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Dina Sokolova (Pavel Sokolov)

SP Training Materials^

 

Case Focus:  Language barrier and different explanatory models of hypertension treatment

Presenting Complaint: Patient is coming in for routine follow-up visit to Family Medicine Clinic for hypertension.


CASE SUMMARY: 

Dina is a 52-year-old Russian female who lives in Charlottesville. She is a refugee and came with her family from Russia in 2007. She had been diagnosed with hypertension in Russia in 2005 and was given treatment there. She has been followed by learners in Family Medicine for her routine health care and hypertension. She is otherwise healthy. Current medications are hydrochlorothiazide 25 mg once daily and metoprolol XR 50 mg daily. The doctor added the second medication at her last visit 2 months ago because her blood pressure was not well controlled on single therapy.

Unknown to the doctor, Dina does not really understand what hypertension is and why it needs to be treated. She believes that her headaches occur when her pressure is high, and that is when she needs to take her medication. Otherwise, she does not take her medication every day. She has her husband take her pressure when she has a headache, and if it is “high,” she takes both medications or maybe just one or the other. “High” to her is systolic of 150 or so. She doesn’t really understand the lower number (diastolic) pressure.

In Russia, she was treated with a shot once a month at the clinic, so she isn’t that familiar with taking tablets, and definitely not on a daily basis. She worries that she would be taking too many tablets if she were to take them every day as the doctor instructed. Instead, she drinks green tea with sugar and lemon on a daily basis, which she learned from her mother and friends is a treatment for hypertension. In Russia, the doctors never explained hypertension and at Family Medicine she didn’t get any information about the disease either. Dina works in the hospital cafeteria as a salad maker and stands on her feet all day. Otherwise, she gets no exercise and does not understand the role of diet and exercise in hypertension. She eats a fairly high fat and high salt diet.


LEARNER OBJECTIVES

  1. Work with an interpreter
  2. Use the LEARN model and Kleinman’s explanatory model to discover that the patient is non-adherent to medication use because she lacks understanding of what hypertension is and how it is treated; and
  3. Recommend and negotiate treatment to include daily medication, diet and exercise

Your challenge as the Simulated Patient is:

  1. Appropriately and accurately reveal the facts about Dina Sokolova’s medication usage and limited understanding of hypertension
  2. Observe the resident’s behavior while performing the role; and
  3. Accurately recall the resident’s behavior and complete the performance checklist


PRESENTATION/EMOTIONAL TONE:

You are friendly and happy to be seeing the doctor. You answer questions freely and without embarrassment, but don’t ask too many questions yourself.

Beginning of the Encounter:

You are respectful of the physician and friendly. When asked “What you are here for today?” you say:

“For blood pressure.” “I have also been having some headaches, once or twice a week, mostly when I feel a little stressed or tired.”

Throughout the Encounter:

You are mainly going to be answering the questions posed by the doctor. However, with the right questions, you will reveal that you are having your blood pressure taken by your husband when you have a headache, and if your pressure is high, that is when you take one or both medications. You think it is the “water pill” (the first medication prescribed) but are not sure, and you did not bring your medications in with you today. You do not generally take your medications every day, and are not sure why you would need to. No one has ever explained what hypertension is and why it needs to be treated, especially when you are feeling fine most days. The doctor mentioned diet and exercise a couple of times, but never explained what kind of diet and exercise or how often, so you didn’t know what to do.


PAST MEDICAL HISTORY:

No allergies
Medications as above
You are in good health except as above
Two normal deliveries, no other hospitalizations


SOCIAL HISTORY:

You have two children, ages 30 and 28, who are married and living in Charlottesville in their own homes with their families. You have been married for 32 years and your husband works as a painter. You have a 12th grade education and can read and write in Russian. You can only speak a few words of English, and are finding it difficult to learn English.


SUBSTANCE USE:
You do not smoke, drink or use illicit drugs.

