The Use of Standardized Patients to Evaluate Interpersonal and Communication Skills of Anesthesiology Residents: A Pilot Study

Abstract

Objective

The study was conducted to explore the feasibility and validity of using standardized patients (SPs) in assessing the interpersonal and communication skills (ICS) of anesthesiology residents.

Methods

A cross-sectional study was conducted to assess the ICS of anesthesiology residents using SPs. Each resident participated in two staged encounters and was graded by the SPs using a modified SEGUE framework. Each encounter was videotaped and reviewed independently by two senior faculty members using the same checklist.

Results

The ICS scores improved with advancement of training. This was confirmed by both SP and faculty (CA−1, 47.8 ± 9.8 and CA−3, 64.8 ± 1.9, P=0.022) assessments. There was strong inter-faculty agreement for individual residents (r=0.95, P<0.001). In-training exam (ITE) scores appeared to correlate with the faculty ICS score (r=0.61, p<0.05).

Conclusion

Standardized patient encounters using a modified SEGUE framework may be a useful tool to assess ICS among anesthesiology residents. Resident performance improves even in the absence of interventions to teach ICS. The improvement appears to correlate with increasing experience and knowledge.

Introduction

The Accreditation Council for Graduate Medical Education (ACGME), as part of its Outcomes Project, has established six core competencies. Residency programs are expected to develop tools to assess the progress of residents in each of these competencies. The assessments can be formative, providing feedback to residents during training, or summative, determining whether a resident has achieved the specific knowledge, skills and attitudes expected of a new practitioner.

One of these core competencies is interpersonal and communication skills (ICS). Anesthesiologists face communication challenges that are unique to the circumstances of anesthesia practice. ¹ The ACGME Toolbox suggests several methods for evaluating resident ICS. These include the Objective Structured Clinical Exam (OSCE) with standardized patients (SPs) and the 360~degree evaluation of which patient feedback may be the most important. ² Having actual patients assess the ICS in anesthesiology residents may be difficult. Typical physician-patient interactions in anesthesia are brief. Often the encounter fades into multiple other encounters the patient may have with other health care providers such as attending staff, other residents, medical students, and nursing providers. In addition patients are anxious prior to surgery. The large variability of this patient population makes standardization of ICS assessment using patient feedback nearly impossible and does not allow comparison of resident performances.

Various strategies have been utilized by different residency programs to teach and assess ICS. ³–⁵ A SP based encounter using a SEGUE framework appears to be a commonly employed evaluation tool.³ SEGUE is an acronym for Set the stage, Elicit information, Give information, Understand the patient’s perspective, End the encounter. It is a checklist of medical communication tasks designed to facilitate the teaching and assessment of these skills.

Acknowledging that patient encounters in anesthesiology may be different from those in other specialties, we conducted the following explorative study. Our goal was to investigate the feasibility of using SPs and to validate their use as an assessment tool for ICS amongst anesthesiology residents. We therefore assessed ICS through SPs in both junior and more senior trainees and compared SP assessments with faculty assessments of ICS.

Methods

Following Institutional Review Board approval, several standardized patients (SPs) were trained for use in the ICS assessment. Each SP was coached to respond with a chief complaint and a history of present illness. The SP was given specific instructions for answering questions during the review of systems establishing a past medical and surgical history. In addition, each SP was provided with a medication list and drug allergies as well as social, psychiatric and family histories. The actors were experienced veterans of prior communication skills assessments and were instructed in evaluating resident ICS using the SEGUE framework evaluation form. For each encounter the SP had three prompts/questions that had to be addressed during each interview. The SPs were instructed and coached to portray specific behaviors, affects, and mannerisms. Information from the SPs was divided into that which was to be given freely and information to be given only if asked. Full scripts illustrating SP training are provided in the appendix.

The two SPs used in this study each presented with specific needs. One SP was a female Jehovah Witness scheduled for a radical cystectomy, with a high probability of significant blood loss. The other SP was a reluctant elderly male scheduled for emergency abdominal aortic aneurysm surgery with a poor chance of survival and family members in attendance. The family members of the second SP were scripted to be distracters and as such did not evaluate the ICS of the residents. This was a cross-sectional study and at the time the study was conducted no specific teaching of ICS was being provided.

