Sally King - Fastly



John (Joan) Shaw

Consent for a procedure

(Original case by Win May, MD, PhD and Beverly Wood MD, PhD

Presenting complaint: CT guided lung nodule biopsy

Length of patient encounter: 10 minutes

Learning Objectives:

1. The resident will demonstrate good patient-physician interaction skills when explaining the procedure and risks of the lung biopsy.

2. The resident will be able to discuss difficult issues with the patient during the clinical encounter.

3. The resident will be able to address the patient’s concerns.

Diagnosis: Possible Carcinoma of the Lung

Target Group: Residents - 2nd year radiology residents

Type of case : Assessment

History only

Case Summary

Patient demographics:

Name: John or Joan Shaw

Gender Male or Female

Age range: 50 - 60

Race: Any

EQUIPMENT NEEDED:

None

Resident:

You are a 2nd year resident in radiology on your first rotation of Interventional Radiology. You have observed several lung biopsies, but have not performed one yourself. You are nervous about this one as your first case, but want to do the procedure and will be supervised by an experienced faculty member.

Training Materials

John Shaw

PROFILE:

John (Joan) Shaw is a 50-year-old healthy male(female). He had a dry “bad cough” 3 weeks ago. At that time he saw his physician who obtained a chest X ray that showed no pneumonia, but did show a solitary nodule in the posterior part of the left lung, behind the heart, and measuring about 16 mm in diameter. The nodule was not calcified, had not been present on a previous study 10 years before, and had some possible surrounding scarring. You are nervous because you have a history of smoking 1 pack of cigarettes/day for 15 years from age 18-33. You have not had a cough before.

The challenge in this case for you, the standardized patient, is threefold:

1. Accurately portray the emotions of someone who is coming into the imaging center for a biopsy of the lung that might be a cancer. You are nervous about the procedure itself, the radiation, and the possible diagnosis of cancer. You are fearful that something will go wrong.

2. Observe the residents’ behavior while you are performing the case.

3. Accurately recall the residents’ behavior and complete the communication skills checklist.

PRESENTATION/EMOTIONAL TONE:

You are a security guard for a medium sized business. You are serious, capable, and concerned about your job, home, and family. You are married and have three children and 6 grandchildren all living nearby. Your main recreation is fixing up an antique car.

Since having the chest X ray 3 weeks ago, you have not been able to think of anything else. You are nervous and upset because you are worried about cancer and possible complications of the biopsy procedure, however, you try to remain calm and in control. You do not ask a lot of questions, hoping that if you stay cool everything will turn out all right. You are stoic and self-controlled, but fearful and become increasingly nervous as the resident explains the procedure. You are convinced you have cancer as you used to be a smoker; and you are convinced the procedure will be dangerous. You do not understand what the resident is telling you about possible complications, and are worried about the resident’s inexperience.

You are worried that you have a cancer and will die leaving no one to take care of your family.

As the resident enters the room you are sitting in a chair, dressed in street clothes.

HISTORY OF PRESENT ILLNESS

You had a dry “bad cough” 3 weeks ago, without any fever or chills. You had not had any cold or flu prior to that. At that time you saw your physician who after an examination, obtained a chest X ray that showed no pneumonia, but did show a solitary nodule in the posterior part of the left lung, behind the heart, and measuring about 16 mm in diameter. The nodule was not calcified, had not been present on a previous study 10 years before, and had some possible surrounding scarring.

PAST MEDICAL HISTORY:

You have smoked for 15 years, and stopped at age 33. You have not smoked since. Your health has always been good and you have no lung symptoms. You work as a security guard, a job you have held for 20 years. You have never missed a day of work. You are the major provider for your immediate family.

You finished High School, but did not attend college.

Your wife is a 4th grade teacher.

FAMILY MEDICAL HISTORY:

Your father died of cancer of the lung at age 65, and he had smoked his entire life. Your mother is alive, but had cancer of the ovary 12 years ago. She is well now.

