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* FACILITATOR’S GUIDE *

Geriatrics Medication History Objective Structured Clinical Exam

Authors

Maria H. van Zuilen, PhD

Jose E. Gonzalez, MD

Enrique A. Aguilar, MD

Juan Carlos Palacios, MD

Michael J. Mintzer, MD

Geriatrics Institute

University of Miami Miller School of Medicine

June 2010

Geriatrics Medication History

Objective Structured Clinical Exam

INDEX OF MAJOR SECTIONS

Description of the Session 3

Objectives 3

Intended Audience and Prerequisites 3

Required Resources 4

Procedures and Implementation 4

Assessment Results 5

Evaluation 6

Relationship to Other Materials 7

Lessons Learned 7

Citation 7

Acknowledgements 8

Funding Source: This work was supported by the Donald W. Reynolds Foundation grant “Comprehensive program to strengthen physicians' training in geriatrics.”

| |

|Description of the Session |

This 12-15 minute performance-based assessment is designed in the format of an Objective Structured Clinical Exam (OSCE) and measures students’ clinical competency in taking a comprehensive geriatrics medication history. This assessment is intended for students who have received instruction on how to take a medication history with older patients and who have some clinical experience allowing them to practice this skill. Although this OSCE is designed primarily as a summative assessment tool and is used at our institution at the end of the third year of training, the format allows the activity to be easily adapted into a formative assessment tool. Students are asked to interview a simulated patient (SP) regarding their medications and to make appropriate recommendations for problems identified. The SP brings to the assessment a “brown bag” including all their prescription medications. A faculty rater observing the interview completes a performance checklist which includes individual items as well as two global ratings of performance.

|Objectives |

The student will:

1. Take a medication history to gather information regarding the:

a. patient’s understanding of their medications

b. problems and factors influencing adherence

2. Outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence

|Intended Audience and Prerequisites |

This OSCE is designed for medical students (MS3 or 4) but can be used to evaluate primary care residents and trainees of other healthcare professions who participate in the medical assessment of older adults. We recommend this performance-based assessment be used during the clinical years of medical school training. It is helpful if the student has received basic instruction on taking a comprehensive medication history and has had a chance to apply their learning with patients in clinical practice. We have previously designed a related instructional activity that is implemented during students’ second year of training.

Mintzer MJ, van Zuilen MH, Cordero M, Kaiser RM (2008). The Medication History: A Small Group Session on Interviewing a Patient Regarding Medication Use. MedEdPORTAL; Available from , ID = 1112.

|Required Resources |

• A small room with three chairs and a table or other area large enough for the learner to sort and examine the patient’s medication bottles.

• An instruction sheet posted at the room with the objectives and directions for the learner (Appendix A)

• A simulated patient script (Appendix B)

• A brown bag

• 6 medication bottles

• Medication bottle labels (Appendix C)

• Simulated pills (candy)

• A laminated pocket card reminder (cheat sheet) for the SP with of all their medications (Appendix D)

• Additional Clinical Information for the Raters (Appendix E)

• A performance checklist (Appendix F)

• Guidelines for the faculty rater for giving feedback (Appendix G)

• A time keeping device

• A clipboard

• OPTIONAL – Session evaluation forms

|Procedures for Implementation |

Current Use

This medication history OSCE has been incorporated into a 10-station OSCE administered to all medical students at the end of the MS3 year. In order to assess all students in a 2-day period, three medication stations run concurrently, thus requiring multiple SPs and faculty raters.

Simulated patient training

In order to standardize the SPs responses, a training session should be held to allow the SPs to practice answering questions according to the script guidelines. We use a role-play format (a faculty member acts as a student asking questions) to achieve a high level of authenticity to the actual OSCE. The SPs receive immediate corrective feedback. The SPs also receive an initial overview of the assessment and a copy of their script several days in advance of the training session so they can study it in preparation. A script, while essential, will not contain all possible questions medical students may ask. Some guidelines are included in the script in the event a student asks a non-scripted question. Still, there will be times SPs will need to use judgment and the practice session will help them learn some strategies to answer non-scripted questions.

Our training of SPs is based on the OSCE being an end-of-year summative assessment. It is not a “high-stakes” assessment, but students who do poorly may be required to complete remediation during their fourth year. To achieve a moderate degree of standardization, SPs are trained for 2 hours. In the case of a high-stakes assessment, a higher degree of standardization may be required which will involve additional SP training. This assessment could be modified for use as a formative assessment. Although we have not used it in such a manner, we believe that SP training would not need to be as intense.