Residents were instructed to perform a pre-anesthesia evaluation of these SPs. Each SP provided a consistent time-limited (15-minute) encounter. The residents were evaluated by the SP following each encounter using an evaluation form (appendix 1) based on the SEGUE framework. ³ The checklist evaluation form used in this study was modified from the 25 basic communication tasks used by Makoul ³ to make it more relevant for a pre-anesthesia evaluation. The SP encounter evaluated the residents on a total of 17 different communication tasks. Residents were graded on a nominal (yes/no) scale receiving a score of 1 for successfully completing the task and 0 for failing to accomplish the task. The SP evaluated the quality of each resident interview on the above 17 point grading system. A summed score for each encounter was given for each SP interview. The residents participated in two separate SP encounters allowing a maximum score of 34. Each of the 17 communication tasks evaluated one of five different areas of the ICS assessment. Those areas and their corresponding tasks were as follows; opening the interview (1,2), listening skills (3,4,5,6), interview content (7,8,9,10), therapeutic core qualities (11,12,13,14), and closing the interview (15,16,17). The SPs were unaware of a resident’s level in training.

In addition, each SP-resident encounter was video taped for subsequent independent review by faculty members. Two senior faculty members participated in this portion of the ICS assessment. They reviewed the video tapes of both SP encounters for all residents involved in the study. The two faculty participants did not receive formal training on evaluating ICS except for an explanation of the communication skills assessment scoring system. The faculty were not blinded to resident year and their evaluations were conducted independently of each other. The two faculty members scored each encounter using the same 17 point checklist allowing a maximum score of 68 for each resident.

A total of 12 residents participated, 4 from each year of training. This group represented all residents in the program (14) who were available, excluding one each on vacation and on an off-site rotation. The ICS assessment was done in the last quarter of the resident training year, temporally close to the in-training exam (ITE), to allow ITE score correlation with the SP and faculty evaluations.

The ICS scores obtained by residents in each training year were compared with those obtained by residents in other training years using Kruskal-Wallis one way analysis of variance. This test was used to reflect the fact that our nominal data was not normally distributed. The strength of the association of each resident’s scores determined by the two faculty members and between the faculty and the SP was done using Pearson product moment correlation. The association between the ITE scores of the individual resident and their ICS scores determined by the SP or the faculty was also done using the Pearson product moment correlation. A P value <0.05 was considered significant. Statistical tests were performed using SigmaStat v3.0 (SPSS Inc., Chicago, IL.).

Results

Non-parametric tests of the results were chosen (Kruskal-Wallis one way analysis) because of the small sample size of the study and the use of nominal data. The mean ICS scores determined by the SPs by resident training year are presented in Table 1. The scores increased with each passing year however this increase did not reach statistical significance (P=0.167). The mean faculty evaluation scores of resident performance also increased by CA year [Table 1]. The increase in ICS scores determined by the faculty was statistically significant when comparing the performance of CA−3 residents with CA−1 residents (P=0.022). The scoring by the SPs was consistently high, with tight standard deviations. The evaluations by the faculty showed much lower ratings of the CA−1 and CA−2 years with wider ranges; only for the CA−3 year did standard deviations markedly narrow and the overall scoring approached that of the SPs.

Inter-faculty correlation of ICS scores for each resident was strong (r=0.95, P<0.001) (Figure 1). Faculty and SP scores for each resident were also correlated (r=0.80, P<0.002) (Figure 2).

Figure 1.

Correlation of the ICS scores awarded by the two faculty members for each resident. There is a significant correlation between the two faculty members r=0.945, P<0.001.

Figure 2.

Correlation of the ICS scores awarded by the SPs with the faculty scores for each resident. There is a significant correlation between the scores awarded by the two SPs, r=0.803, P=0.002.

The ITE scores for individual residents appeared to correlate poorly with the ICS scores determined by the SPs (r=0.45, P=0.148) (Figure 3). The individual resident’s ITE scores appeared to correlate better with the ICS scores determined by the two faculty members (r=0.61, P<0.05) (Figure 4).

Figure 3.