SOCIAL HISTORY:

You have been married for 35 years and you have 3 children – and 6 grandchildren. All live in Riverside County and Orange Co. You see the children and grandchildren almost every week.

In addition to your work as a security guard, you are fixing up an antique car. You have little time or money for vacations, but you see your family almost weekly.

THE ENCOUNTER:

Beginning

You can start off with a question, such as:

“Well, doctor, what is going to happen to me today.”

The resident should explain the CT to you and how you will be positioned for the biopsy, what you will feel, and what are possible complications. You want to know who will do the procedure, how much experience they have, if it is painful, and if there is a risk of death. The resident worries you because he/she seems very young.

Middle

Once you hear the resident explain the procedure, you ask about complications and when you will know the results of the biopsy. You keep pushing the resident concerning the possibility of cancer. You also want to know if the procedure is painful and what are the chances of complications. You have never been hospitalized before and feel very uncomfortable in the medical setting.

If after giving you the information, the resident looks willing to go on talking, you may say…

• My father had lung cancer. Does that mean that I might get it also?

• I’m only 50 – isn’t that young for cancer?

• Did my smoking cause it? I stopped it when I was 33 – it’s been 17 years. I thought I would be clear.”

Based on whether the resident has been empathetic and informative with you or not, you can then ask what will happen after the biopsy, how soon you will get the results, who will talk with you about them, and if you can be treated and how successful the treatment is.

if the resident has a difficult time relating to your concerns and questions, you can become angry with the system for sending someone who is so inexperienced to talk with you about something so important.

End

If the resident has not been sensitive, responsive, and empathic, you tell him/her that

you would like to talk to his/her supervisor before you agree to have him/her do the procedure.

If the resident has been sensitive, responsive, and empathic you tell him/her that it is fine to go on with the procedure and for that resident to perform it. You can ask if the resident will come and talk with you about the procedure when it is finished.

If the resident asks you if you have any more questions, respond by saying:

“I can’t think of any right now, maybe we can talk later.”

Questions you can ask the resident :

• Did my smoking cause this, even though I stopped so long ago?

• Is it hereditary? Since my father had cancer, will I too?

• Have you done this biopsy before? Should someone else do it?

• What is the chance that something will go wrong during the biopsy?

• What can happen while you do this biopsy?

• How soon will I know whether it is cancer or not?

What the resident should be telling you:

1. The resident should inform you that the mass (nodule) may not be cancer and inform you of the reason for the biopsy.

2. The procedure – (s)he should explain about a CT scan, the position in which you need to lie, preparation for the biopsy, and the biopsy itself. There should be a description of the possible complications of the procedure (pneumothorax, bleeding) in language you understand. If you do not understand, then you should ask.

3. The results of your biopsy- Inform you of when the results of the biopsy will be known, and who will talk with you.

ADDITIONAL MATERIALS

Presenting Situation

and

Instructions to the Resident

John Shaw

John Shaw is a 50-year-old man/woman who saw his/her physician for a persistent dry cough about 2 months ago. The cough has since cleared, but a chest X ray at the time showed a nodule (about ¾ inch in diameter) in the posterior part of the left lung. An earlier X ray 10 years before did not show the nodule. It is recommended that a biopsy be performed.

Biopsy results:

Pending/ possible adenocarcinoma of the lung.

You are to:

• Discuss the procedure and obtain consent from the patient

• Discuss with the patient the possible complications of the procedure

• Address the patient’s concerns both about the procedure and about the possible diagnosis

You will have 10 minutes to perform these tasks.

(A bell will ring 8 minutes into the encounter. At the end of the encounter you will be asked to leave the room.)

You will then have 4 minutes to answer questions related to this case outside of the room.

