On Care and Cruelty
Reflections from a Standardized Patient
For the last two decades, medical schools and nursing programs have hired actors to portray patients in role-playing simulations with their students. The goal of these simulations is to help prospective doctors and nurses practice their bedside manner and communication skills. In these simulations, Actors are given detailed patient backstories ahead of time to prepare and are then asked to respond naturally to the student. After a simulation is over, actors sometimes give students feedback on how they did. In my time doing this work, I have played characters who have coped with everything from depression to addiction to physical injuries. Each patient comes with their own set of questions, conflicts, and anxieties. Over time, I have grown very protective of each character.
One of these characters is a young man named Vivek, who recently immigrated from India and has come to the doctor to get medication for back pain. Vivek has previously been weary of seeking care, fearing people will find out about his undocumented status. Over time, his back has only worsened and he now worries he will be unable to work if the pain continues. Vivek is supposed to begin the session intensely guarded and only open up if the doctor makes him feel safe. Whenever I play Vivek, I feel a seismic responsibility not just to perform well, but to embody his lived experience with integrity and nuance. In most cases, Vivek walks away from the session feeling more protected, and I find it easy to return to the real world. Yet, in one instance, he walked away completely broken and I struggled to recover.
I begin outside in a hallway. I take a few moments to get in touch with my breath. I try to find the character in my body and voice. I give myself time to consider his thoughts, worries, and fears as he enters the doctor’s office.I allow myself to become Vivek and walk into the room slowly. There are several students seated near the window and a facilitator right next to them. In the middle of the room is a male student who will be playing the doctor. The moment I first see the student is always telling. While I never know how they will perform, I can almost instantaneously sense their energy. Mostly, I enjoy this reveal. But in this instance I feel immediate dread. The student lounges in his chair, tipping it back and forth. He laughs under his breath. He reeks of overconfidence and sports a smug smile, one that would certainly frighten my character. I try to hold back judgement but on some level I already know what I am about to experience. As I sit, he deftly avoids eye contact. He greets me with a disinterested mumble (one that makes the real me shudder).
As I speak, he looks down and smirks. My body tenses and I quietly seethe. It is always evident when a student finds a training unnecessary. Throughout the conversation, he responds, sometimes mockingly, sometimes coldly, and sometimes with a sneer. He snorts as I struggle to find the right words and repeats everything at an obnoxious volume. When my English becomes unintelligible, he laughs, seemingly holding in the urge to mock my accent. As I explain my back pain, he barks at me for more details. I feel my body tighten and my hands shake. I fight back tears. I am waiting for a time out.
As my character trembles in fear, I try to quell my own anger. It shouldn’t feel personal but it does. When we finally timeout, the facilitator asks me to step out of character to give feedback. The student remains seated, still sporting a self-satisfied grin. I take a moment, wondering if it would be diplomatic to tell him to go fuck himself. I pull my emotions back and search for the appropriate words. I land on a few adjectives- cold, racially insensitive, disengaged, harsh. But none of those words can truly elucidate the rage I feel on behalf of Vivek. The student nods dutifully as I give feedback but I wonder how much he actually hears. My anger persists. It follows me through the rest of my day and through the next morning. Cruelty is very hard to shake. It pierces the skin and disturbs the psyche. Our bodies recognize the lack of care.
Fortunately, simulation experiences like this are rare. While students sometimes struggle to find the right words, you can almost always sense their desire to make their patients feel better. And you can sense the massive responsibility they feel to work towards that desire. Surgeon Atul Gawande has noted that “betterment is a perpetual labor.” In his book Better: A Surgeon’s Notes On Performance, Gawande writes that “to live as a doctor is to live so that one’s life is bound in others and in science, and in the messy complicated connection between the two.”
I find Gawande’s words deeply moving but also struggle to negotiate the real world complications. I immediately think of the real life scenes currently playing out; nurses working exhaustive hours in understaffed facilities; caregivers for the elderly working to ensure that their patients remain safe during a pandemic; hospital workers dealing with lack of resources and PPE; millions working to support their families while risking their own health. How does one continue to work towards betterment when they are not given the tools to do so? How can one prioritize responsibility when those in power absolve themselves of it?
Keeanga- Yamahtta Taylor recently asked her readers to “consider the plight of the healthcare worker.” She wrote:
Millions of such workers attend to a largely elderly and homebound population for meagre hourly wages and often without health insurance. In 2018, home health-care workers, eighty-seven per cent of whom are women and sixty per cent of whom are black or Latino, made an average of about eleven dollars and fifty cents an hour. These workers are the sinews of our society: they must work to insure that our society continues to function, even as that work poses potential threats to their clients and the general public. As job losses mount, millions of workers will lose their insurance while the public-health crisis surges.
In general, Black and brown populations are particularly vulnerable to infection because poverty is a fount of underlying conditions, such as diabetes, hypertension, pulmonary disease, and heart disease, that make it more likely that the virus will be deadly. They are also more vulnerable because greater rates of poverty and under-employment have hindered access to health care.
In reconciling this reality, I feel the same rage that I felt during my simulation with that medical student. This after all is a magnified version of the same cruelty and lack of care. Yet it is seldom characterized that way, even by those who speak out against our country’s systemic failures (and the failures of the current administration). For the most part, American politicians stick to civil normative language, pointing out either ideological disagreement or technical objection. Members of both parties laugh at the idea of Medicare for All, citing its financial impossibility.
Yet, few truly acknowledge what it means for a nation to not take it peoples’ health seriously. It is an action that we recognize as cruel on an interpersonal level but ignore when multiplied and universalized. The fact that a country decides everyday that all its inhabitants are not worthy of care is somehow erased. And we normalize the state’s violent disregard for the health, safety and well-being of all who are vulnerable. Of course, to truly grapple with our country’s history and present is to be overwhelmed with systemic cruelty.
In discussing the violence of our past and present, we many times move towards sophisticated political and sociological language. Yet in this process we lose the visceral, the personal, and the emotional. We lose the simplicity that helps us understand harm and process pain at its most primal and human. My experiences as a standardized patient will always be limited and entirely privileged (as will all my experiences as an actor.) I only spend moments imagining realities that others live. But in those fleeting moments, I get to live in the visceral, in the personal, and in the emotional. I get to momentarily feel care at its deepest and lack of care at its harshest. My life is not linked to another’s life, but I do feel a responsibility to speak the truth of my characters’ conditions to the world. And to fight for a world where care is universalized instead of cruelty .