Correlation of the individual resident’s ICS score (as awarded by the SP) with their ITE scores. There appears to be a weak correlation between these two variables r=0.45, P=0.148

Figure 4.

Correlation of the individual resident’s ICS score (as awarded by the two faculty members) with their ITE scores. There appears to be a significant positive correlation between these two variables r=0.61, P<0.05

In a detailed examination of the ICS scores, senior residents (CA−3) did better than their less experienced colleagues (CA−1) in each of the five assessment areas [Table 2, 3]. This was consistent in both SP and faculty evaluations. The exception was listening skills that appeared to be less well performed by the more experienced residents as seen by the SPs [Table 2]. However, this did not reach statistical significance. Although the “interview content” improved from CA−1 to the CA−3 years, residents appear to make the largest gains in the areas of “therapeutic core qualities” and “closing the interview” [Table 2, 3].

Discussion

Effective interpersonal and communication skills (ICS) are necessary in all specialties of medicine. Sound ICS lead to the effective exchange of information between the patient, his/her physician, colleagues, and other members of the health care team. Additionally, effective ICS has been shown to result in improved health care outcomes, increased patient satisfaction, and fewer malpractice suits. ⁴,⁵ It is only through good ICS that a physician can effectively demonstrate mastery of other competencies, such as medical knowledge, systems-based practice and professionalism. ²

In anesthesiology where the majority of physician time is spent with patients who are either sedated or anesthetized the need for ICS may not be as obvious. Anesthesiologists in the past have received lower patient satisfaction scores compared with other specialists. ⁶ As a group, anesthesiologists were unable to predict what patients most valued in their pre-operative care. ⁷ Specialty physicians as a whole were shown to have limited use of ICS, focusing rather on the biomedical aspects of disease. ⁸

Anesthesiologists usually meet their patients immediately before surgery and in a short period of time must assess a patient’s medical condition, formulate an anesthesia care plan, and establish rapport with the patient. However, despite its brevity, if effective ICS are utilized, this visit can yield positive results. A pre-anesthesia visit by an anesthesiologist without the use of premedication has been shown to be more effective in decreasing anxiety in patients than using premedication without the benefit of such a visit. ⁹

Emergency medicine may be the only other medical specialty where patient encounters are similar. They are often single encounters and the duration and quality of the encounter are influenced by time pressures. The emergency physician must achieve the same objectives as an anesthesiologist, i.e., assessment, treatment plan, rapport, trust, and communication with the patient, family and other health care providers. Excellent ICS have been determined to be a key component of a well-rounded emergency physician. ⁵

The Kalamazoo II report ¹⁰ examined ICS as an integrated competence with two distinct parts. Interpersonal skills which are considered relational and process oriented, i.e., the effect communication has on another person, and communication skills which are the performance of specific tasks and behaviors. The two skill sets are inherently related. Interpersonal skills build on basic communication skills. They have been described as the “humanistic qualities” we strive to create and sustain in a relationship. The end goal being to establish a sense of shared thoughts and feelings with the patient regarding their care. In fact communication skills may not be accurately assessed if interpersonal skills are lacking in a patient-physician relationship.

Many different medical specialties have used SPs to assess the ICS of their residents. Some investigators have demonstrated that evaluations relying solely on faculty ratings may not always identify residents with poor communication skills. Non-physician evaluators such as SPs may, in fact, more effectively rate ICS in residents and students. ¹¹ Yudkowsky et al ¹² showed that a SP based OSCE was an effective method to assess ICS and also provided useful information for curriculum review.

Since ICS assessment may be impacted by the nature of the resident-patient interaction, we developed specific SP scenarios to evaluate those ICS that may be relevant for anesthesiology residents. For the purposes of evaluation we have modified a SEGUE framework for assessing ICS among anesthesiology residents. The SEGUE framework is a checklist type assessment that targets specific communication tasks, focusing on whether or not they were accomplished. It is one of the most widely used structures to teach and assess communication skills. The SEGUE framework has been studied amongst medical students and residents in other specialties, and has been shown to have significant inter-rater reliability and validity. ³

Our primary finding was that even without specific intervention, the ICS of the more experienced residents was better than that of their less experienced colleagues. The improvement was confirmed by both SP and faculty assessments [Table 1]. As residents advance in training they acquire many skills and experience. Anesthesiology residents have an increasing number of patient interactions (pre-anesthesia evaluations, post-op checks, etc.) throughout their residency. In lieu of structured teaching, the experience from these patient encounters and the informal feedback they may receive may be responsible for the improvement in ICS. Indeed, the assessment of ICS of emergency physicians by Reisdorf et al ¹³ showed similar results. Though they did not compare different resident years they did show that experienced clinicians (faculty) had better ICS than less experienced clinicians (residents).

