this simulated medical context where a medical student is impersonating a doctor and a theater student is impersonating a patient, is a polite word for seduction, a means to an end; it helps get things done. The medical student who isn't kind is chided, but competence is what really matters. If the patient walks out with an undiagnosed pulmonary embolism, kindness has been irrelevant.

Until Veri's Communication Quality presentation, I had not been asked to memorize how to speak to patients since I was given the student's review of symptoms list thirty years ago. But then, rather than speaking to a simulacrum, I was handed a list of real patients on a real ward housing the citizens of Harlem, and told to assemble the histories of half-dressed men and women who shared four-bed rooms, and report back.

As Veri had us watch twenty minutes of short video clips of Visits Gone Bad--unhappy patient-doctor interactions in offices and emergency rooms across the country--I thought of my sister's report of her recent visit to a dermatologist. She had gone to discuss a new treatment for her mid-life psoriasis that had been triggered by a strep throat that did not respond as promised to standard therapies. She called me as soon as she got home. "Eight minute appointment. He never addressed me by my name. He never looked me in the eye. He kept his eyes on my skin. He never said, 'How are you doing with all this? How's your mood been?' I was simply a body. I could have been any body. Not a person, a body, waiting to be told what to do. Not even a body, a collection of red spots. So he told me what drug to take next, without giving me the time to ask a question or make a decision about whether to accept. I guess all skin doctors are superficial," she said sarcastically.

There's not enough time to get all our work done and be universally nice was our group's general conclusion after watching Veri's videotapes and thinking about the day's upcoming patients.

She was ready for this objection. Don't just show us the problems, Veri knew we would insist: give us the answers, as concretely as possible. "I'm here to offer you a set of tools and strategies for structured communication, for Being Clear," she said. "These scripts will begin to solve your satisfaction problem. You should know that the leaders of your practice have decided that in the near future, your patients' satisfaction survey responses will be used to incentivize you financially."

I should have known that even a Communication Quality meeting would eventually lead back to Money. I turned and looked longingly at the muffins on the table against the back wall.

She handed us a short stack of laminated index cards. "These are essential elements of communication. They are also basic manners," she said. It was difficult for us not to get our backs up when we were spoken to like children. It was mind boggling that we needed this redress after years of seeing patients. We were competent, Veri was suggesting, but we needed to be reminded to be kind to patients.

Case reports of saving a man with an abdominal stab wound, or a woman with a punctured lung and leg crushed under her refrigerator during a tornado, or the resuscitation of a child who almost drowned in an icy fish pond, are recorded in the Annals of Surgery. Surgeons' depictions of doing just the right thing--requiring a combination of expertise, execution, and large casts of health care professionals, whose series of technical, manual tasks are clear (the articles often include photographs), and death encamps close by--seem endlessly worthy of reporting.

Yet case reports of saying just the right thing are never written up in the Annals of Medicine. Primary care, where patients actually sit and talk (unlike surgery where patients are unconscious and the journals describe the mathematics of fluid volumes and chemistries, planes of dissection, the positions of tubes and drains) seems far simpler. The requirements of office-based attention, thoroughness, and diagnostic technique seem less pressing than the operating room drama of surgery. The outcomes are less immediate, and so less critical. Yet these conversations of diagnosis and prognosis can be equally complex and intricate, similarly life-improving for patients, and mistakes in communication are equally damaging, affecting work, relationships, peace of mind. If surgery is complicated like an Apollo launch, primary care medicine presents the day-by-day uncertainty of raising a child. Surgery has an end-of-mission date and a clear notion of success; with office-based medicine, you may never know if you've done it right; the child goes away, another awkward interaction over, without any realization of dramatic improvement but a bit wiser about himself, and will call back only when the problem recurs or a new one arises.

It is a complicated piece of theater sitting with a patient: the lights, the costumes, giving them what you think they need, protecting yourself, controlling the outcome. A great stage or screen actor is not putting something on as much as being. To be convincing, the actor must link emotional moments from his life with that of his character so as to become that character. A doctor too is expected to carry an expanded emotional spectrum from his life as a doctor who has seen thousands of patients; indeed this is the source of his imaginative sympathy. He must have the emotional control and manipulation techniques familiar to an actor (who works from a script).