Rater training

Rater training focuses primarily on standardizing how credit is given for performance checklist items. Raters need to be familiar with the SP script so they can provide corrective feedback as needed to the SPs between assessments. Raters should also be trained on how to provide feedback to students. During our OSCE, feedback time is limited to 2 minutes. We focus on overall student performance (e.g., review of all illnesses, review of all medications, recognition of side effects, etc.) rather than an “item by item” review of the checklist. If this was to be used as a formative assessment and more time was allotted, more detailed feedback could be given.

Debriefing

Periodic debriefing is part of the ongoing quality improvement process. We schedule a debriefing session with the raters shortly after the OSCE sessions are completed to obtain feedback, identify problems, and make improvements. During the two days of the assessment, we also talked to raters and SPs after each set of ten students completed the station to discuss any difficulties encountered and devise standardized solutions. Feedback from these debriefings has resulted in minor SP script revisions.

|Assessment Results |

We have successfully implemented this OSCE with the entire class of MS3 students (N=168) in the spring of 2009 during our annual OSCE weekend. The table below displays the percentage of students who addressed the core items on the checklist.

|Did the student consider or discuss: |% | |Ability to pay |81.5 |

|Current medical conditions |54.2 | |Physical barriers to taking meds |75.0 |

|Current medications: | | |Availability of family/friends support |64.9 |

|OTCs |61.9 | |How the meds are organized |66.7 |

|Herbals |41.1 | |Did the student recommend: |% |

|Vitamins |48.2 | |Informing ALL doctors of ALL meds |41.7 |

|Medication “borrowing” (Meclizine) |81.5 | |Simplifying the schedule |64.9 |

|Which/how many MDs prescribe |64.3 | |Eliminating Omeprazole |58.3 |

|Pt’s understanding of indications for meds |94.6 | |Large print labels |56.5 |

|Pt’s understanding of how to take meds |88.7 | |A pillbox to organize medications |82.7 |

|New medications or dose adjustments |50.6 | |Use of a mail/ delivery option |32.7 |

|Side/adverse effects |86.3 | |Getting regular caps |32.1 |

|Allergies to medications |6.0 | |Did the student consider or discuss | |

|Beneficial effects |45.8 | |Safety concerns with borrowing meds |77.4 |

|Barriers | | |Multiple meds as a cause of side effects |58.3 |

|Adherence |81.0 | |Therapeutic duplication |42.9 |

|Cognition/memory |30.4 | |Potential drug risks |46.4 |

|How are refills obtained |54.8 | |Financial assistance for meds |70.2 |

The average score for the 31 main items was 18.4 (SD=4.0).

Faculty raters completed two global ratings on each student. The results were as follows (displayed as percentages)

| |Unacceptable |Needs Improvement |Meets Expectations|Well Above |Truly Rare Top 5% |

| | | | |Expectations | |

|Data Gathering: The student's medication |3.0 |23.2 |47.0 |23.8 |3.0 |

|history | | | | | |

|Interpretation/Management: The students |1.9 |18.9 |53.5 |22.0 |3.8 |

|analyses/ synthesis & recommendations | | | | | |

|Evaluation |

Several methods were used to evaluate this OSCE during the design and development phase. After completing the initial draft, we elicited feedback from the medical school administration and several geriatricians who provided suggestions for clarifying content and improving the checklist. Following the SP training session, we made additional improvements to the checklist and the SP script.

Faculty raters (N=13) at each station were asked to complete an evaluation form immediately after completing the OSCE (see table below for results). A debriefing session was held with the faculty raters approximately a week after the OSCE. Based on feedback from the faculty a number of script and checklist scoring clarifications were made, but no items were added or removed from the checklist.