Experience, however, may not be the only reason for the improvement in performance of the CA−3 residents compared to their junior counterparts. As residents advance in training their knowledge base increases and it is the acquisition of greater knowledge that may contribute to the improvement seen. A study by Laidlaw et al ¹⁴ found a significant relationship between clinical knowledge and communication skills performance among residents participating in an OSCE. They surmised that a greater knowledge base allows residents to better elicit information, synthesize it, and then convey it back to the patient making for a more satisfying ICS assessment. We also found a positive correlation between individual resident ITE scores and ICS scores as graded by the faculty but not with the SP scoring (Figure 3, 4). Faculty may subconsciously be affected by their perception of a resident’s knowledge and this may impact how they score the ICS. It is possible that the SP may be free of this bias and so focus more objectively on the resident’s ICS.

We have found a good correlation between the SP evaluations and the faculty evaluations of individual resident’s ICS. This is in accord with the findings of Williams et al ¹⁵ who also showed good reliability between the SP and faculty for functional assessment and communication skills in a geriatric patient population. Although correlation between the overall faculty and SP scores exists, there are subtle differences in how the faculty and the SP evaluate the same encounters [Table 2, 3]. The faculty evaluators tend to rate the residents lower than the SPs across all assessment areas and these differences were especially pronounced for the CA−1 residents.

CA−1 residents seemed to have the greatest difficulty with closing the interview. This was seen as a deficiency by both the SPs and more notably by the faculty [Table 2, 3]. The difficulties included: summarizing pertinent information, asking the patient whether they had further questions, concluding the interview, and informing the patient what would happen next. Closing the interview is primarily a communication task. It is in this skill area where most improvement is demonstrated with increasing levels of training. Since this was a time limited exercise, closing the interview may have been problematic for inexperienced residents. As their experience increases the residents become more efficient with the communication tasks necessary.

In the area of interview content, also primarily a communication task, the faculty found the resident use of open-ended questions followed by close-ended ones to be inconsistent and especially troublesome for the CA−1 residents. Additionally, the faculty found the CA−1 residents to be deficient in providing reassurance and guidance, a therapeutic core quality and an integral part of interpersonal skills. Neither of these areas were a concern for the SPs. The SPs did object to the use of medical jargon by the residents to which the faculty evaluators were immune.

From the SP perspective, listening skills declined as residents progressed in training. It appears that CA−1 residents are better listeners when compared to CA−3 residents. The faculty scores did not reveal a similar decline. The reason for this divergence could be that as residents become more knowledgeable and experienced they are better able to focus on key points of the pre-anesthesia evaluation. Conversely, the relatively less experienced CA−1 residents are unsure of what is important so they are intent on listening and recording everything. Therefore, they are perceived as more attentive.

When comparing faculty assessment scores with SP scores, it appears that the emphasis may be different. It appears that what the SP values is different from what faculty evaluators feel is important. The SP seems to be more attuned to interpersonal skills while the faculty seems to care more about knowledge and communication tasks. This may support the conclusion by Brinkman et al ¹¹ that evaluation procedures that rely solely on attending physician ratings may not identify residents with poor ICS. The knowledge of these differences and deficiencies between residents will allow us to develop more specific educational programs for residents to improve these skills.

There are several important limitations of this study. Because of the small sample size any conclusions drawn from this study must be viewed with caution. Based on our results we have determined that the expected difference between groups (CA−1, CA−2, CA−3) to be 2.0 points (single exam and one evaluator per resident). With an expected standard deviation of scores within a group being 1.5, we would need to study 12 residents per group for the study to have a power of 0.8, if the P value is kept at or below 0.05. With a larger sample size we could also look at how other factors, such as gender, age, previous experience with SPs impact performance during the ICS assessment. Follow up longitudinal studies would also be more meaningful.