 

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Open Resident Instructions
(Dina Sokolova)

CLINICAL PERFORMANCE EXAMINATION (CPX)

Resident Instructions^

Dina Sokolova^


Station Length:         
15 minutes maximum

Patient Name:            Dina Sokolova

Reason for Visit:

The patient, Mrs. Dina Sokolova, has presented to the clinic and has been taken to a patient room by the nurse. Vital signs have been documented by the nurse in the chart.

A Russian interpreter has been summoned to assist and is already in the room.

Resident Instructions:

You are seeing continuity patients in the Family Medicine Clinic. Your first patient is a native Russian speaker with limited English proficiency. You have not met her before, but a quick review of the record shows that you are seeing her today for follow-up of hypertension, which was diagnosed in Russia in 2005. She was started on Metoprolol at her last visit 2 months ago because her pressure was not controlled just on HCTZ. She has also complained of headaches in the past.

Conduct your interview as per usual, keeping in mind the possible cultural aspects of her condition and the cultural tools and interpreter skills you learned in your preparatory sessions.

Vital signs: BP 160/100 by nurse and repeated by you, same. Other vital signs WNL.

 

NO FURTHER PHYSICAL EXAM IS NECESSARY


After leaving the room, complete the checklist on the computer.

 


PLEASE DO NOT WRITE ON THIS PAGE

 

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Open Resident Instructions
(Pavel Sokolov)

Pavel Sokolov^


Station Length:         
15 minutes maximum

Patient Name:            Pavel Sokolov

Reason for Visit:

The patient, Mr. Pavel Sokolov, has presented to the clinic and has been taken to a patient room by the nurse. Vital signs have been documented by the nurse in the chart.

A Russian interpreter has been summoned to assist and is already in the room.

Resident Instructions:

You are seeing continuity patients in the Family Medicine Clinic. Your first patient is a native Russian speaker with limited English proficiency. You have not met him before, but a quick review of the record shows that you are seeing him today for follow-up of hypertension, which was diagnosed in Russia in 2005. He was started on Metoprolol at his last visit 2 months ago because his pressure was not controlled just on HCTZ. He has also complained of headaches in the past.

Conduct your interview as per usual, keeping in mind the possible cultural aspects of his condition and the cultural tools and interpreter skills you learned in your preparatory sessions.

Vital signs: BP 160/100 by nurse and repeated by you, same. Other vital signs WNL.

 

NO FURTHER PHYSICAL EXAM IS NECESSARY

 

After leaving the room, complete the checklist on the computer.

 

 

PLEASE DO NOT WRITE ON THIS PAGE

 

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Open Patient Chart
(Dina Sokolova)

Patient Charts ^

Dina Sokolova^

 

Temp    37                        BP       160/100         HR      80                  

Patient Name    Dina  Sokolova            Patient Age     52     

History Number  022557                            Chart Number             086254       

RR       12                    HT                               WT                           

Complaint:      follow up for hypertension                                                              

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

Reviewed w/attending

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Open Patient Chart
(Pavel Sokolov)

Pavel Sokolov^

 

Temp    37                        BP       160/100         HR      80                  

Patient Name   Pavel  Sokolov               Patient Age     52     

History Number  022557                            Chart Number             086254       

RR       12                    HT                               WT                           

Complaint:      follow up for hypertension                                                              

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

Reviewed w/attending

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Open SP Checklist

Russian Patient Dina Sokolova (Pavel Sokolov) 52 y.o.

Standardized Patient Checklist^

Language and Cultural Literacy

 

Your Name ______________________ Resident Name _____________________


Part 1: Skills in working with the interpreter and a limited English proficient patient

  1. The resident introduced himself/herself to me and the interpreter (interpreter is already in the exam room).

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident introduced self to patient AND interpreter.

DONE INCORRECTLY: The resident failed to introduce self to patient OR interpreter.

NOT DONE: The resident failed to introduce self to patient AND interpreter.

  1.  The resident defined the role of the interpreter.

DONE             NOT DONE

DONE: The resident told me that the interpreter would repeat everything I said.

