An Oscar for the Patient: inspiring active learning through action methods

Irina Stefanescu (Romania)

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I do what I like and I like what I do... every day

(Mary Poppins by Dr. P.L.Travers) CONTEXT A business manager in a pharmaceutical company invited me into her office on a November day and said:
I am organizing a symposium on epilepsy to reinforce our product placement in the marketplace. I have arranged speakers and a festive dinner, and I thought I had done everything, but do you know what several neurologists asked me yesterday? Could you bring the facilitator we worked with last year in October as we remember that workshop as a very special one. We discussed a lot, we shared from our experience, we all had time to speak, there were some serious issues we focused on, and we had fun together!

When I asked How many participants? her answer shocked me: Between 100 and 120. This would be the first time I had worked with so many specialists, many of them considerably older than me. The workshop in October one year before had been with forty participants. I took a deep breath and I started to interview her. After a long discussion about her specific goals for the workshop, we ended up focusing on three key outcomes. We wanted to create: 1. clear pictures of the patient profile in the prescribers minds; 2. clear statements of the products benefits compared to other products;

3. a memorable event for the doctors, to reinforce a favourable impression of both the company and the product. We also considered some valuable background information: the neurologists are generally not fond of diagnosing and treating epilepsy; although the product is highly effective, it isnt the first choice prescription because of its high cost and powerful impact; patients with epilepsy perceive the disease as a stigma and many of them experience discrimination in their families or working environments.

I agreed to design and run the workshop, as long as there were neither scientific presentation nor commercial claims included. This would enable the participants to be free to express their opinions, fears, likes, dislikes and experiences. HOW I DID IT Set-up and resources The huge square conference room was ideal for this workshop. There was plenty of room for 110 chairs around the room in a big double circle; the carpet was vividly coloured and I could use the forms and colours to arrange working spaces. The sound was good and the best thing of all for me was the lighting system, a large circle of light projectors on the ceiling that could highlight a round scene on the floor. I had a small wooden stage, two cordless microphones, a beamer, a laptop to project five slides, three mantles (cloaks) made of sackcloth, to indicate the presence of the medical condition, and four differently coloured sets of three ribbons. I also had three colleagues to work with, a video camera, and a lighting operator. The scientific resource I needed most was three real clinical cases, minus private details, appropriate for treatment with the product involved. These had been prepared two weeks beforehand with the help of a university lecturer and researcher who had considerable experience with the product. Time: half a day Warm-up
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For the warm-up, I needed a good, impactive story to reach their minds and hearts, and also to redefine their role as therapists. Why should they move, as they dont like epilepsy too much? I needed to empower them to believe in their therapeutic holistic role they are treating not only a disease, but also a human being with mind, soul, spirit and body. I remembered Jrg Burmeisters story about Flamenco, about the significance of this dance. The simplest Flamenco step, used by both women and men, means I have the right to be, here I am! So the title of the workshop was Restore self-confidence with just one step. I beamed a huge picture of Flamenco dancers dressed in red, with Flamenco music in the background, onto the wall. I introduced myself briefly, stated the goals of the workshop and named the doctors as architects, who restore the inner beauty of your epileptic patients by helping them to regain their self-confidence . I told a story about Flamenco and its birth in Andalusia, made the dance step two or three times, quite loudly, on the stage and then invited everybody to do it. Once they were standing and dancing, they became involved! In just seven minutes they were up on their feet, stepping and smiling! Participants needed to feel secure and to begin to explore the space we were working in, so I asked everybody to show where they came from. I asked the resulting groups to demonstrate the specific sound of their place. They talked for one minute, then started smiling and became curious about the sounds of other places. I needed to know quickly which participants were the most experienced in working with this product, so I invited the group to form a spectrogram. After interviewing five of them, I learnt who were the specialists I could count on for any technical questions. The last thing before warming up for roles was to establish twelve groups of equal size. I used the months of the year, inviting the participants to arrange themselves according to the month of their birth. The twelve groups were: three groups of patients (P1, P2 and P3); three groups of therapists (doctors, neurologists etc.) (T1, T2, and T3 T1 is therapist for P1, T2 for P2 and T3 for P3); four groups of drug treatment products or molecules (M1, M2, M3, M4 M1 represented the companys product; M2, M3, M4 represented three competitors products); one group to be the Ministry of Health (MH);

one group to be the National Health Insurance House (NHIH).

I showed three slides detailing the three clinical cases and then gave the clinical report of patient 1 to P1 and T1, that of the second patient to P2 and T2 and the third one to P3 and T3. All three clinical cases were also, simultaneously, handed to M1, M2, M3, M4, MH and NHIH. There were no diagnoses, no names, no jobs, and no information about family; just age, gender, symptoms and some previous episodes described very briefly. Each group had 18-20 minutes to carry out the following tasks: 1. 2. 3. 4. to introduce themselves to each other saying their name, the town they came from and three personal traits; to find two things they had in common apart from being doctors, neurologists or something other highly obvious category; to select a main actor for the group; to prepare: P1, P2, P3 the stories of the three patients; T1, T2, T3 the questions to be used to probe the patients; M1, M2, M3, M4 the possible benefits for each patient of that particular treatment product; MH and NHIH what is most important when dealing with these patients from these organisations perspectives and what are their main goals.

Enactment As the patient groups sent their representatives, one after the other, onto the stage to tell his / her story, we dressed that person with the disease mantle and invited the person to sit on a chair. We handed a set of three ribbons to each molecule (or drug product) group. 1. P1 told their story to T1. T1 asked questions and received answers. We then repeated the process with pairs P2-T2 and P3T3. 2. T1, T2 and T3 were invited to return to their groups and discuss the possible diagnosis. 3. Meanwhile M1, M2, M3 and M4 were invited, one at a time, to go to each patient and tell why that particular molecule (treatment product) would fit or fail to fit the patients needs,
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outlining indications, main benefits, side effects, treatment terms, drug interactions and the mechanism of action. If a molecule considered herself appropriate for a patient, then she would place a ribbon around the neck of the patient. 4. T1, T2 and T3 groups were then invited to confer for three minutes about the treatment they would have recommended as therapists. 5. T1, T2, and T3 then informed their patient (T1 to P1, etc.) of their diagnosis and the recommended treatment, and advised the patient about the appropriate life-style for the treatment to be effective. If they didnt validate a molecule, then they took the ribbon off the patient while justifying the decision. 6. MH and NHIH assessed the treatment according to their particular goals and policies. Sharing The patients took off their disease mantles while still on the lit stage, and shared loudly from role about how they felt they had been treated and what had happened to them during the enactment. This was a very important part of the workshop, because it was a powerful educational moment about managing the relationship with the patient. Nobody normally tells the specialists how to manage relationships with patients. Then, back in groups, people had twelve minutes to briefly share from roles and from their personal experiences linked to what had happened on the stage. They then reflected and made a record of the learning points they were taking back home; these were presented to the entire audience through another group member. End Finally back on the small wooden stage, with the Flamenco music in the background, I explained my conclusions from my observations and congratulated them on their role of self-confidence restorers. I got everyone to dance the Flamenco step again, thanked the group and said goodbye. Conclusion What happened to the three goals we had? Fourteen months have passed since then and the doctors, in their feedback to the medical representatives, still remember the workshop. They retained vivid images of the patients on the stage and they remember which drug treatments

(molecules) were chosen and why. The medical representatives can still rely on those images to build new patient profiles and to remind them of the products benefits.