| |Yes |No |Comments |

|Do you feel that the clinical scenario presented to the students was |13 | | |

|realistic? | | | |

|DO you feel that the clinical presentation/direction sheet given to the |13 | | |

|students was clear and complete? | | | |

|Do you feel that there was enough time for the students to meet the |12 |1 |Barely |

|objectives of the station? | | |For the most part. No one fulfilled all the |

| | | |objectives |

|Were there any skills not included on the checklist that you feel should|1 |12 |Add “expiration date” |

|have been included? | | | |

|Were there any skills on the checklist that you would not have included?| |13 |Allergies were not asked frequently |

|Based on the performance of the students at your station, do you feel |12 |1 |For the most part; more time would have helped |

|that you could accurately assess their true clinical skills, including | | |Yes, because it is a very typical scenario |

|areas of strength and weakness? | | |Time does not allow eval of other areas |

|7. Other comments. |

|Well organized, realistic; maybe cut down on the numbers of meds to save time |

|Most students were lacking the medical/medication assessment and diagnosis, perhaps due to over emphasis on mechanisms of eliciting the |

|patient’s understanding of medications. |

|Students were often off track and needed redirection |

|I was having problem rating #40 (Potential drug risks) |

|Very realistic station, good props. It was great to see students gain insight as they were looking at the labels. |

|Relationship to Other Materials |

As mentioned previously, in our program medical students participate in an instructional activity on the medication history during their second year of training. This simulated patient interviewing session is a 45-60 minute small group designed for 4-8 medical students. The facilitator simulates the role of a patient and brings to the session a “brown bag” with medications. The students complete 3 tasks in the time allotted: 1) take a medication history; 2) identify problems with the medication use and formulate a plan to improve medication use; and 3) communicate the plan to the patient. After the 3 tasks are completed, the facilitator conducts a formative feedback session with the students. The learning objectives for this session are closely aligned with those for the medication interviewing OSCE.

The instructional materials are published on MedEdPORTAL

Mintzer MJ, van Zuilen MH, Cordero M, Kaiser RM (2008). The Medication History: A Small Group Session on Interviewing a Patient Regarding Medication Use. MedEdPORTAL; Available from , ID = 1112.

|Lessons Learned |

The training of the SPs as a group helps the faculty raters as well as the SPs in standardizing the interview. Despite this training, we found that during the initial student-SP interview sessions, it was occasionally necessary for the faculty rater to intervene and assist the SP in maintaining standardization and keeping the interview “on track.” At times, the SP would forget a script cue, inadvertently add complexity to the case, or a student would begin asking detailed questions about peripheral issues that were not clearly scripted for the SP, thereby losing valuable time. The faculty rater would quickly correct or clarify information to get the student back on track.

|Citation |

van Zuilen MH, Gonzalez J. Aguilar E, Palacios JC & Mintzer MJ. Geriatrics Medication History Objective Structured Clinical Exam. Miami, FL: University of Miami, Geriatrics Institute, 2010.

|Acknowledgements |

We would like to thank Dr. Alex Mechaber for his thoughtful comments on the initial draft of the performance checklist and Dr. Chi Zhang for his assistance in overseeing the data entry and the generation of summary reports for the OSCE station.

Appendix A

Instructions for the learner to be posted at the station

GERIATRIC MEDICATION HISTORY

OBJECTIVES:

1. Take a medication history to gather information regarding the:

a. patient’s understanding of their medications

b. problems and factors influencing adherence

2. Outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence

SCENARIO:

A 75-year old patient with hypertension comes to your preceptor’s office for an annual health maintenance check-up. Your preceptor (Dr. Baxter) has asked you to take a comprehensive medication history.

DIRECTIONS:

1. DURING THE FIRST 8 MINUTES:

a. DETERMINE WHAT MEDICATIONS THE PATIENT IS TAKING

b. ASSESS PROBLEMS OR ISSUES WITH MEDICATION USE

c. OFFER RECOMMENDATIONS TO ADDRESS PROBLEMS OR ISSUES IDENTIFIED

2. DURING THE FINAL 2 MINUTES YOU WILL PRESENT A SUMMARY OF YOUR ASSESSMENT AND PLAN TO THE PATIENT THAT ADDRESSES THE MEDICATION PROBLEMS IDENTIFIED

Appendix B

Simulated Patient Information and Script

Overview

You are a 75-year old who has been a patient of Dr. Baxter for many years. Today you are coming to the office for an annual health maintenance examination. The student is instructed to take your medication history and to make recommendations for the medication problems identified

Your Medical History

• Hypertension which you have had for many years (at least 10)

• Atrial fibrillation (an abnormal heart rhythm) diagnosed a few months ago

• Arthritis which mostly bothers your right hip - You have had this for many years

• Cataracts that were diagnosed a few months ago

The student is told you have hypertension, but they may ask about your other medical problems. You are aware of the above problems as they have all been diagnosed. You have one new problem (lightheadedness) which you have not yet told your doctor about. Only give this information if the student asks about any other problems.

