Standardized Patient Materials

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Open SP Training
Materials

Mr./Mrs. Mendoza

SP Training Materials^

 

Case Focus:  Discussing a Cancer Diagnosis with a Latino Patient who does not want to know the diagnosis.

Presenting Complaint:  Patient is coming in for follow-up visit to Family Medicine Clinic for results of colonoscopy.


CASE SUMMARY:

Mr/s. Mendoza is a middle-aged (can be older if available standardized patients are older) man or woman who is of Mexican origin. S/he speaks English adequately for communication, but prefers to speak Spanish at home and with friends.

Mr/s. Mendoza recently saw you for complaints of fatigue and mild RLQ abdominal pain. S/he also complained of occasional dark stools. At that time, physical examination was remarkable only for positive guaiac stool on rectal exam. The remainder of his/her exam had been negative except for a 5 pound weight loss from a prior visit 5 months earlier. You had ordered some labs and found that his/her CBC showed a microcytic anemia. His/her comprehensive metabolic panel was all within normal limits.

You requested a colonoscopy and the patient is returning to discuss the results of this. Unfortunately, a mass in the cecum was identified on colonoscopy, which pathology revealed to be adenocarcinoma.

At the patient’s last visit, he/she was accompanied by his/her son, Luis. Luis had pulled you aside for a moment while his father/mother went to check out to tell you that his father/mother should not be told any bad news, especially if there is something serious like cancer. He explained that the family wants to protect his father/mother from the shock of any bad news and not make him/her sicker by making him/her afraid.

Mr/s. Mendoza lives with his/her son, daughter-in-law and grandchildren. His wife/her husband died 3 years ago


LEARNER OBJECTIVES:
 

  1. Discuss with a patient his/her wishes regarding disclosure of a cancer diagnosis (a potentially terminal illness)
  2. Use the patient’s and family’s wishes to guide the physician’s approach to disclosure of diagnosis, recommendations for additional testing and treatment possibilities.

Your challenge as the Simulated Patient is threefold:

  1. Describe Mr/s. Mendoza’s wishes regarding learning his/her diagnosis and how much s/he wishes to know
  2. Observe the physician’s approach to asking the patient about his/her wishes and to future testing and treatment options while performing the role; and
  3. Accurately recall the physician’s behavior and complete the performance checklist


PRESENTATION/EMOTIONAL TONE:

A little reserved and anxious about learning the results

Throughout the Encounter

You are mainly going to be answering the questions posed by the doctor. You are respectful of authority and are also not used to asking too many questions yourself. You trust the doctor to do the right thing for you and are optimistic that everything will be fine.

Basically, you do not want to hear bad news, namely that you have cancer. You are willing to do what the doctor recommends regarding additional testing and treatment. You want your son involved in decision making too.


PAST MEDICAL HISTORY:

No allergies, No medications. You are in good health except for the above problems. Your only surgery was an appendectomy as a child in Mexico.


SOCIAL HISTORY:

You were born in Mexico and came to the U.S. at 19 years of age with your husband/wife. You lived in Florida. You worked in construction/housekeeping all your life and moved to Charlottesville 3 years ago to be closer to your son, Luis, after your husband/wife died. You retired when you came to Charlottesville. You have two children, ages 35 (Luis) and 32 (Anna). Anna lives in Washington, DC. You have an 8th grade education and can read and write in Spanish. You speak English conversationally and can read and write a little. You are an observant Catholic and go to church regularly. You have started to make some friends through the church.


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

 

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Open Resident
Instructions

CLINICAL PERFORMANCE EXAMINATION (CPX)

Resident Instructions^

 

Station Length:          15 minutes maximum

Patient Name:            Mendoza


Resident Instructions:

The patient is here for follow-up to discuss results of his/her recent colonoscopy.


HPI:

Mr/s. Mendoza has been your patient since internship year. S/he doesn’t come in too often as s/he has been very healthy and has no chronic medical problems. A month ago, Mr/s. Mendoza came to see you for complaints of fatigue and mild RLQ abdominal pain. S/he also complained of occasional dark stools. At that time, physical examination was remarkable only for positive guaiac stool on rectal exam. The remainder of his/her exam was been negative except for a 5 pound weight loss from a prior visit 5 months earlier. You had ordered some labs and found that his/her CBC showed a microcytic anemia. His/her comprehensive metabolic panel was all within normal limits.

You requested a colonoscopy and the patient is returning to discuss the results of this. Unfortunately, a mass in the cecum was identified on colonoscopy, which pathology revealed to be adenocarcinoma.   You want to refer the patient to a surgeon and obtain additional x-rays.