          NOT DONE: The resident does not define the role of the interpreter.

  1.  The resident reassured me that information shared is confidential.

DONE             NOT DONE

DONE: The resident used language to assure me that the conversation is confidential.

NOT DONE: The resident did not use any language to assure me about confidentiality.

  1. The resident positioned the interpreter next to me (interpreter can be slightly behind).

 DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident placed the interpreter immediately next to me or slightly behind.

DONE INCORRECTLY: The resident placed the interpreter between him/herself and me, resulting in an open angle triangle that required me to look away from the learner.

NOT DONE: The resident failed to direct the interpreter in any way with regard to position within the room.

  1. The resident spoke in short phrases/1-2 short sentences, allowing interpreter time to interpret.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident spoke in short phrases/1-2 short sentences AND allowed time to interpret.

DONE INCORRECTLY: The resident used lengthy phrases/sentences OR did not pause long enough to allow for interpretation.

NOT DONE: The resident repeatedly interrupted the interpreter OR spoke at the same time as the interpreter.

  1.  The resident maintained eye contact with me.

 DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident maintained adequate eye contact to convey interest throughout the visit.

DONE INCORRECTLY: The resident only made occasional eye contact.

NOT DONE: The resident did not make eye contact with me, e.g. only looked at notes.

  1. The resident spoke to me in a normal tone of voice.

DONE             NOT DONE

DONE:  The resident spoke in a conversational volume and speed.

NOT DONE: The resident spoke loudly OR excessively slowly OR excessively fast.

  1.  The resident spoke directly to me (not to the interpreter) for most of the interview.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident spoke to me >75% of the interview.

DONE INCORRECTLY: The resident spoke to me 25-75% of the interview.

NOT DONE: The resident directed <25% of the interview to me.

Part 2: Skills in using the LEARN model and eliciting the patient’s explanatory model/health beliefs

  1. The resident elicited my understanding of what hypertension is and what causes it (my understanding is incorrect and knowledge of the condition is limited).

DONE             NOT DONE

DONE:  The resident asked questions about my understanding of hypertension and its causes.

NOT DONE: The resident ONLY discussed hypertension based on his/her frame of reference.

  1. The resident elicited my medication adherence history and the reasons why I am not taking medications properly.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident asked if and how I am taking medications and why I am not taking them properly. The resident may have used direct or indirect questions to elicit this information.

DONE INCORRECTLY: The resident inquired about medication adherence but did NOT use any language to inquire about why this is happening, i.e., my perspective.

NOT DONE: The resident did not inquire about medication usage.

  1.  The resident elicited my use of green tea as a home remedy for hypertension.

DONE      NOT DONE     UNSURE

DONE: The resident asked what I think is the best treatment for hypertension or if I am using any home/traditional remedies.

NOT DONE: The resident did not inquire regarding non-prescription remedies.

UNSURE

  1. The resident acknowledged that he/she and I have different views about hypertension and tried to find common ground.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident explained what hypertension is, why it is necessary to treat even if I feel fine, i.e., not having a headache, while ALSO acknowledging that my belief is common and understandable.

DONE INCORRECTLY: The resident explained about hypertension but did NOT acknowledge my belief system.

NOT DONE: The resident did not discuss hypertension AND did not acknowledge my belief system.

  1. The resident negotiated agreement on treatment, taking into account my wishes and perceptions.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident acknowledged that my use of green tea is fine, while getting my agreement to take medication daily; the resident may have decided to request that I use only one medication since I am reluctant to use too much and was not taking it properly before.

DONE INCORRECTLY: The resident identified a treatment plan, but did not negotiate the plan with me.

NOT DONE: The resident did not identify a treatment plan.

  1. As a patient, I would want to continue seeing this resident for my future care.

STRONGLY AGREE         NEUTRAL         DISAGREE         STRONGLY DISAGREE

  1. Comments (if needed):