• You have been experiencing some lightheadedness for a few months now

Your Social and Economic History

You retired 10 years ago from your job as an office worker. Your finances are tight, with income coming from social security and a small pension. For insurance you have Medicare (Parts A and B) but you DO NOT have prescription drug coverage and have to pay for your medications.

You divorced many years ago and currently live alone in a small home. Your only sister lives within walking distance. You have no children. You have a few friends in the neighborhood and try to be active in community events. Because of the cataracts, driving is becoming more difficulty and this makes it harder for you to go out (including going to the pharmacy to get your refills). You do not like to rely on your friends or your sister to take you places. You are still able to take care of all your daily activities (cooking, cleaning, managing your finances etc.) but the arthritis slows you down a bit.

Your Medications

You bring a brown bag with your prescription medications to today’s office visit. With each new student, put the medications back in the bag. The bag will be on your lap as the student walks in. When asked what medications you take, give the bag to the student and say “Here are my prescriptions, Doctor”

The following table gives a complete list of your medications – those that are prescribed and included in the bag; those that are not prescribed but are over-the-counter (Tylenol, vitamins, and herbal tea) and are not in the bag. Included in the table below is the information you know about each medication. You should only answer the specific questions asked. Provide the special information only when the student clearly asks a question regarding this information. Later in the script, you will see some general cues you can use if a student really gets stuck or is not focused on the medication history.

|Medication |If asked: |If asked: |If asked: |Special information |

| | | | |Provide only if asked about |

| |“What you are taking the |“How you are taking this|“How long you have been |specifics |

| |medications for” |medication” |taking it | |

|HCTZ 25 mg |Blood pressure |Once a day after |Many years | |

| | |breakfast | | |

|Cardizem CD 180 mg |Blood pressure, this is the|Once a day before |Three years |Increased 3 months ago to help |

| |expensive one |breakfast | |heartbeat |

|Warfarin 5 mg |To help prevent strokes |Once a day before dinner|3 months |You do not use aspirin or other |

| |because of my irregular | | |NSAID; your; blood is tested |

| |heartbeat | | |regularly |

|Acetaminophen (300) with |Arthritis |Usually twice a day, but|3 months |Before this you were taking Naproxen|

|codeine (30) | |3 or 4 when my arthritis| |for several years |

| | |is bad | | |

|Omeprazole |I don’t know. The doctor |Once a day after dinner |Several years | |

|20 mg |gave it to me | | | |

|Meclizine 25 mg |For the lightheadedness I |after lunch and at |A few weeks |Borrowed from your sister, Alice |

| |have had for a few months |bedtime | | |

|Regular Tylenol |To help my arthritis |Two pills, twice a day, |Several years |You did not know it is also |

| | |sometimes three times | |acetaminophen |

|Multivitamin |Vitamins are good for older|When I eat my dinner |For at least 10 years | |

| |folks | | | |

|Herbal Tea |Tea is supposed to be good |After dinner |Several years | |

| |for you | | | |

Simulated Patient Script Guidelines

* * Remember, students will likely ask questions in a different order * * *

Please answer the students in keeping with the guidelines outlined in the above medication table and the script cues given below. Students will generally take out all the bottles and go over each one with you. Remember to only answer the specific questions asked unless otherwise noted in the script. So if a student hands you the bottle of HCTZ and asks you why you are taking it, say “for my blood pressure.” Do not give the students any other information on the label such as the dosing or the prescribing doctor.

QUESTIONS ABOUT YOUR MEDICAL PROBLEMS

If asked what medical problems you have, say:

• High blood pressure, abnormal heart rhythm, arthritis, and cataracts

If asked how your blood pressure is, say:

• It runs about 135 over 85. (you get it checked regularly and it has been stable)

If asked if you have any other problems, say:

• I have been experiencing some lightheadedness for a few months now (if asked, it is mild; it is not associated with changes in position or a feeling of spinning; you have no other symptoms; you have been taking the Meclizine for it because your sister said it would help)

If asked if you have or have ever had heartburn, gastroesophageal reflux disease, or any other stomach problems, say:

• Not since the doctor switched me over to the acetaminophen (the medication you were taking before that – Naproxen – caused some stomach upset and heartburn).