The doctor's patient is his co-star, but also his audience. She is acting too; she is considering how to present herself, how to be taken seriously. She also exercises the demands of an audience, sitting before the doctor with her wounds, memories, agony,-she wants her visit to be a self-revelation and an education in herself. She hopes her doctor notices and knows her, but also that he knows what's going on in her body and shares the news, even if he wears a mask and a white-coat.

Sometimes an office visit from an addict, with his secret needs and hidden agenda, takes my acting to its limit. Some patient interactions cannot go well despite my best intentions. The day before Veri's visit, I saw a new patient who complained of knee pain. He was middle-aged and bow-legged and he came in hobbling, wearing a gray hoodie. A friend of his, a patient of mine, had sent this man to me, vouching I was a good doctor and that I'd tell him straight about what was wrong with his knee.

My new patient told me how he hurt the left knee many times over the years--most recently getting into a fight with a stranger who was hassling a thirteen-year-old girl in his neighborhood, a story of good citizenship and self-defense--and that all the ibuprofen he'd tried was killing his stomach. He denied ever using anything stronger such as narcotics; this seemed unlikely, given the severity and duration of his pain. But I didn't say anything. As I examined him, our conversation moved on to how far he'd gone in school and what it was like for him to live alone and to have two brothers dead from drug overdoses. And then I asked him to give a urine sample. I wanted to make sure he wasn't using Percocet or Vicodin, wasn't doctor-shopping for pain pills. Which was when he confessed. I said, "I thought you'd never used narcotics." "It was just for the pain," he said. It was as if I was both the student hearing one history and also the professor getting a very different one, all in the same encounter.

"Now you've put us in a bad place," I told him. "We're twenty minutes into our meeting and I've learned you've lied to me. How can I trust your answers anymore? I don't see how I can take care of you and your knee." I could have kept these thoughts to myself, and worked within my new understanding of him as an addict. I could have acted surprised. He had been acting for me; should I have acted for him? If I accepted his lie without confrontation and moved on, it would set a troubling precedent for whatever came next in the visit and would be a lousy message to my other patient, his friend, if they were to discuss this visit. Had I taken the right approach? I'm not sure. He looked stunned and disappointed with himself when I told him it would be better if he found another doctor. Thinking about his visit as I listened to Veri, I also knew that he was disappointed with me, and if he were sent a satisfaction survey, I wouldn't do well.

The scripts, one to a card, were key phrases to use at key times. The scripts informed us about how we were to speak to patients. "You can do it better than you have been," Veri said. Which is another way of saying we weren't doing it right. One by one she projected the phrases on-screen as we flipped through the cards. The scripts were clearly directed at the friendliness and courtesy questions from our patient satisfaction survey.
    Upon an initial greeting:
     "I'm sorry for any wait you had. How can I best help
     "Sorry that you're in so much pain. Let's see how we
can get
   you feeling better."
   While listening to express concern:
     "This must have been very difficult for you."
     "You've been through a lot."
   During the exam, offering reassurances:
     "Your lungs sound clear."
     "Your heart rhythm is steady."
   When outlining what you propose:
    "Let me describe what I have in mind, based on what you've
   me, and you can tell me how it sounds to you."
    "I'm going to suggest some options for what I think the
   steps could be, and why, and you should let me know if it makes
   sense to you."
   In closing:
      "Have I forgotten anything?"
      "Is there anything else you were hoping I could do for you

I didn't think of myself as having a Communication Quality problem when I sat in front of a patient, but I became self-conscious as I listened to Veri. The simulation training of the new generation of doctors included interview checklists with recommended actions to show concern and express kindness. I wanted to be open-minded about Veri's cue cards for kindness, but I was unsettled by her advice, although I hadn't yet figured out why exactly. It made me think of something I'd overheard a colleague say to a group of medical students the other day, "During training you become a professional doctor and an amateur human being."