The faculty evaluators were not blinded to the residents so biases from prior interactions with these residents may have influenced their ICS scoring. We were encouraged by the strong correlation between the faculty participants. Independent evaluators trained in communication skills or anesthesiology faculty from other programs, unaware of a resident year in training and without biases from previous interactions would lend more significance to the results.

Measuring ICS by using a nominal checklist such as the one used in this study also presents limitations. It only reveals whether or not an action occurred, not how well a task was accomplished. The checklist used did not include anchoring statements, that is, written descriptions of poor or ideal behavior. Subtle “humanistic qualities” that are inherently important in physician-patient communication may not be revealed by these kinds of checklists. Focusing on summary scoring, residents may score high overall, but miss critical ICS tasks that would lead to patient dissatisfaction. Lastly, this study does not address non-verbal ICS such as “body language” or written communication.

Conclusion

A SP based encounter using a SEGUE framework evaluation is a useful tool to assess the ICS of anesthesiology residents. Even in the absence of specific intervention or formal teaching, senior residents perform better than their junior counterparts on the ICS assessment. Increasing experience and knowledge appears to correlate with improvement in ICS. Though overall faculty and SP resident evaluations are similar, examination of the individual skills areas reveal subtle differences that can be the target of focused teaching. We regard the fact that we found higher ICS scores among senior residents and good correlation between SP and faculty ICS evaluations as evidence for construct validation of SP-based assessment of resident ICS. The conclusions presented are preliminary findings and further work needs to be done to confirm these results. Though this was a pilot study, our overall experience was positive and we will continue to use SPs to assess this core competency.

Table I:

Details of Standardized Patient ICS scores in the various assessment areas (mean ± SD) broken down by residency year.

Standardized Patient Resident Year ICS Assessment Areas (Max Possible)	CA 1 Mean ± SD	Resident Year CA 2 Mean ± SD	CA 3 Mean ± SD
Opening the interview (4)	4.00 ± 0.00	4.00 ± 0.00	4.00 ± 0.00
Listening Skills (8)	8.00 ± 0.00	7.75 ± 0.50	7.50 ± 1.00
Interview Content (8)	7.25 ± 0.50	7.50 ± 0.58	8.00 ± 0.00*
Therapeutic Core (8)	7.75 ± 0.50	8.00 ± 0.00	8.00 ± 0.00
Closing the Interview (6)	3.50 ± 1.29	4.50 ± 1.00	5.00 ± 1.15

^*indicates P value < 0.05 when compared with CA−1 year.

Table II:

Details of Faculty ICS scores in the various assessment areas (mean ± SD) broken down by residency year.

Faculty ICS Assessment Areas (Max Possible)	CA 1 Mean ± SD	Resident Year CA 2 Mean ± SD	CA 3 Mean ± SD
Opening the interview (8)	7.25 ± 1.50	7.38 ± 0.48	8.00 ± 0.00
Listening Skills (16)	14.50 ± 0.41	14.63 ± 2.42	15.50 ± 0.58*
Interview Content (16)	12.00 ± 3.81	13.63 ± 2.59	15.75 ± 0.50
Therapeutic Core (16)	11.00 ± 4.10	14.38 ± 1.31	16.00 ± 0.00
Closing the Interview (12)	3.00 ± 2.58	6.13 ± 1.55	9.50 ± 1.00*

^*indicates P value < 0.05 when compared with CA1 year.

Appendix 1

Center for Creative Instruction

University of Toledo College of Medicine

Anesthesiology CPX	Case Name:
Communication Skills Assessment	Resident:

	When conducting the preoperative evaluation, the resident	Yes	No
1.	Introduced self in a respectful manner and used proper name of patient
2.	Verified purpose of visit
3.	Seated self in an appropriate manner and distance in relation to the patient
4.	Maintained appropriate eye contact
5.	Did not interrupt unnecessarily
6.	Appeared attentive and interested
7.	Used open-ended questions followed by closed-ended questions
8.	Used vocabulary consistent with patient background, avoided jargon
9.	Obtained information in a systematic, orderly process
10.	Was non-judgmental
11.	Provided reassurance and guidance if necessary
12.	Showed a courteous attitude toward patient
13.	Showed a compassionate attitude toward patient
14.	Explored patient’s concerns or perspectives regarding the problem
15.	Asked if the patient had questions or anything to add at the end of the interview
16.	Summarized pertinent information to clarify for patient and interviewer
17.	Informed the patient that the interview concluded and what would happen next
	Total Score (Maximum of 17)