QUESTIONS ABOUT YOUR MEDICATIONS

When asked, “What medicines do you take?”

• Hand over the bag and say “Here are my prescriptions, Doctor.” Students may go over each bottle with you. If they ask you to look at a bottle and tell them what you take it for, how you take it, or how long your have been taking it, respond using the information in the table. Keep your answers short and only answer the question asked. When you look at the label on the bottle, use nonverbal behavior (squinting your eyes or moving the bottle closer) to indicate you are having some difficulty seeing the words on the label.

If asked about OTCs (over-the-counter medications) or if you take any medications not prescribed by your doctor, say:

• I take regular strength Tylenol everyday (if asked, you were not aware that this is also acetaminophen – you thought they were two different types of pain pills)

If asked about vitamins, say:

• I take a daily multivitamin

If asked about herbals/alternative/complimentary medication, say:

• I usually drink herbal tea in the evening

If asked if you take medications belonging to someone else (medication borrowing), say:

• My sister gave me the meclizine

If asked if you ever share your medications with others, say:

• No, never

If asked how long you have been on these medications, say:

• Most of them I have been taking for a while. The new arthritis pill and blood thinner I have taken for about 3 months. (students may then ask about each medication – answer based on the information in the table)

If asked who prescribed the medications or who your doctors are, say:

• Dr. Baxter is my regular doctor and I sometimes see the rheumatologist (Dr. Sommer)

• Dr. Sommer is the one who gave me the pain medication for my arthritis (acetaminophen with codeine)

If asked if you have recently started any new medication, say:

• I have been taking the meclizine for about 2 weeks

If asked where you got the meclizine, say:

• From my sister, she said it would help my lightheadedness

If asked if any of your medications are expired or if a student misinterprets the dates on the labels and tells you a medication is expired, say:

• All my medications are up to date

If asked a broad or vague question about problems you may be experiencing with your medications (e.g. Are you having any problems with your medications), say:

• Well, it’s not easy with all these medications (if needed, you can prompt a student to ask a more specific question, by saying “What specific problems do you mean?”).

QUESTIONS ABOUT ADHERENCE

If asked a broad or vague question about your adherence (e.g., do you remember to take your medications, or do you take your medicines on schedule, as prescribed, or as directed), say:

• I try to, it’s not always easy

If asked specifically if you ever miss or skip a dose (intentional misses), say:

• Sometimes I don’t take the Cardizem (If prompted why, indicate it is expensive and you try to make the pills last longer)

If asked a more specific question about your ability to remember to take your medications (accidental or unintentional misses), say:

• Once is a while I forget to take a pill, not too often

If asked if your medications make you feel better, say:

• They seem to be helping

If asked if any of your medications make you feel worse or have side effects, say:

• I don’t know if it’s the medications, but I have been feeling some lightheadedness for the past few months

• If asked about the time of onset of the lightheadedness in relation to the start of new medications or change in dose, acknowledge that it did start after some changes were made - the Cardizem was adjusted, the Warfarin was added, and the Acetaminophen with Codeine was started)

If asked if you are allergic to any medications, say:

• I don’t think so

IN THE PSYCHOLOGICAL DOMAIN

If asked if you have any problems remembering to take your medicines or ever forget to take your medications, say:

• I try to remember, but it gets confusing with all these different medication

• Once in a while I forget to take a pill, not too often (if asked what you do when you realize you forgot a dose, say you take it when you remember unless it is time for the next dose)

Note: You only occasionally forget to take your medications. Remember, this is different from the Cardizem which you purposely do not take at times because of the cost.

If asked how you keep track of your medications or if you have a method to help you remember when to take you medications (e.g., a pill box), say:

• I just keep the bottles on the kitchen table (you do not have a pill box or other reminder)

If asked any other questions about your mood or memory, say:

• I am feeling fine

IN THE PHYSICAL DOMAIN (Including functional)

If asked if you have any difficulty reading your medicine bottles [or written directions for taking the medication], say:

• My cataracts are getting worse and I have to hold the bottles under bright light to read the labels

If asked if you have any problems hearing or understanding the instructions when this [these] medicine[s] was prescribed, say:

• I think I heard everything all right. The doctor did not say all that much.

