Appendix 2. Clinical Case Scenario for Resident Interaction
The specific details from the bad outcome workshop will be used for illustration. For the standardized patient interactions, the standardized patients were given guidance on their clinical scenario and how they may react to certain resident statements, but they were not provided a script. The residents were given some initial information about the patient and the interaction that was about to take place in appropriate amount and detail to simulate a clinical situation. For one bad outcome standardized patient scenario, the following information was given to the standardized patient and the resident.
Instructions for the Resident
Patient Information:
Sallie Refsun
Age 56
Your Role: Neurosurgeon who performed craniotomy yesterday for resection
of small occipital tumor.
Situation:
Sallie Refsun is a 56-year-old woman who presented in the emergency room
three days ago with complaints of visual scotomas in the left visual field
and headaches. A one centimeter enhancing tumor was found in her right occipital
lobe. She was reluctant to have surgery on her brain and wanted to leave the
hospital, but after a long discussion, she agreed to stay and have the tumor
resected. During surgery, you used the frameless stereotactic system to identify
the location of the tumor. You saw some abnormal tissue in the brain, so you
sent some to pathology and removed the rest. The pathologist said that it may
be diagnostic tissue. Postoperatively she was difficult to extubate and she
has unpleasant memories of struggling to breathe with the endotracheal tube
in place when she first emerged from anesthesia. Now on postoperative day one,
the repeat MRI shows that the entire tumor remains and that you were close
but missed the tumor. The pathologist says that the tissue is nondiagnostic
on permanent sections.
Your Task: Explain the mistake.
Standardized Patient Instructions
Sallie Refsun
The Scenario:
You are a 56-year-old woman who underwent brain surgery yesterday on the
back, right side of your head for removal of a tumor. When you woke up in the
recovery room, you were still intubated and this was a very unpleasant experience
for you that made you feel as though you could not breathe. You have now been
extubated and are awaiting transfer out of the ICU and news about what the
tumor is and what the repeat postoperative MRI shows.
Patient History: Type 2 diabetes, for which you take glyburide
5 mg twice daily, Hypertension for which you take lisinopril 10 mg daily, hypercholesterolemia
for which you take pravastatin 40 mg daily.
Family History: Mother, died at age 72 from complications
after toe amputation surgery, had Type 2 diabetes, father died at age 76 of
a cerebrovascular aneurysm, one sister has Type 2 diabetes, and two brothers
are healthy.
Social History: You work as an executive assistant in a
private law firm, you are married, and your husband is a retired contractor.
You have four children who are grown and all married. You live in a house in
a middle class neighborhood with your husband and two cats. You and your husband
do not smoke and only drink at family occasions two-to-three times a year.
The Medical Encounter
Sallie Refsun
Opening statement: What did the MRI from last night show? (Worried,
irritable, uncomfortable)
You are concerned because you did not want this surgery to begin with and you had a very bad experience waking up intubated. You do not want to have another surgery.
When told that the tumor is still in and/or there is no diagnosis of the type of tumor, say “You are kidding! You have to be kidding! I can’t go through that again!” (Shock, then moderate anger.)
If your doctor does not tell you that the entire tumor is still there, ask “How much of the tumor did you get?”
If your doctor does not tell you that the surgery resulted in no diagnosis, ask “Did you find out what kind of tumor it is?”
If told that the computer guidance system was off or that the pathologist gave the wrong diagnosis during surgery, say “Couldn’t you see the tumor during surgery? If you didn’t take out tumor, what did you take out?”
When your doctor tells you he/she made a mistake say, “I can see that,” but begin to sound forgiving. If he doesn’t admit he made a mistake, say, “Who is to blame for this?” and continue angrily.
Flow
Emotional modulation: Moderate 5 – 6/10 (0 = flat, 2 – 3 = normal;
10 = intense): you are upset, moderately angry, but willing to forgive and
move on if the doctor communicates well.
1. Start out worried, irritable, in some distress from waking up intubated.
2. After hearing the error—shock (wide-eyed stare, confused expression,
furrowed brow), then moderate anger.
3. If the doctor admits error—begin to sound forgiving.
4. If the doctor fails to admit error—sound upset (5/10)
5. If the doctor apologizes—your tone becomes less angry, more forgiving.
6. If no apology—act reserved, speak tersely and avoid eye contact.
The standardized patient is trained to objectively evaluate the resident’s interaction and is given specific instructions on how to rate the resident statements based on the principles of the workshop. These workshop principles and the following rating scale are based upon current studies concerning effective patient communication (Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP: To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 12: 770 – 775, 1997, and ACP Ethics Manual, Ann Int Med 117[11], 1992). Following is the rating sheet used by the standardized patient in this scenario:
Guide to the Checklist with Verbal Responses:
Emotion Scale 0 = flat; 10 = intense; 2 – 3 = normal
Opening statement: What did the MRI from last night show? (Worried, irritable, uncomfortable)
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Content specific |
0-10 |
Emotional/Verbal Response |
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1c. If the doctor states clearly that he/she made a mistake. |
6
3-4 |
When you first hear of the mistake you are upset, moderately angry. You react with shock (wide-eyed stare, confused expression, furrowed brow). If the doctor admits the mistake, say: I can see that (with mild irritation); begin to sound forgiving. (Give a 0 if doctor doesn’t clearly take ownership of the mistake—e.g. “I made a mistake” gets credit, but 0 for “we made a mistake” or “a mistake was made.”) |
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2c. The doctor explained the events surrounding the mistake. |
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3c. If the doctor apologizes for the mistake. |
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Say: I guess anyone could make a mistake…(in a forgiving tone) If no apology, act reserved, speak tersely and avoid eye contact. End with, “I need some time to think about this.” |
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4c. The doctor provided information on corrective action to be taken (must address system change to receive credit: e.g. we need to not rely on the computer guidance system so much during surgery but rather use more traditional anatomical landmarks as well; or, I will talk about this with the pathologist so we can come up with a policy to prevent this from happening again…)
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Give a 0 if doctor doesn’t address system change—e.g. “I will be more careful next time.” |
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5c. The doctor proposed some compensation for me. |
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Examples: Did you have a co-pay? Let me see if I can get it waived. Let me see if I can get you medications at no cost. Let me give you my cell phone number in case you have other questions… |
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GENERAL: ANY TIME DURING THE INTERVIEW |
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1. The doctor used affirmations (“positive speak” about specific behaviors, such as I’m impressed with…, that’s a good point… you are very courageous…) Satisfaction index: Should make you feel good about yourself for the choices you made, the actions you took, or your thoughts and comments. |
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2. The doctor used partnership statements (let’s work together on this…) Satisfaction index: should make you feel like you and your doctor are a team |
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3. The doctor explored my feelings (how do you feel about this…) Satisfaction index: Should feel like you have been able to fully share your feelings, no matter how silly. |
6 |
Say: I just can’t believe this; I’m so upset! I really can’t take another surgery!
