AIM

This poster describes the use of Standardized Patient encounters to augment a Resident Family Medicine training program addressing Mental Health, Cultural Competence and End-of-Life Palliative Care.

Palliative end-of-life Cases-- Case 1 – Truth Telling in a Terminal

Diagnosis –

You are the attending physician for Lloyd Jones, a 65 year old man whose needle biopsy today revealed inoperable cancer. Your resident has already spoken to the daughter, Gwen Jones, and told her of her father’s poor prognosis with and without treatment. Ms. Jones has requested to see you ASAP, and you’ve heard that she is insisting that no one tell her father about his diagnosis. You are about to see her in a small hospital conference room to address her concerns.

Learner Task: The learner is expected to discuss with the family the concepts of truth telling and address family fears and concerns regarding the right to know.

-- Case 2 – Challenging Request in a Terminal Diagnosis –

You are a family physician about to see your patient of 5 years, Mr. Carl Wagner. You last saw him 6 months ago when he came in complaining of a chronic cough. A chest x-ray revealed a large apical tumor, which turned out to be squamous cell lung cancer. The tumor is not respectable, and he has exhausted all treatment options. He has been referred back by his oncologist for treatment to keep him comfortable. He told the nurse he has increasing pain, which is keeping him up at night. He asks you for a three-month prescription of pain medication.

Learner Task: The learner is expected to address the patient’s fears at end of life which include being a burden to his family, remaining autonomous, and issues of dignity. Learner is expected to introduce and explain the role of hospice and arrive at an understanding that his fears and needs would be attended to while addressing his request for euthanasia.

Case 3 – Congestive Heart Failure --

Mr. Shorter, a patient of yours for many years, is suffering from end-stage Congestive Heart Failure, secondary to long-standing ischemic cardiomyopathy. Severe life threatening thrombocytopenia from Heparin has impacted negatively on any other surgical interventions. He suddenly acutely worsened 8 weeks ago. He is in his 5th hospitalization in the past 2 months.

Learner Task: The learner is expected to present bad news in an empathic manner, recommend hospice level care as a positive next step, and to assure the patient of non-abandonment and total dedication to his needs as he approaches his end of life.

Cultural Competence Cases-- Case 1 – Productive Cough --

Patient is a 16 year old Cambodian male who is new to your office. He presents with five days of fever, chills, dizziness, fatigue and productive cough. The patient is a first-generation citizen in this country, who lives with his mother, father, and two brothers. He attends a local high school.

Learner Task: Examination of patient reveals petechiae and ecchymosis on posterior chest consistent with the traditional practice of cao gio (coining), but which might be confused with remnants of abusive treatment to the uninformed observer. Learner is expected to identify cultural practices and incorporate them into treatment plan.

Case 2 – Fatigue and Dysmenorrhea –

You are seeing the patients of a colleague away on a family emergency including a follow-up visit with this 40 year old patient, a Jehovah's Witness, who is here today to review her blood work and pelvic ultrasound that a GYN doctor had ordered. A copy of these test, as well as the GYN opinion has been sent to you. The patient is looking for your input. Recently ordered blood work reveals anemia. A recently ordered pelvic ultrasound reveals uterine fibroids.

Learner Task: Patient is looking to the learner for input given the conflict between her medical needs, the strong recommendation of her GYN and her religious practices. Learner is expected to identify religious practices and beliefs and incorporate available alternative therapies into the care of this patient.

-- Case 3 – Caretaker Malaise --

You are the primary care physician for your patient, Gracia Morales, a 50 year old Hispanic patient in your care for over 10 years. Your patient’s husband, also a patient of yours, was diagnosed two years ago with colon cancer. Three weeks ago, after not seeing Ms. Morales for a while, you saw her for various non-specific complaints – aches, pains, fatigue, insomnia – as well as gastrointestinal distress (diarrhea, cramping). Your physical exam at the time, and the tests you subsequently ordered, revealed no physiological explanation for the complaints. Ms. Morales is back for a follow-up visit to discuss your findings and receive your counsel.