Opening the Interview (1,2)

Listening Skills (3,4,5,6)

Interview Content (7,8,9,10) Therapeutic Core Qualities (11,12,13,14)

Closing the Interview (15,16,17)

PLEASE INDICATE HERE WHICH QUESTIONS MAP TO EACH OF THE 5 DOMAINS

CENTER for CREATIVE INSTRUCTION UNIVERSITY of TOLEDO COLLEGE of MEDICINE

INSTRUCTIONS TO RESIDENT

You are seeing Mr. James Slater who is scheduled to have emergency surgery to repair a leaking abdominal aortic aneurysm. He has some reservations about proceeding with the surgery.

You have 15 minutes to perform a pre-anesthesia evaluation and to discuss an anesthesia plan.

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PATIENT SCRIPT

BEHAVIOR, AFFECT & MANNERISMS

You are in the pre-op holding area. You will be dressed in a hospital gown and surgical cap. You will have an IV in place as well as monitors. You are presently experiencing sharp abdominal (belly button area) and back pain (lumbar area). You rate this pain as a 9 on a scale of 1-10 with 10 being the worst pain you have ever felt. You are extremely nervous about having surgery and are considering not going ahead with it. You will answer questions freely, but are very anxious because of the seriousness of your situation. The surgeon told you that you have a 50/50 chance of surviving the surgery because you have a bad heart and lungs as well as some kidney problems.

INFORMATION TO BE GIVEN FREELY

“I’m scheduled to have emergency surgery and I’m not sure I want to go ahead with it.”

INFORMATION TO BE GIVEN ONLY IF ASKED

History of Present Illness

You are scheduled to have emergency surgery to repair a leaking abdominal aortic aneurysm. You began having sharp back and abdominal pain early this morning. The pain started in your belly button area and travels to your back. The pain was so severe you had your daughters take you to the emergency room. The first ER at a small community hospital diagnosed an aneurysm, treated your low blood pressure with fluids and blood an transported you by ambulance to the University of Toledo Medical Center where they were better able to take care of you. Your aneurysm is located above your kidneys. Your daughters are urging you to have the surgery and this is adding to the anxiety you are already feeling.

Past Medical History

You have significant cardiac, pulmonary and kidney disease. You have had high blood pressure for over 30 years treated with several medications. You had a heart attack 10 years ago. Your doctor put you on a low fat, low carbohydrate diet that you follow fairly regularly. You were advised to exercise but you have trouble doing this because of poor circulation in your legs that causes them cramp after walking a short distance. This started 3 years ago and has been getting worse. You have emphysema for over 20 years.

Surgeries

Hernia (age 40), Gall Bladder (age 60) – No problems with either surgery

Medications

Norvasc (high blood pressure), Atenolol(high blood pressure), Albuterol inhaler (emphysema), Atrovent inhaler (emphysema)

Allergies

None

Social History

You are a retired insurance salesman. Your wife died 10 years ago from lung cancer. You have two daughters that live in Toledo. Stephanie is 45 and works as an x-ray technician. Charlotte is 38 and is a stay at home mom. Both daughters are happily married and each has two children. Both of your daughters are insisting that you go ahead with the surgery. You are their only living parent, and because of the seriousness of your situation, they are very anxious and almost combative with you about proceeding. Stephanie is very bossy and acts like she is a physician. Charlotte agrees with everything Stephanie suggests. Your daughters have many questions for the anesthesiologist. These questions should be spaced throughout the interview. You smoke about 4-5 cigarettes a day now, down from 2-3 packs per day when you were in your twenties. You’ve tried to quit on many occasions but feel this is a guilty pleasure that you are entitled to even though you have emphysema.