If asked if you have any problems opening medication bottles, say:

• Sometimes the caps on the bottles are hard to get off.

If asked any general questions about your ability to manage your daily activities (shopping, cooking, bathing etc), say:

• I may be slowing down a bit but I manage (you are not driving much any more because of the cataracts and you are less physically active because of the arthritis)

IN THE SOCIAL AND ECONOMIC DOMAINS

If asked, if anyone helps you with your medications, say:

• My sister sometimes drives me to the pharmacy to get my refills

If asked how you get your medications; who helps you get them; or if you ever have trouble getting your medications, say:

• My sister sometimes drives me to the pharmacy, but sometimes I have to wait to get a refill when she goes out of town

If asked, if anyone helps you put out your medications or helps you remember to take your medications, say:

• No, I take care of it myself.

If asked if you would like or need help with your medications, say:

• That would be nice

If asked how you pay for your medications, say:

• My insurance doesn’t cover it so I have to pay for them myself. I pay for them myself

If asked if you have any difficulty paying for your medications, or if you do not get your prescription refilled because of the cost, say:

• The Cardizem is pretty expensive and sometimes I wait to get it.

GENERAL GUIDELINES AND CUES TO USE

Students should focus on the medication history but may occasionally wander off topic or ask too many specific questions about a topic. In general, keep your answers to questions about other topics short and minimize or deny problems in these other peripheral areas (for example questions about your daily activities, your mood, medical history, family history, or hospitalizations)

You will be given a “cheat sheet” with the table of medications that you can look at if needed. If a student asks you about this sheet, let them know that it is just for you (to help you remember your role).

If a student spends too much time on unrelated questions, say:

• The doctor said you were just going to ask me about my medications

• I thought you were going to ask me about my medications

If a student does not ask a lot of in depth questions about the medications and related problems, say:

• I am concerned I am taking too many medications

• I am starting to have a hard time managing all these medications

• Do I really have to take all of these?

• I am a bit worried about this lightheaded I have been feeling lately

During the final two minutes of the interview, you can prompt:

• Is there anything I should be concerned about with my medications?

• Are there any other recommendations you have for me?

• What could be causing my lightheadedness?

Appendix C

Medication bottle labels

Note: The labels below are for a testing date in June 2010. Both the original prescription date and the expiration date need to be made current for the timing of the OSCE. RX dates for the HCTZ, omeprazole, warfarin, and Cardizem CD need to be approximately 3 months prior to the OSCE, and have 3 refills remaining. The acetaminophen with codeine prescription is prescribed about 1 week after the date of Dr. Baxter’s prescription. The meclizine dates need to be current for the OCSE but should be different from the others since it is a borrowed medication. All the labels are designed to fit on Avery label template 5395

|MVK Healthcare Clinic Dr. S. Baxter |MVK Healthcare Clinic Dr. S. Baxter |

|(305) 555-1234 |(305) 555-1234 |

|RX date: 3/1/10 [pic] |RX date: 3/1/10 [pic] |

|Alex Miller |Alex Miller |

|Take 1 tablet by mouth daily after breakfast for blood pressure |Take 1 capsule by mouth daily before breakfast for blood pressure and |

| |heart rate |

|HCTZ 25 mg TAB Qty: 30 | |

| |CARDIZEM CD 180 MG DAILY CAP Qty: 30 |

|Refills: 3 Expires: 1-Dec-10 |Refills: 3 Expires: 1-Dec-10 |

|MVK Healthcare Clinic Dr. P. Drury |MVK Healthcare Clinic Dr. S. Baxter |

|(305) 555-2789 |(305) 555-1234 |

|RX date 1/25/10 [pic] |RX date 3/1/10 [pic] |

|Alice Metzger |Alex Miller |

|Take 1 tablet by mouth every 6-8 hours as needed for dizziness |Take 1 tablet by mouth daily before dinner for blood thinning |

| | |

|MECLIZINE 25 MG TAB Qty: 120 |WARFARIN 5 MG TAB Qty: 30 |

| | |

|Refills: 2 Expires: 10-Oct-10 |Refills: 3 Expires: 1-Dec-10 |

|MVK Healthcare Clinic Dr. S. Baxter |MVK Healthcare Clinic Dr. C. Sommer |

|(305) 555-1234 |(305) 555-8903 |

|RX date: 3/1/10 [pic] |RX date: 3/8/10 [pic] |

|Alex Miller |Alex Miller |

|Take 1 capsule by mouth after dinner |Take 1 tablet by mouth every 6 hrs as needed for hip pain |