Learner Task: Upon questioning it is revealed that Ms. Morales is caring for her terminally-ill husband and she is very depressed. The learner is expected to identify cultural variations of disease presentation such as depression.

Mental Health Cases-- Case 1 – Forgetfulness -- 

The patient is a former patient of your practice. Three years ago she moved to a retirement community with her husband and switched providers because of travel distance. You had heard through the community that the patient’s husband had died about 1 ½ years ago. Your last contact with her was when you sent a condolence card. As a favor to the patient’s very concerned daughter, Joan, also a patient of yours, you have agreed to see her. The chart is in storage and could not be retrieved for this visit.

Learner Task: After performing a complete history, Mental Status Exam, Mini Mental Exam, and physical, the learner is expected to diagnosis and discuss various causes of memory loss including dementia and major depression.

-- Case 2 – Headache --

You are a physician working in primary care. The daughter of one of your patients comes to be seen to have her headaches evaluated. The patient is new to you. There is no prior relationship and no prior chart.

Learner Task: Diagnose one of the most common mental illnesses seen in primary care, anxiety disorder. Recognize how anxiety disorders are often seen in combination with other disorders especially mood disorders.

-- Case 3 – Restlessness –

You are a physician working in a primary care office in a community with psychiatrists scattered few and far between. One of your patients seeks you out to provide care for her mentally ill son, who seems to be having an exacerbation of his primary recurrent symptoms. The patient is new to you, however, his mother, Mary Russell, has been a patient of yours for several years. The patient has recently been discharged from the area Hospital for the Mentally Ill and you were soon to become his primary care provider. However, the appointment has been moved up because of escalating symptoms that are worrisome to the mother and very disturbing to the son (the patient). The patient’s medical records have not yet been received from his hospitalization.

Learner Task: Perform a complete history, physical, and mental status examination on this patient who presents with anxiety, depression, and restlessness. The learner is expected to arrive at a diagnosis of Schizophrenia (Axis I) and Akathisia (Axis III) and discuss an appropriate treatment plan.

Simulation Exercises to augment new Residency Training Program in Family MedicineSimulation Exercises to augment new Residency Training Program in Family MedicineAF Clowers, DO, MG Herring, MD, FJ Humphrey, DO, LB Weiss, MS, SC Bennett, MPH RD, FA Filipetto DO

School of Osteopathic Medicine, Department of Family Medicine , University of Medicine and Dentistry of New JerseySchool of Osteopathic Medicine, Department of Family Medicine , University of Medicine and Dentistry of New Jersey

MENTAL H

EALTH

CULTURAL

COMPETENCE

PALLIATIVE

CARE

Simulation exercises with formative feedback and evaluation can be very effective for residents to improve and refine their interpersonal and communication skills in managing palliative, mental health and culturally sensitive patient needs. Residents’ performance improved as a result of the 2 formative standardized cases where residents are evaluated and given feedback regarding the competencies identified. The summative case had the highest scores in competency achievement in the areas of mental health and palliative care.

% Competencies

Case Achieved

Mental Health (OGMI)

{{ Headache 62%

{{ Forgetfulness 82%

{{ Restlessness 83%

Cultural Competence (OGMII)

{{ Productive Cough 50%

{{ Fatigue& Dysmenorrhea 93%

{{ Caretaker Malaise Analysis to be completed

 

Palliative Care (OGMIII)

{{ Challenging Request 82%

{{ Truth Telling 85%

{{ Heart Failure 94%

Nine, 30-minute, Standardized Patient (SP) scenarios were developed as part of the integration of new curricula for Family Medicine residents focusing on mental health, cultural competence and palliative end-of-life care. Residents received Web-CT instruction in these areas correlating with both formative and summative SP cases. Checklists identifying 25 competencies were developed focusing on history and diagnostic acumen, psychosocial and cultural issues, community resources and interdisciplinary care, as well as treatment and case management.

DISCUSSIONRESULTS

Formative Formative CaseCase

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Summative Summative CaseCase

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METHOD