The day after the meeting with Veri, when I started to say to a patient, "That must have been very difficult for you," I hesitated. I worried that the patient, who had been telling me about her faints, sudden hospitalization, and pacemaker insertion, whom I'd known for many years, would see through me because these were not words I'd ever used. I wondered what exactly the problem was that Veri's script was trying to fix. That doctors were likely to say too much or too little in an attempt to cover the awkwardness and enormity of the moments when illness is inflicting misery on patients?

Perhaps the goal of Veri's script was less about kindness than it was about avoiding saying something unkind. Because we would be working from a script, the words were supposedly focus-group tested, mistake-proof. I got it. Patients had long memories of bad medical conversations, memories of ungenerous interactions ("He never looked me in the eye. He kept his eyes on my skin.") that last until the satisfaction survey arrives and they can have revenge through low ratings. A scripted, stock, positively worded phrase was a form of malpractice insurance. For the medical student, learning a script was a defense against self-doubt, but also a kind of license: you know you will always have something to say in the emotion-filled moments that will inevitably arrive in your office.

Perhaps, said convincingly, "This must have been very difficult for you," may be understood as a kindness. Maybe I should be using a script; maybe patients found me callous or off-putting at times.

Veri did not use the word "kind" in her presentation. She did not use it to inspire our room full of doctors, as in, "Try to be kind when you have to deliver bad news." Kindness is not included in any of the thirty satisfaction survey items, nor is any one of the names kindness goes by--sympathy, generosity, benevolence, compassion, empathy. The survey questions work their way around the idea of kindness: "concern for your questions and worries," "friendliness/courtesy," but don't quite get there. "Did the staff work together to care for you?" Here the word "care" sounds utilitarian, Walmart-ian, not compassionate or empathetic--or kind. "To care for you" implies providing a patient with a competent, timely, efficient encounter and a smooth release back into the world. Is kind too old-fashioned a word, a left over from the days of house calls? Is it too abstract, too difficult to measure? Or finally, is kindness not mentioned in our new satisfaction survey because it's irrelevant?

There are certainly situations where the doctor's very act of providing complete information during a visit increases the patient's perception of the physician as compassionate, caring, and empathic, and there is research to show that it is this perception of completeness, not the facts provided, that relieves a patient's anxiety. Is satisfaction the reduction of anxiety during the medical visit? Is that what's remembered and transformed into the responses on satisfaction surveys?

I had a friend who at the time of her newly diagnosed pancreatic cancer asked her doctor what she could hope for. A miracle, he said. She pressed him. Prognostically, how long do I have, she asked. She knew it wasn't long, months, maybe a few years. He couldn't, or wouldn't, tell her. Everyone's different, he said, but some treatment, palliative, not curative, would make it longer. Was this an example of providing complete information? Yes, if we expect doctors to know the future. Was it a satisfactory answer? For her, that day, it was.

Veri suggested that it doesn't take a doctor very long to produce satisfactory service. An experiment was designed almost two decades ago to vary perceptions of a physician's compassion by varying the methods that express support, sympathy, and compassion for a patient's difficult situation both in words and by touch. Oncologists were videotaped offering consultations to advanced breast cancer patients regarding a new treatment. Five common components from these conversations were extracted: an introduction, a summary of previous treatment, the objective of the new treatment, a discussion of treatment risks and benefits, and treatment alternatives. The researchers then wrote a script that included the best of all five components, using a pastiche of the oncologists' own words. They then recorded a master videotape with another oncologist acting the part of the physician and reciting the prepared script to a woman, who had not had cancer previously, acting the part of the patient. The dramatized oncologist-breast cancer patient tape lasted approximately eighteen minutes. The researchers edited two versions of this dramatized scene to be tested against one another measuring a viewer's sense of the physician.