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4. When I expressed feelings, the doctor normalized and/or “reflected” (acknowledged) my feelings (Anyone would feel that way…; sounds like you’ve had a rough time) or used another method to validate my feelings (really? Wow!) Satisfaction index: should make you feel like your feelings have been understood and appreciated. |
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UNDERSTANDING THE PROBLEM |
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5. The doctor asked about my perspective/perception/explanation about the problem (what are your thoughts/concerns about what is going on?/about what I just told you?/before I came in to see you?). Satisfaction index: Should feel like you have been given the chance to fully share what you have been thinking before you came to see the doctor, no matter how silly. |
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Say: “After all I went through; I thought that the tumor would be gone. Waking up with that tube down my throat was horrible!
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6. When providing information, the doctor put it in language I understood, offered it in small chunks, and checked along the way—“any questions?”—“does this make sense?”)—must do all three to receive any credit. Satisfaction index: Should feel like you have been able to have a dialogue, not like you were lectured; doctor should use your responses as a guide as to how to proceed. |
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7. The doctor asked me for my understanding of what we talked about (e.g., what is your understanding of what we just talked about? Or, If you had to present what we just talked about to someone close to you, what would you say?) Satisfaction index: Should allow you to summarize your understanding fully, no matter how silly. Should clarify any misunderstandings in a friendly, non-condescending way |
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AGREEING ON A PLAN |
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8. In talking about a plan, the doctor acknowledges concerns, ideas, or expectations you previously mentioned. (I know you have had a terrible experience with surgery in the past, but…) Satisfaction index: Should hear some of your own words repeated in a sympathetic way; should feel the doctor incorporates what she knows about you in talking about a plan. |
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9. The doctor explored my reactions and concerns about the plan (will this work for you? Do you see any obstacles?) Satisfaction index: Should feel like you have been able to fully share your thoughts, no matter how silly. |
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10. The doctor explained access—how I could reach him or another doctor if I needed help or had further questions. Satisfaction index: Should make you feel confident that you can reach a doctor quickly and easily if you become worried. |
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STANDARDIZED PATIENT CHECKLIST
Sallie Refsun
Opening statement: What did the MRI from last night show?
(Worried, irritable, uncomfortable)
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NOT DONE
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DONE How SATISFIED WERE YOU PERSONALLY with how the doctor performed the item |
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Content Checklist—Case Specific |
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Very Dissatisfied |
Dissatisfied |
Neither Satisfied nor Dissatisfied |
Satisfied |
Very Satisfied |
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1c. The doctor stated clearly that he/she made a mistake. |
0 |
1 |
2 |
3 |
4 |
5 |
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2c. The doctor explained the events surrounding the mistake. |
0 |
1 |
2 |
3 |
4 |
5 |
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3c. The doctor apologized for the mistake. |
0 |
1 |
2 |
3 |
4 |
5 |
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4c. The doctor provided information on corrective action to be taken (I now would like to do another surgery to remove the tumor…or, I have instituted a double check system so this kind of mistake will not happen again.)
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0 |
1 |
2 |
3 |
4 |
5 |
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5c. The doctor proposed some compensation for me. Examples: Did you have a co-pay? Let me see if I can get it waived. Let me see if I can get you the Decadron at no cost |
0 |
1 |
2 |
3 |
4 |
5 |
Checklist References
General: counseling, negotiation, relationship development, and organization/time management, and global checklists
Content specific: (Based on literature from primary source Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP: To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 12: 770 – 775, 1997, and ACP Ethics Manual, Ann Int Med 117[11], 1992)
- State clearly that you made a mistake.
- Explain the mistake in terms the patient can understand (covered in the standard checklist).
- Explain the events surrounding the mistake, including decisions the patient was involved in
- Express personal regret and apologize for mistake.
- Show sensitivity towards possible patient/spouse anger, frustration (covered in the standard checklist).
- Provide information on corrective action to be taken.
- Assess patient’s understanding of the situation (covered in the standard checklist).
After the residents had their initial standardized patient interaction, they reconvened in a conference room for the DVD presentation. The DVD was divided into several segments, including an introduction the illustrative patient, suggestions for communication skills in the given topic area, an example of an ineffective patient interaction, and an example of an effective patient interaction. For the bad result workshop, the following suggestions were given.
Principles of communicating about a medical error:
- Admit – state clearly that you made a mistake.
- Explain – the events surrounding the mistake.
- Apologize – express personal regret for the mistake.
- Correct – provide corrective action to be taken.
- Compensate – provide some form of compensation.