| | |

| |ACETAMINOPHEN WITH CODEINE (300/30) TAB Qty: 90 |

|OMEPRAZOLE 20 MG CAP Qty: 30 |Refills: 3 Expires: 8-Dec-10 |

| | |

|Refills: 3 Expires: 1-Dec-10 | |

Appendix D

Pocket Card Reminder (Cheat Sheet) for the SP

High blood pressure - Arthritis - Irregular heartbeat - Cataracts - NEW Dizziness

|MEDICATION… |FOR… |WHEN… |HOW LONG… |

|HCTZ |Blood pressure |After breakfast |Many years |

|CARDIZEM |Blood pressure |Before breakfast |3 years |

| | | |Increased 3 months ago |

|WARFARIN |Prevent stroke |Before dinner |3 months |

|ACETAMINOPHEN with CODEINE |Arthritis |2-4 times/day |3 months |

|OMEPRAZOLE |Don’t know |After dinner |Several years |

|MECLIZINE |Dizziness |After lunch & bedtime |A few weeks |

|TYLENOL (regular) |Arthritis |2 pills twice/day |Several years |

|MULTIVITAMIN |Good health |1 daily |Ten years |

|HERBAL TEA |Relaxation |Evening |Several years |

Note: This card is only for use by the standardized patients in the Geriatrics OSCE

Appendix E

Additional Clinical Information for the Raters – Not Given to SPs

1. Hypertension: the BP has been well controlled for many years. Cardizem has been causing a mild lightheadedness since it was increased from 120 to 180 three months ago to treat both the HTN and the newly diagnosed atrial fibrillation. The 180 mg dose is expensive and occasionally the patient misses doses at then end of the month if money is short. A change to a different medication is warranted.

2. Atrial fibrillation: discovered 3 months ago; not associated with heart failure. Warfarin was added at this time and may be contributing to the lightheadedness. Regular lab work demonstrates a therapeutic range. No anemia, melena or other signs of blood loss are present.

3. Arthritis: the right hip arthritis has been progressively worsening over the past 4 years. The patient was unable to tolerate a high dose of NSAID (naproxen) needed to provide relief because of GI upset, even with the addition of a proton pump inhibitor. Three months ago the naproxen was discontinued and the patient was started on acetaminophen with codeine. The physician failed to simultaneously discontinue the omeprazole.

4. Lightheadedness: this is likely a side effect of the increased dose of Cardizem, the warfarin, the acetaminophen with codeine, or any combination of these medications.

5. Therapeutic duplication: The patient does not realize that acetaminophen is the same as Tylenol. This raises the potential for a serious medication side effect (liver toxicity).

6. Multiple Physicians: Dr. Baxter is the primary care physician who may not be aware of the medication changes made by Dr. Sommer, the rheumatologist. Dr. Drury is not the patient’s physician.

Appendix F

Performance Checklist

Student: Evaluator:

Date/time:

|Did the student consider or discuss: |Yes |No |Comments |

|Current medical conditions (In addition to HTN, patient has atrial fibrillation, | | |(Credit only if student clearly asks about ALL |

|cataracts, arthritis) | | |medical conditions not solely about illnesses |

| | | |related to medications |

|Current medications: | | | |

|OTCs (regular Tylenol) | | | |

|Herbals (tea) | | | |

|Vitamins | | | |

|Medication “borrowing” (Meclizine) | | | |

|Which/how many MDs prescribe | | | |

|Patient’s understanding of indications for medications (prescribed and other) | | | |

