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A Contract of Good Faith (3/7/21)

Updated: Mar 9, 2021


Part of my job in medical education is to orient students for ‘experiential’ exams. Each student will soon talk to a real person -- portraying a specific patient -- so they can put into practice the skills they’ve learned, ‘apples to apples’ since many humans are embodying the ‘same’ patient. Students arrive for an exam like this with high stress over both the knowledge content and the performance anxiety of interacting with a stranger, for a test.


With huge class sizes, last week I gave each group of 10 students the same 15-minute Powerpoint, 21 times over 3 days. (Feedback comes back strong; they much prefer a live person talking. Fair enough, especially for our 1st-years, who started med-school over Zoom. We don't know yet when we'll meet, in person.)


These orientations include reminders for all our interactive experiences, whether for learning or assessment. One is an obligation to cover ground rules. Are students allowed to perform (or direct) physical-exam maneuvers? If so, any limitations there? Should students assume, in Zoom world, they're conducting a telehealth visit, or that they’re with a patient in an exam-room?


Another is a ‘contract’ I added several years ago, a derivation of ground rules used with complex artificial humans, to address the ‘fakiness’ of interacting with a SimMan or SimBaby. The idea is to acknowledge that fakiness up-front and try to get past it, toward whatever learning and feedback are possible. "We're all doing our best," is the sim gist.



Working in real-people methodology, I thought ‘why not acknowledge our human-patient aspect as well'? Remind students, for example, that these trained patients "know you’re not doctors yet, you’re on your way, and doing your best."



I’m also trying to concede to human nature in general. Our staff, trained patients, students, even wifi connections, all include margins for error. As humans, we're capable of misspeaking, misunderstanding, we might be functioning on less sleep or caffeine than usual. Any of us might be weather-impacted, hunger-, lack-of-exercise-, mostly-full-bladder-, overflowed-toilet-just-now-impacted. Or having just received tough news ‘in real life’ but needing to focus on this human, and so on.


Without quite spelling those out. Just: We’re all human beings here, not sim-computers, and acting in ‘good faith’ about one another. Obliging each other with a sense of trust. Trying to right-size all our expectations.


I fumble over some of the sentences about ‘doing our best’ without meaning to -- proving my point, hopefully, for the nth time -- somewhat sleep-deprived and with an overflowed and unaddressed toilet on one of those exam days.


Rather than stress over the high-stakes of it all, how about we try to open ourselves to the wonderfulness, the nourishment, of interacting – even virtually – and imperfectly, with even one Other of us?


When I stop sharing the slides and return to 10 students’ faces in boxes, I usually see a shift from their arrival anxiety to a kind of thoughtfulness. I can see that most of them accept this good faith, may feel relief from it, some are even moved by it. Part of my job, as I see it, is to help them breathe before an exam, to calm themselves if they can, so their brains might work as well as possible, when meeting a stranger.


You might think hearing myself say these faithful words, over and over for days, would make it easy for me to remember my own doing-best. You might think I could carry this reminder, right in my front pocket, through my evenings and weekends. Would that it were so easy.


O the mess these students would see, if I turned my laptop-camera around to the other side of the room! Unwashed breakfast dishes, the pile of unread mail, a half-stack of still-unwritten New Years’ cards (now, if I’m lucky, St. Patrick’s Day or April Fools’ cards), that thin rope of cobweb on my ceiling light-fixture. The unopened InstaPot box that I ordered over a year ago, still functioning as a foot-rest.


They wouldn’t even see a family member’s text that I still don’t understand. Or know about the phone call I haven’t returned from an old friend whom I love, and who I think understands how hard it is for me, on a ‘live set’ most days, to talk on the phone at all, but even if she understands, I feel bad. Or know I'm wondering when my rot- and woodpecker-damaged back deck will finally collapse. Wondering if I’ll ever find a literary agent for my unfinished memoir, especially when I’m not actively pursuing an agent but only wondering, still. Wondering when I will manage to hug my mother, whom I haven’t seen in person since Christmas of 2019. Even though I know the whole world is doing its best, considering.


All doing our best, okay, as a full year of COVID-life closes. Trusting that some of these undone's are not essential. That half the work is sorting out what is essential, and taking care of that, if imperfectly. And that preparing for any test, whether multiple-choice-question or interactive and experiential, with some stranger-human, carries some good faith.