In the "standard" videotape version, the physician described two options for metastatic breast cancer, High Dose Chemotherapy and Low Dose Chemotherapy, using the five components. The "enhanced compassion" videotape was identical to the standard videotape (i.e., the same footage was used) except for the addition of two short segments. In these two segments, the oncologist acknowledged the psychological concerns of the patient, expressed partnership and support, validated her emotional state and the difficulty of making a decision, touched her hand, and tried to reassure her. The brief segments were:
    Segment 1: I know this is a tough experience to go through and I
   want you to know that I am here with you. Some of the things that
   I say to you today may be difficult to understand, so I want you to
   feel comfortable in stopping me if something I say is confusing or
   doesn't make sense. We are here together, and we will go through
   this together.
   Segment 2: I know this is a tough time for you and I want to
   again that we are in this together. I will be with you each
   step along the way. 

Segment 1 appeared near the beginning of the videotape, before the physician provided treatment information. Segment 2 came close to the end of the consultation. The two segments added exactly forty seconds to the videotape.

Both breast cancer survivors and women who had never had cancer were recruited to view the videotapes and answer questions about the doctor-patient interaction. Participants rated the physician's compassion using five pairs of physician characteristics, each rated from 0-100. The characteristics were warm/cold, pleasant/unpleasant, compassionate/distant, sensitive/insensitive, and caring/uncaring.

When the physician acknowledged the patient's emotional state during the forty seconds of "enhanced" compassion in the course of an eighteen-minute visit, viewers perceived this physician as significantly more empathic than the "standard." In addition, the more compassionate physician was also rated higher on wanting what was best for the patient, caring about the patient, acknowledging the patient's emotions, encouraging questions, and encouraging involvement in decision-making. As one viewer put it: "It's not that he'll treat you better. It's like a back-stage pass. The show's the same. You're just closer."

So Veri's suggestion that even short, rote statements--forty seconds worth, or maybe even less--affect the patient's experience had empirical support. Just as it is the perception of completeness that matters, it is the perception of compassion that matters. Studies indicate that this sense that your physician is compassionate is directly related to patient satisfaction.

As a good consultant, Veri had constructed a way to manipulate patient perception, just as the enhanced compassion videotape had. To produce consistent and excellent results day after day, to reduce the avoidable error of turning patients off inadvertently during office visits, her Being Clear scripts might help. The scripts would not be foolproof at catching communication lapses (grimacing, sarcasm, slips of the tongue, patient misinterpretations), but they were a defense against fatigue and inattention and forgetfulness. They were bolsters for the bottom 10 percent.

Said repeatedly, scripts may even begin to move the amateur human being into a full and alert human being. There is room to individualize (an actor would say ad lib) with the patient in front of you, but even mechanical empathy can produce the perception of caring. Actually caring, instead of just impersonating a caring doctor, was the doctor's problem in Veri's world.

An office visit is a delicate emotional play that comes to neither a tragic nor happy ending. If the doctor does his job during their time together, the patient feels she's told a story that makes her visible to herself, a portrait her doctor has seen clearly, and she understands the options available to make her better, or make her feel better. The doctor has shared some news the patient didn't know on the way into the office.

Will Veri's formula, with these simple statements of solidarity, fulfill what patients expect? Can her plan, which ensures forty seconds of compassion, ensure that patients will not feel disappointed? Her scripts offer no promise of a cure, just a good faith process to keep the patient feeling the doctor cares. Will this be enough? Or is satisfaction more closely related to outcome (splint applied painlessly, heart attack prevented, psoriasis gone) as the student in his simulation exercise believed?

The play-acting of the doctor is the opposite of Method acting--his words are often not an extension of his emotional state. Reciting a script, no matter how artfully performed, does not depend on how the doctor feels; a script provides the illusion of feeling. This acting, the emotional labor of doctoring, brief for surgeons who focus on manual labor, is extended for psychiatrists who must engage a vital part of themselves with every interaction, but who know better than most that perhaps it's sometimes best not to say anything.

Acting like a doctor requires a repertoire of performances desired or demanded in a particular situation at a particular time. Is being able to act well a selling out, a betrayal of my "authentic self," or a sign of virtuosity? What's wrong with wanting to please? After all, patients are comparing my performance with the performance of other doctors and with the wished-for doctor in their minds.