At the patient’s last visit, s/he was accompanied by his/her son, Luis. Luis had pulled you aside for a moment while his father/mother went to check out to tell you that his father/mother should not be told any bad news, especially if there is something serious like cancer. He explained that the family wants to protect his father/mother from the shock of any bad news and not make him/her sicker by making him/her afraid.


SOCIAL HISTORY:

Mr/s. Mendoza was born in Mexico and came to the U.S. at 19 years of age with her husband/his wife. S/he is a naturalized US citizen. They lived in Florida. S/he moved to Charlottesville 3 years ago to be closer to his/her son Luis after her husband/his wife died. S/he retired from construction/housekeeping in a public school system when s/he came to Charlottesville. S/he has two children, ages 35 (Luis) and 32 (Anna). Anna lives in Washington, DC. Mr/s. Mendoza has an 8th grade education and can read and write in Spanish. S/he speaks English conversationally and can read and write a little. Mr/s. Mendoza is an observant Catholic and goes to church regularly. S/he has started to make some friends through the church.


INTERVIEW INSTRUCTIONS:

Conduct your interview as per usual, keeping in mind the cultural aspects of disclosing this cancer diagnosis and future steps, taking into account his/ her son’s wishes and the approaches you learned in your preparatory session. After determining the patient’s wishes, you will discuss additional imaging and blood testing and referral to the surgeon.


PHYSICAL EXAM:

Vital signs: BP 120/80, Pulse 84. Resp. 14, Temp 37.2, Weight 75 kg (same as last visit)

 

No additional physical examination is needed today, as the visit is for discussing results and next steps.

 

Once you have obtained a focused history and discussed recommendations with the patient, you are to leave the room and complete a checklist on the computer.

 

 

PLEASE DO NOT WRITE ON THIS PAGE

 

 

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Open Patient
Chart

Patient Chart^

 

 

Temp      37.2                   BP       120/80                    HR      84                 

Patient Name    Mendoza                               Patient Age                           

History Number  022557                            Chart Number             086254       

RR       14                    HT                               WT      75 Kg           

Complaint:                Follow-up to discuss results of the recent colonoscopy

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

Reviewed w/attending     

 

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Open SP
Checklist

Mr/s. Mendoza

Standardized Patient Checklist^


Discussing a Cancer Diagnosis with a Patient Who Does Not Want to Know the Diagnosis

 

Your Name ______________________ Resident Name _____________________

 

  1. Mr/s. Mendoza was satisfied with this resident encounter.                      YES        NO
  1. The resident appropriately greeted me and asked me how I have been feeling since my last visit.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:    The resident appropriately greeted AND asked me how I have been feeling/doing since my last visit

DONE INCORRECTLY:   The resident appropriately greeted OR asked how I have been feeling since my last visit.

NOT DONE:    The resident did not ask either.

  1. The resident asked me my preferences as to how much I wanted to know about my diagnosis.

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:     The resident asked me what I would like to be told about my diagnosis.

NOT DONE:     The resident did not ask my preferences.

  1. The resident asked me if I would like the resident to talk with my son or other family members about the diagnosis and treatment options.

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:    The resident asked if I would like the resident to talk with my son or family members about diagnosis and treatment options.

NOT DONE:    The resident did not ask about this.

  1. The resident respected my preferences in discussing the results of the colonoscopy (i.e., did not tell me that I had “cancer” but used other words).

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:    The resident discussed the results of the colonoscopy, but did not use the word “cancer.” Instead, the resident said that I had a “growth” or similar type word.

DONE INCORRECTLY:   The resident revealed the diagnosis of cancer.

NOT DONE:   The resident did not discuss the results of the colonoscopy.

  1. The resident explained the results in a way that I could understand.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:   The resident explained things in easy to understand language and terminology.

DONE INCORRECTLY:   The resident explained things using medical words that I did not understand.

NOT DONE:    The resident did not explain the results.

  1. The resident discussed next steps in a way that respected my wishes not to be told the diagnosis.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:    The resident discussed next steps—such as blood test, CT scan, and referral to the surgeon—without mentioning “cancer.”

DONE INCORRECTLY:   The discussed tests but revealed that I might have cancer.

NOT DONE:   The resident did not discuss next steps.

  1. As a patient, I would want to continue seeing this physician for my future care (circle one):
  1. Strongly agree
  2. Agree
  3. Neutral
  4. Disagree
  5. Strongly disagree
  1. Comments (if needed):