Scripted Role Play on sexual harassment of doctors by patients

The findings of a survey of 180 doctors by Melbourne and Monash Universities hit the media in Oct 2013 after being published in MJA. The survey results showed that 55% of Australian female GPs had been sexually harassed by patients and 65% been asked for inappropriate examination. It was stated that less than 7 per cent of the GPs  surveyed said they had been trained on how to deal with sexual harassment by a patient.

Reading the report prompted me to consider how we could cover this with trainees and thought that a scripted role play (*see explanation below) may be an effective method to broach this difficult topic.  I wrote the short script below to use with GP registrars.
Please feel free to use and/or adapt it if you wish.  All I ask is that appropriate attribution is made and that you let me know how it goes if you do run it with students or junior doctors. I always appreciate receiving feedback.

* Explanation

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

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Workshop structure (approx. 30mins):  

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read).  I would suggest the roles are played by two females to minimise any discomfort, given the material.

2)  Introduction to session

3)  Scenario (projected via PowerPoint and/or read aloud)

4)  Reading of dialogue by volunteers with break midway (as per script) for discussion

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scenario:

Dr Emma consults with new patient, 72 year old Fred Jackson.

Script: 

Emma:  (At doorway) Fred Jackson?

(Emma comes in with Fred, an elderly man.)

Emma:  (holding out her hand to shake) Hello Mr Jackson, my name is Emma Roberts. Welcome to the clinic.

Fred:  Well hello Emma, aren’t you a sweet little thing?

(Fred shakes with his R hand and uses his L hand to stroke Emma’s forearm. She withdraws it quickly without any fuss or change in facial expression and motions for Fred to sit. They both sit down.  Fred edges his chair a little closer to Emma’s. She edges hers back slightly)

Emma:  How can I help you today, Mr Jackson?

Fred:  No need for the formalities, darlin’, we’re all friends here.  I’m been Freddie since the day I was born, seventy-two years ago today.

Emma:  Happy birthday, Freddie.

Fred:  It’s all the more happy now I’ve seen you, darlin’. You’re the kinda present I’d love to unwrap. Tasty! (drawn out pronunciation: Taste-ee)

Emma:  Let’s focus on health matters, shall we?

Fred:  I’m just having a bit of fun, darlin’. I don’t mean nothin’ by it. You wouldn’t begrudge an old man a bit o’ harmless fun on his birthday, now would ya love?

Emma:  I’d feel more comfortable without that kind of banter, if that’s OK.

Fred:  You’re a bit uptight, aren’t ya love?  No worries, I’ll tone it down.

Emma:  So what can I do for you today?

Fred:  I know what I’d LIKE you to do for me, with those soft white hands and rosy red….

Emma:   (interrupting) Freddie, that is inappropriate.

Fred:  Sorry, sorry.  Don’t get your cute little knickers in a twist. I’ll behave.  OK, well it’s kinda embarrassing. I’ve bin havin’ problems with me waterworks. No longer Niagara Falls, more like a pissy little dribble that won’t even put out unless you talk to it real nice and buy it dinner first. (laughs at his joke)  Me regular doc reckoned it is probably me prostate and wanted to stick a finger up me bum to check it out. I told him, no way any bloke is putting any of his bits in my hole – just doesn’t feel right, ya know love?

Emma:  It’s a routine medical examination, Freddie, there is nothing sexual about it.

Fred:  Maybe, but I’d feel a lot better if a nice young lady doctor did it. You’ll treat me gentle, I can tell.  Might even be fun, and God knows, I don’t get much of that kinda fun anymore.

Stop:

Discussion:  How do you think Emma is feeling right now?  Why is Freddie behaving this way? (dirty old man, inappropriate but harmless/ well meaning or someone  who is trying to cover up his embarrassment with “humour”) How has Emma handled things so far? What would you have done differently? What can she do now? Get volunteers to say what they think Emma’s next response should be)

Emma:  First, I’ll need to take a full history and perform a general examination. If I agree that a rectal examination is indicated, I will ask my colleague, Dr Michael Harris to come in and act as chaperone.

Fred:  We don’t need no chaperone, darl. I trust ya. I’ll put my bum in your hands anyday.

Emma:  It is for my comfort as much as yours, Freddie. It is my policy not to perform that kind of examination without someone else present.

Fred:  How about a sexy nurse then?  Always fancied a threesome.

Emma:  Again, I must warn you about your language, Freddie. I find it offensive and if you continue, I’m going to have to ask you to leave.

Fred:  Sorry love. I’m harmless. Just like joking around.

Emma:  If are not comfortable with Dr Harris being present, and you need an intimate examination, I’m afraid I’ll have to ask you to go elsewhere for the examination. I’d be happy to pass on any relevant information to the doctor of your choosing.

Fred:  Blimey!  Are you some kind of bloke-hating women’s libber? Talk about overreacting to a bit of friendly chat.

Stop:

Q and A in role 

De-role readers

Group Discussion:  Has anyone experienced inappropriate sexual behaviour from patients? How did you handle it? Stats (55% GPs 2013 study) What are your options? What systems in place in your practice?