|Patient’s understanding of how to take meds | | | |

|New medications or dose adjustments | | | |

|Side/adverse effects (dizziness from Cardizem, Codeine, or Warfarin) | | | |

|Allergies to medications | | | |

|Beneficial effects (does the pt feel the meds help) | | | |

|Barriers | | | |

|Adherence (is patient taking meds as prescribed) | | | |

|Cognition/memory (does pt forget to take meds?) | | | |

|How are refills obtained | | | |

|Ability to pay | | | |

|Physical barriers to taking meds (e.g., vision, arthritis) | | | |

|Availability of family/friends support | | | |

|How the meds are organized | | | |

|Did the student recommend: | | | |

|Informing ALL doctors of ALL meds | | | |

|Simplifying the schedule | | | |

|Eliminating Omeprazole (no indication) | | | |

|Large print labels | | | |

|A pillbox to organize medications | | | |

|Use of a mail/pharmacy delivery option | | | |

|Getting regular caps (easy-open bottles) | | | |

|Did the student consider or discuss |Yes |No |Comments |

|Safety concerns with borrowing or sharing meds | | | |

|Multiple meds as a cause of side effects | | | |

|Therapeutic duplication (acetaminophen) | | | |

|Potential drug risks (e.g., liver injury from acetaminophen duplication, bleeding | | | |

|from warfarin) | | | |

|Financial assistance for meds (Medicare Part D, drug insurance, discount plan, | | | |

|generic meds) | | | |

|Did the student… |Satisfactory |Marginally |Unsatisfactory |

|(Check how student ranked in each area below) | |Satisfactory | |

|Introduce him/herself to the patient? | | | |

|Act in a professional and appropriate manner? | | | |

|Make appropriate eye contact? | | | |

|Ask questions in an organized fashion? | | | |

|Allow patient time to answer? | | | |

|Avoid leading questions? | | | |

|Appear comfortable with the interaction? | | | |

|Please assess the following by checking the appropriate box: |

|UNACCEPTABLE |NEEDS IMPROVEMENT |MEETS EXPECTATIONS |WELL ABOVE EXPECTATIONS |TRULY RARE TOP 5% |

|Data Gathering: The student's medication history |

|( Inaccurate, unreliable, |( Unfocused, disorganized, |( Complete, accurate, |( Focused, detailed, precise,|( Efficient, insightful, |

|major omissions |incomplete |chronologic, identifies major|well organized, identifies |appreciates subtleties, uses |

| | |problems beyond the medical |minor problems |facilitative, directive, & |

| | |domain | |clarifying techniques |

|Interpretation/Management: The students analyses/synthesis and recommendations |

|( Fails to identify major |( Problems not well-defined, |( ID’s major problems, |( Problems well-defined, |( Understands and |

|problems, unable to explain |superficial thought process, |Addresses issues beyond the |reflects thoughtful |interrelates complex issues, |

|simple issues, unable to |limited interpretation, |medical domain. Offers |under-standing, Addresses |Synthesizes medical, |

|offer basic recommendations |offers only basic |appropriate recommendations |medical, functional, |functional, psychological, & |

| |recommendations |for major issues |psychological, & |socio-economic info into |

| | | |socio-economic domains. |sound plan and |

| | | |Recommendations are complete |recommendations |

Do you have any other comments about this student’s performance?

Appendix G

Faculty feedback discussion points

At the end of the OSCE, the faculty rater has two minutes to give feedback to the student before the next student arrives. Because of this time limitation associated with our OSCE, the following recommendations are provided to our faculty raters for giving feedback to students.

• Ask students to reflect on their own performance first (what went well, what went less well or what was challenging); then mention what they did well followed by what areas need improvement. Use the checklist as a guide to give students global feedback but refrain from mentioning every single item they may have missed. Include some comments about their interviewing style and professionalism.

• At the end of the checklist are two global ratings. These ratings should correlate reasonably well with the number of items checked off. Students should leave the station with a sense of their global ratings so that they will not be too surprised later when they find out their score. If you have serious concerns, please do no hesitate to introduce these, but be mindful that the student may have nine more stations to complete, so whenever possible, end on an encouraging note. Remember, these students will have one more year to practice their clinical skills before residency. Let them know what skills need improvement.

• Reinforce the importance of asking questions in all domains (economic, social, psychological, and functional) since these factors can impact adherence. If time allows, you can even ask the students what recommendations they would make now that you have discussed some additional concerns. Note: you will NOT score these on the checklist, but it might make students feel better they were able to think of additional recommendations.

• Students are always curious about how they performed. Do not tell them they “passed” or “failed.” (In the past, students who needed remediation would often tell the OSCE faculty director, “But my preceptor said I did well.”) The best method for handling the “pass-fail” question is to give honest and kind feedback and say that you are not the person who determines which students need remediation and reassessment.

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