So why was I upset when the meeting with Veri came to an end? Why did I react badly and get angry and dramatically toss her index cards in the garbage on the way out? Because I believe there are visits where the doctor is polite, makes good eye contact, does not rush, is courteous, yet remains somehow neglectful. Because, as a romantic, I believe in kindness, which starts with, but is different from, civility. Kindness occurs when some existential dimension of a patient's suffering that needs to be touched is touched. Because I don't want to be told what to say to be human. Because I don't want to feel, after all these years, like I still have to act as I did when I was a student at Harlem Hospital.

I was upset, but I was also dismayed. It was sad that any group of doctors needed index cards to be kind.

Kindness, and unkindness, occur, notably, in times of uncertainty, and most medical visits are loaded with uncertainty, on both sides, about what we will hear or say. Kindness occurs when a doctor lets his patient know, "You're in the middle of something of impact; nothing you say is foolish." The risk of a script is that it becomes a coerced, mechanical response. The risk of a script is that it becomes tired, redundant, and the patient feels that he is one among many, not the one who needs treatment now.

Kindness appears at the intersection of randomness and alertness, those unplanned moments when I am unprepared for what I hear and feel from a patient. Perceived as a duty, the precise, explicit conversational plan of a script precludes these unplanned moments, and without the possibility of surprise, there is little reason to listen carefully. The risk of a script is that the doctor stops listening because his responses are already programmed, because his next words could be applied to any patient, because he's said them all before.

When am I dissatisfied as a patient? My answer is the same as my sister's: When I am not listened to. When the responses I receive from my doctor are rote, thoughtless, and impersonal when we are talking about the most personal things in my life.

There are now specialized electronic, wireless, lapel "badges" used by some companies to transmit data about employees' interactions as they go about their days. The badges capture all sorts of information: conversational length and tone,-how much employees talk, listen, and interrupt; the degree to which the speakers demonstrate empathy and extroversion. The goal is to shed light on what differentiates successful from unsuccessful workers and teams. Soon there will be technology (which could be applied around-the-clock as gadgets gets cheaper) where employees view their own communication performance more or less in real time so that they can see how they fare, relative to the benchmarks of highly "successful" employees. This torrent of data can sit on servers awaiting analysis to determine who had a productive day. Next year will Veri have us wear these badges?

The satisfaction survey our practice has purchased is trying to measure, after the fact, the way doctors and patients interact. The scripts are meant to be spoken lines that promise a fine encounter. If enacted, each doctor's line might produce a check on some checklist of perceived kindness. But kindness must be more than received ideas and information presented in the form of approved emotions. Kindness is fresh response. It requires an effort to see clearly and feel directly. Kindness, which is always a matter of subtle calibration, isn't always possible, or more likely, it is impossible to predict if and how it will be received at all.

Are scripts, delivered with feeling, the technique we must master to cope with the psychological demands of a rushed profession? Is learning to speak a script convincingly a skill equivalent to learning to read an X-ray, one gathering information from a person, the other from a machine? Should we admit, as doctors, that we're playacting? Does this acting create an unsupportable tension with the scientific truth we are there to transmit? Do patients want us to act? Do they care? Could they even tell? Maybe scripts are the right approach for amateur human beings, and if you believe that medical training turns too many who enter the field into amateurs, then scripts may indeed improve those in the bottom ten percent. Yet I suspect that if I were to say the same thing many times even the illusion of feeling would get refined out of it.

There is drama to being a doctor. At its best, doctoring is a specific form of impersonation, or in-personation. It is when I take a patient's passion (her pain, her complaint) within myself for a few seconds. When the disorder of a meandering conversation pulls me into the patient's story, making their story my story, and seeing it through their eyes begins to create order in me. It is a kind of self-transformation. It can't be acted. It lies in some deeper script indelibly written in the nervous system, connecting astonishment and gratification.
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Author:Stein, Michael D.
Publication:Southwest Review
Article Type:Essay
Geographic Code:1USA
Date:Jun 22, 2015
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