John Shaw

STANDARDIZED PATIENT CHECKLIST

| | | |

| | | |

|SP’s | |Examinee’s |

|Label | |Label |

| | | |

Date: /07 Program:

|Please check the appropriate box. |Outstanding|Very good |Good |Needs |Marginal |Unacceptabl|

| |** | | |Improvement| |e* |

| | | | | | | |

| | | | | | | |

|The examinee: | | | | | | |

|A. As John Shaw, rate your overall level of satisfaction with this examinee | | | | | | |

|encounter. | | | | | | |

Case-Specific Items

I felt the resident

1. explained the procedure in a straightforward but sensitive manner. YES NO

2. used simple language without technical jargon or euphemisms. YES NO

3. gave me the appropriate amount of “space” to experience my YES NO feelings of nervousness and to ask my questions

4. was aware of my nonverbal cues related to the procedure. YES NO

5. paused frequently and used silence and body language as tools to YES NO

facilitate discussion

6. encouraged me to share some of the thoughts and questions that were going through

my head. YES NO

7. initiated a discussion of what I considered to be my greatest concerns. YES NO

Interpersonal Skill: Personal Warmth and Sensitive Respect

8. I felt the resident greeted me warmly upon entering the room.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

9. I felt the resident was friendly throughout the encounter.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

10. I felt the resident treated me like we were on the same level.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

11. I felt the resident showed interest in me as a “person.”

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

12. I felt the resident displayed patience when I asked questions.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

13. I felt the resident offered support and empathy.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

Communication Skill

14. I felt the resident was telling me everything and not keeping things from me.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

15. I felt that the resident discussed the situation with me.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

16. I felt the resident made sure that I understood the situation.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

17. I felt the resident encouraged me to ask questions.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

18. I felt the resident answered my questions, without avoiding them.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

19. I felt the resident clearly explained what I should expect.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

Structure of Communication

Maintained eye contact appropriately YES NO

20. Moved from open to closed ended questions YES NO

21. Interview unfolded in a logical manner YES NO

22. Used explanatory transitional statements when moving from

one section to another YES NO

23. Used segment summaries to check that his /her understanding was accurate YES NO

24. Asked clarifying questions when appropriate YES NO

25. Summarized the session briefly including plan of care YES NO

Post-Encounter Exercise

Resident Self-Evaluation

Resident’s Name: _______________________________________ Date: _____________

Name of the Patient you just saw: ____________________________________________

I felt that I

1. Discussed the procedure a straightforward, sensitive manner. YES NO

2. used simple language without technical jargon or euphemisms. YES NO

3. gave her the appropriate amount of “space” to experience her YES NO feelings regarding the nervousness and concern

4. was aware of her nonverbal cues on hearing the bad news. YES NO

5. paused frequently and used silence and body language as tools to YES NO

facilitate discussion

6. encouraged him to share some of the thoughts that were going through YES NO

his head.

7. initiated a discussion of what he considered to be his greatest concerns. YES NO

Interpersonal Skill: Personal Warmth and Sensitive Respect

8. I felt I greeted the patient warmly upon entering the room.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

9. I felt I was friendly throughout the encounter.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

10. I felt I treated him like we were on the same level.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

11. I felt I showed interest in him as a “person.”

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

12. I felt I displayed patience when he asked questions.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

13. I felt I offered support and empathy.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

Communication Skill

14. I felt I was telling him everything, not keeping things from her .

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

15. I felt that I discussed the procedure with him .

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

16. I felt I made sure that he understood the procedure (the situation).

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

17. I felt I encouraged him to ask questions.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

18. I felt I answered his questions without avoiding them.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

19. I felt I clearly explained what she should expect next.

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

Structure of Communication

I maintained eye contact appropriately YES NO

20. I moved from open to closed ended questions YES NO

21. I felt that the interview unfolded in a logical manner YES NO

22. I used explanatory transitional statements when moving from

one section to another YES NO

23. I used segment summaries to check that his /her understanding was accurate YES NO

24. I asked clarifying questions when appropriate YES NO

25. I summarized the session briefly including plan of care YES NO

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