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Scripted Role Play on Infertility

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I use this scripted role play in registrar sessions I facilitate on infertility to illustrate how emotionally charged and difficult consultations relating to infertility can be, and how easy it is to “put your foot in it”.

Why scripted role plays? It is well established that the use of role plays in communication skills training can be of great value, however unscripted role plays in group settings can be terrifying for participants. Some will disengage and/or use avoidance strategies, impeding their access to learning opportunities.

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

Workshop structure

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read)

2)  Introduction to session which starts with this clip…

…and includes a discussion on while a lot of us spend a good deal of our reproductive aged lives trying NOT to get pregnant, there often there comes a time when the tables turn and pregnancy becomes the goal, not the mistake, and that unfortunately, for many, their plans don’t go to plan.

3)  Definitions, statistics and the role of the GP in diagnosing/ managing the infertile patient.

4) Discussion on the psychological aspects of infertility.

4)  Reading of dialogue by volunteers

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scripted role play on the psychological aspects of Infertility.

Characters:

Patient: Robyn, 40 year old female

GP registrar: Jeff Larson, aged 25 – 40

Script:

Jeff: Hi Robyn, I’m Jeff Larson, what can I do for you today?

Robyn: I was hoping to see Dr Kate again but the receptionist said that she’s left and you’ve taken her place.

Jeff: Yes, Kate has moved to another practice but I have access to her very thorough notes and will help you as best I can.

Robyn: That’s always happening here. I just get used to someone and they up and leave. Is it that bad a place to work?

Jeff: Not at all. It’s great. The reason that doctors come and go here is because it’s a training practice. Kate and I are registrars – GPs in training. We’re required to work at different places to improve our breadth of experience and get moved around periodically.

Robyn: I think you’re wrong about Kate – she’s no student doctor. She’s the most knowledgeable and caring doctor I’ve ever had.

Jeff: (under his breath) So her patients keep telling me. (to Robyn) GP registrars are not student doctors – we’re fully qualified doctors doing extra training in general practice. But let’s get back to why you’ve come along today…

Stop for Q and A in role, and discussion.

How are you feeling right now Jeff / Robyn? Who has had patients complain that doctors don’t stay? Who has had patients try to make you feel guilty for leaving? How do you think Jeff handled it? What would you have done differently? Do you tell patients you’re in training? How do you explain the concept of GP registrar?

Jeff: So how can I help you today?

Robyn: I need another referral to Dr Orford.

Jeff: The gynaecologist?

Robyn: Yes. I have an appointment next week and my last referral has run out.

Jeff: Sure, I can write you one. I see from your chart that you’ve been seeing him for fertility issues. Is this what the referral is for?

Robyn: Yes. I can’t get pregnant.

Jeff: I’m sorry to hear that. It’s really common in women your age. Fertility rates drop off a lot after 35.

Robyn: I’ve been trying to get pregnant since I was 29… 11 years ago. Isn’t that in my chart?

Jeff: Probably. I’m sorry, I didn’t have a chance to read it fully before you came in. Sounds like you’ve had a really difficult time of it. (pause… then trying to make a joke to lighten the mood). Well, at least you have a good excuse to get in lots of practice.

Robyn: Pardon?

Jeff: (embarrassed) I just mean that you have an excellent reason to have regular sex which will umm… help strengthen your marriage.

Robyn: (incredulous) You think not being able to have kids helps relationships?

Jeff: No, no I didn’t mean that.

Robyn: And that business-like sex on an ovulation-centred schedule is fun?

Jeff: Well maybe not always but…

Robyn: Not that our attempts to get pregnant involve sex anymore… which is one small mercy.

Jeff: Been having IVF?

Robyn: IVF, AI, DI, IUI, ICSI, donor eggs… you name it, we’ve tried it.

Jeff: So what exactly is the nature of your problem, if you don’t mind me asking?

Robyn: I have endometriosis which Dr Orford said has also affected the quality of my eggs, and my husband has a low sperm count. Triple whammy – bad pipes, bad eggs and bad sperm. We’ve just had our 14th IVF attempt.

Jeff: 14! You must be very… umm… dedicated.

Robyn: Obsessed you mean.

(Jeff tries to protest)

Robyn: No, it’s alright, I am obsessed. I have wanted nothing in life except to be a mother. Dr Orford encouraged me to stop after 8 IVF cycles, my husband drew the line at 10, but each time I said ‘just one more try” and they caved in. It’s not going to work again though. It’s the end. That’s why Dr Orford has asked me to see him next week, I need to get a referral for him to tell me he can’t see me anymore. Talk about ironic.

Jeff:  So about that referral…

Robyn: I’m not ready to give up on my dream of having a family though. What can I do?

Jeff: What about surrogacy?

Robyn: There’s no one close that I can ask to do it for me and paying someone is illegal, even if you do it overseas. Besides, bad eggs, bad sperm, remember? Surrogacy is unlikely to work for us.

Jeff: Have you considered adoption?

Robyn: We’re too old- they won’t accept us. George, my husband, is 48.

Jeff: Fostering?

Robyn: They turned us down for that too. Long story.

Jeff: How about coaching a kids’ sporting team or doing some babysitting?