Maybe I'm leading a prayer -- something I'd never thought of until writing today. That the standardized-patient I’m about to meet may not be trying to sabotage or sink my future medical career, that all my practice and hard work might be enough to prove that I'm progressing in my profession. Maybe these humans appreciate that I’m working through my very 1st-year of med-school, and 'just' doing my best.


Trust in others, a complex faith. Especially during this suspended year of other-wise life. Don’t we all long to connect to strangers, as well as our intimates?


Strangers, Others, always been tricky, human-nature-wise. Maybe not all of us long to meet strangers? Or long only to connect with strangers who seem the most like us?

Something deep in our flawed human natures -- those primal and primate-gut feelings -- tells us to suss out a stranger, think fast and decide whether we can trust this Other. A plague might heighten our guts of 'Danger, Will Robinson!'


An Other might just be looking for better weather. Cleaner water. (Maybe in Cancun, rather than Texas.) Maybe a whole tribe or clan or squad needs a more temperate climate, a source of fresh water, some fruit and nut trees, a bite of roasted fish now and then.


Others might bring novel ways of doing things, more efficiently or delightfully.

Hey, what if we scrape some of that tree-bark over there and mix it into our chopped apples over the fire? Oooh, good call.


Oh. You know what? Where we come from, we would fashion those biggest leaves into a funnel, to capture rainwater into carved gourds at a careful, steady pace.


Hey, wow, thanks. Why didn't we think of that?


Lo, curious traveler. Where’d you get those rockin’ sandals? Wait, you made those?

Maybe some unfamiliar object landed on the wind or tide, and we sought the source, or someone from far away sought our local sources. Our curiosity, or even an urge to roam, can override our fear of the unknown.


Then again, some groups’ gut-feelings might be full of fear of the unknown. Fear has become their motivating tool to suss out, think quickly and decide how to respond to an Other.


Very nervous!

Look alive.

Stranger -- en garde, arrows up!

Psst - give them those poxed blankets. Or let their lead-poisoned water go unaddressed.



Then again, sometimes the whole world sees others not at all as Other. Remember how the whole world (with TVs) hugged a group of Chilean miners from our living-rooms, when they were trapped below the Earth? Wait – they're still alive? We cheered from our sofas. We laughed when they sent back up a basket of peaches because “we took a vote and decided we didn’t feel like peaches.” Oh my gosh, we trusted, they were going to be okay. And they did make it out, and we all felt like our kin had survived.


Because our kin had survived.


Here's a tougher one: I try very hard to assume that my country’s previous leadership was, in its way, doing its best. Believed it was doing its best. Even though that ‘best’ inflicted so much damage, cost many more real human lives than necessary, treated so many of our own close kin – fellow Americans – like the Other. They resisted a national response to a national emergency. Hoped it would “all go away, like a miracle.”


Maybe I can only consider that now, after my country right-sized its sense of best, with different leaders. Leaders welcoming, who want to try the strange cinnamon-bark, and learn how to capture fresh rainwater, for everyone’s benefit. Everyone human, and beyond. Everything on our family planet.


So grateful that, once we’re both vaccinated, my mother and I could still hug as warm bodies, maybe go to an art museum together, or walk the Atlantic surf. For one.


A pilot-light of hope and faith, too, at work. That virtual/simulated gatherings between our standardized-patients and students will once again become interactive inside exam-rooms with running water and ophthalmoscopes and mutual eye-contact. That classmates will finally meet each other inside a lecture hall, or over at the food court. That even the fakiness of a telehealth visit over Zoom will mean a broader set of communication/ interpersonal skills that we already teach. How to look at someone (away from them, into a camera’s eye) and only see the person’s eyes when (in their eyes) you've looked away -- yet still convey your care and connection.


I won’t get tired of saying that evergreen reminder: We assume each other’s imperfect humanity and best intentions. That ‘contract’ has always been in place, and I can’t imagine why we’d rip it up now, and I'm lucky to be able to say it out loud, so many times.


Meanwhile, here’s to the light and warmth of holding onto our good faith, in ourselves, and each other.



Thank you for reading this, any friends or strangers.


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