A Place of Safety

Somewhere in England today I was doing some demanding roleplay about domestic violence, to help some young doctors learn to broach the issue with their patients.

The woman whom I was playing had turned up at the surgery complaining of chest pain - the most recent in a series of strange symptoms that she had had. Chest pain can of course be a symptom of a heart attack but it can also be a symptom of other things, including stress. The story was supposed to be that upon thorough examination there was nothing wrong with her heart, but she had substantial bruising on her upper arms.

And that was where the roleplay was supposed to start. "I have examined you: your heart and blood pressure etc are fine, but I couldn't help noticing that you have bruising on your arms - -- "

This is the kind of consultation - raising the possibility of domestic violence - that doctors find extremely difficult, not surprisingly, and that's why they need to practise discussing it with the patient and then dealing with it.

But the first doctor I - playing the role of the patient - encountered - probably because of fear of where it might go if he mentioned the bruising - decided to go straight down the medical route, starting from the beginning.

"May I ask what's brought you to the surgery today?"

Slightly wrong-footed, as it most certainly wasn't the beginning I was expecting, I said "Well, I've been getting pains in my chest."

He was off! On safe ground! Not having to discuss anything else!

"How long have you had the chest pain? Could you describe the pain? Is it a gripping pain or a burning pain? How often does it happen? How long does it last on each occasion? Does it go anywhere else? Into your jaw? Down your arm? How bad is the pain on a scale of one to ten where one is hardly any pain and ten is the worst pain you have ever experienced?"

I wanted to say "Look, sunshine, that's not what this roleplay's supposed to be about and well you know it. I'm not a real patient, I'm acting, and I've no idea what the sodding pain was like because it's only there as a pretext to start the roleplay."

But, of course, I couldn't - I was in role and had to stay in role no matter what happened: that's the first rule of roleplay. The learner can ask for "time out" if they get really stuck: the roleplayer never can, of course - it would be totally unprofessional.

Fortunately I know enough about chest pain to play it all down and make it sound as though I couldn't possibly be having a heart attack, but it was a bit difficult for a while: it was left to the next doctor to have a go at the roleplay to broach the tricky subject of the bruises.

That's what doctors do when they're under threat. It's what we all do - retreat to a place of safety. And to a doctor, a place of safety is often where the body is treated as something like a large piece of Meccano, and the personality and emotions attached to it are ignored as much as possible.

That's not altogether the doctors' fault, of course - as I said, retreating to a place of safety is something that we all do. It's not that they are failing in an easy task - some consultations are incredibly difficult, and doctors are almost always short of time too.

There's no substitute for actually practising saying the words that you might say to broach a tricky emotional subject. It's very, very difficult to do and very easy to say something that will lose all rapport with the patient, or indeed cause them distress that they'll remember for years.

Just occasionally up pops an older doctor who says something like "Oh, we didn't have all this touchy-feely stuff in my day. It's all just common sense."

They are inevitably the ones who are remembered by their patients for all the wrong reasons: for going round spreading misery and fear.

All credit is due to almost all the young doctors with whom I did the roleplay today. They were all scared to try it, but they approached it with bravery and honesty and an acknowledgement that the subject of domestic violence is incredibly difficult to deal with. They are the doctors we need.