Robyn: Do you really think that’s anything like being a parent?

Jeff: In many ways, it’s better. You can give then back at the end and have a free and independent life.

Robyn: Do you have kids?

Jeff: Yes. 3 under 5.

Robyn: And how would feel if you had to ‘give them back at the end’?

Jeff: Sometimes I wish I could, believe me.

Robyn: You regret having them?

Jeff: Of course not!  They’re the best things that have ever happened to me. It’s just that…you know… kids can be a bit…annoying sometimes.

Robyn: No I don’t know, that’s the problem.  Sure, parents often complain that their kids are frustrating and restrict their lives but also say that having children is the most rewarding and fulfilling accomplishment in life.   Can you honestly tell me that this is just a myth designed to help tired and stressed parents cope?

Jeff: No… maybe… I don’t know.

Robyn:  I can’t help but think that I’m missing out on the best thing a person can do in life.

Jeff: (awkward pause) I’m really sorry you can’t have kids. I just don’t know what to say.

Robyn: Dr Kate would’ve.

Jeff: Shall I do that referral for you?

Q and A in role then group discussion

Where did Jeff run into trouble?

What could have he have done differently?

What do you do when patients ask you personal questions?

 

Scripted Role Play on Jargon/ Breaking Bad News

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Scripted Role Play Material is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

This scripted role play is useful in sessions on communication skills especially when trying to illustrate how medical jargon can be problematic and / or the skills involved with how to break bad news.  I’ve found it very useful when working with OTDs (Overseas Trained Doctors) as many OTDs need assistance with communication skills, particularly around inappropriate use of medical jargon.

scripted role play

It is well established that the use of role plays in communication skills training can be of great value, however unscripted role plays in group settings can be terrifying for participants, often more so for OTDs than their Australian counterparts.  Some will disengage and/or use avoidance strategies, impeding their access to learning opportunities.

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

Workshop structure (approx. 45mins to 1hr):  

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read)

2)  Introduction to session

3)  Scenario (projected via PowerPoint or provided on a handout to all audience members)

4)  Reading of dialogue by volunteers

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scenario:

Sally is a 32 year old pregnant woman who presented to the emergency department with a story of PV spotting this morning.  She saw Dr. Jones.

His notes read:

11/40.  G1P0.  PV spotting for 1 day.  Rh+ve.   No other medical problems, no medications, no allergies.

On examination

  • Afebrile
  •  No pelvic tenderness,
  • No blood seen, Cervical os closed.

Reassured that PV bleeding common in early pregnancy

Plan –USS to exclude miscarriage. Review after scan.

The ultrasound report reads:

OBSTETRIC ULTRASOUND

Clinical Details
PV bleeding. ? viable pregnancy.

Report
Contained within the uterine cavity was a gestational sac. A foetus
was identified. CRL = 14.7mm = 7 weeks 6 days. Mean sac diameter =
43mm = 10 weeks 1 day.
No foetal heart was definable.
No myometrial abnormality or adnexal abnormality was identifiable.

Comment
The appearances are consistent with a non viable gestation

Dr. Jones’ shift has ended and you have been asked to discuss the test results with Sally.

Script:

SALLY: So what did the scan show doctor?

DOCTOR: I’m afraid the news isn’t good. The ultrasound revealed that your gestation is non-viable.  There is no cardiac activity.

SALLY:  The heart isn’t beating?

DOCTOR: That’s right. I’m very sorry for your loss.

SALLY: Are you saying my baby has died inside me?

DOCTOR: Yes.  I’m sorry.

SALLY: When did it happen?  I had a scan just over three weeks ago and everything was fine.

DOCTOR: There is a discrepancy between your gestational dates and foetal size which seems to indicate that the foetus stopped developing some time ago – maybe two to three weeks.

SALLY: I’ve had a dead baby in my uterus for two or three weeks?!

DOCTOR: Perhaps, impossible to know though. The good news is that the PV bleeding you’ve had indicates that the body has realised that this has happened and is getting ready to expel the products of conception.  If you prefer, we can offer you a D and C and remove the products surgically.

SALLY: Are you trying to say that I can wait and let my body deal with it naturally or else have a curette?

DOCTOR: Exactly. There are pros and cons with each approach.  Most first trimester spontaneous abortions sort themselves out and do not technically require a curette…

SALLY:  An ABORTION!  I haven’t had an ABORTION!

DOCTOR: No, no, I don’t mean a termination.  A spontaneous abortion is the medical term for a miscarriage.

SALLY: Oh.

DOCTOR: … so as I was saying, we don’t have to rush into a curette as most early miscarriages resolve without intervention, but many women decide to have the procedure. It avoids having to go through prolonged heavy bleeding and severe cramping and also, most women don’t like the thought of retaining a dead foetus for any longer than they have to.  They get “cleaned out”, so to speak and can move on.   Of course there are risks with having a D and C.  Infection, bleeding, uterine damage- even rupture, anaesthetic complications etc.  So what do you want to do?

Discussion points:

What did the doctor in this scenario do well?

What jargon did he/she use?

What would have been more appropriate terminology?

What are other things he/she have done better?