Psychiatric History

Unremarkable

Family History

Your father died at the age of 83 from old age. He had claudication and high blood pressure that was treated with medication. Your mother died at age 87 from heart disease. You are an only child.

PROMPTS/QUESTIONS (MUST BE FIT INTO EACH ENCOUNTER)

Is our father going to die during surgery? If this were your father what would you do? (Pressure the resident to give you a definitive answer, Charlotte’s question).

How are you going to put him to sleep? Will he be on a ventilator after surgery? How long will the surgery last? How long have you been doing this? Are you any good? (Stephanie’s questions, get in the resident’s face when you ask the last two questions).

You look awfully young to be doing this. The only thing I ask if I go ahead with the operation is please don’t let me wake up during the surgery. I’ve heard of too many people hearing everything that goes on (James Slater).

Center for Creative Instruction University of Toledo College of Medicine

INSTRUCTIONS TO RESIDENT

You are seeing Mrs. Dottie Moran who is scheduled to have surgery for bladder cancer. She is a Jehovah Witness. Because of the possible need for blood transfusion she is afraid to have surgery.

You have 15 minutes to perform a pre-anesthesia evaluation and to discuss an anesthesia plan.

****************************************************************************

PATIENT SCRIPT

BEHAVIOR, AFFECT & MANNERISMS

You are scared to have surgery. They want to remove your entire bladder. Because of your religion (Jehovah Witness), you are reluctant to agree to anything that may require you to receive someone else’s blood. The doctor recommended that you consider an epidural because it may decrease blood loss, but you are afraid of this also because of your chronic back problems.

INFORMATION TO BE GIVEN FREELY

“I’m scheduled to have surgery, but don’t want to because if I need blood, I don’t believe in receiving blood from anyone.”

INFORMATION TO BE GIVEN ONLY IF ASKED

History of Present Illness

You are scheduled to have your bladder removed because of cancer. You noticed blood in your urine about 6 weeks ago, and were diagnosed with cancer one month ago. You don’t want to have surgery because you became a Jehovah Witness 10 years ago and your religion does not allow you to have blood transfusions. You were told about an injection that could raise your blood count and you are considering this option.

Past Medical History

You have had high blood pressure for over 40 years. You had a heart attack 5 years ago. You get occasional chest pain and it has stayed about the same for the last year. You had an echocardiogram done last week that showed your heart wall was thickened, one of the valves was leaking and your heart wasn’t pumping as well as it should. You get short of breath occasionally with climbing a flight of stairs. You had pneumonia 2 years ago. You have arthritis in your back that causes you chronic back pain. You have had this for many years. You’ve been feeling really tired lately and were told that your blood count is low. You’ve had diabetes for 10 years. Your lab work that was done a few years ago indicated that you were having kidney problems and you were told by your physician that you might need dialysis one of these days.

Surgeries

None

Social History

You’ve been married to the same man for 41 years (Clarence). You are both retired. Clarence (72) is retired from the railroad. You (73) are retired from the church where you were the organist. You are very active in your church and have attended the same one for the past ten years. You have three adult children, Delores (39) who is divorced and living in Kentucky, Randall (37) who is married with four children living in Atlanta, and Chauncey (35) who is married with five children living in Alabama. You have a remote smoking history but quit 30 years ago. You became a Jehovah Witness 10 years ago. You don’t drink alcohol or use drugs.

Psychiatric History

Unremarkable

Allergies

None

Medications

Atenolol (high blood pressure)

Lisinopril (high blood pressure)

Glucophage (diabetes)

Aspirin

Family History

Your father and mother died in an automobile accident when you were in your early twenties. You have two older brothers and three younger sisters. Your one brother has diabetes and high blood pressure and your other brother has prostate cancer. Of your three younger sisters, two have high blood pressure and the other has really bad allergies. The sister who suffers from allergies has a problem with her heart but you aren’t sure what the problem is.

QUESTIONS/PROMPTS (THESE MUST BE FIT INTO EACH ENCOUNTER)

I’m a Jehovah Witness and I don’t want any blood from anyone.

Why should I get an epidural? I don’t really understand what it is and how it can help me from losing blood. I already have back problems and I don’t want anymore.

Will I wake up during surgery?