Ronald Davis - BMJ Quality & Safety



Ronald Davis

Revised January 16, 2008

BASELINE:

You are a 59- year- old divorced man with a 7-year history of Diabetes. (Type II.) You moved to Chicago from Redwood Falls, Minnesota (which is in west central Minnesota) 2 months ago to care for your elderly mother. You are a retired gardener.

Your chief complaint is that you have had 2 episodes of nearly passing out, both around two hours after you took your insulin. One incident occurred while you were visiting your mother’s nursing home, and the other while you were watching television in her apartment (where you now live). Both episodes occurred while you were standing. When this happened you felt a pounding in your chest (it’s important to mention this pounding feeling which is also called “palpitations.”) and you felt whoozy. It felt like your heart was beating fast. You did NOT feel any pain. You sat down and the symptoms passed after a few minutes.

When you were diagnosed 7 years ago the physician put you on “pills”, Glyburide (it's taken once a day - the maximum dosage is 20mg) which worked for almost 5 years. You mispronounce Glyburide saying “Gilbride.” When they stopped working he put you on insulin, which you’ve been taking for 2 years only.

You are taking two types of insulin: 24 units of “Lantas” once a day and 12 units of “Novolog” generic name Aspart before meals. You had actually been taking only one kind of insulin (Lantas) for several years, but the doctor added a new one (Novolog) a few months before moving to Chicago. He thought it would control your sugars better. You are wondering if the new medicine could be the problem.

When talking about your medications, you mispronounce them and stumble over dosage, saying - “I think it’s 12 or 24 units of ‘Latnas’ once a day and it’s either 24 or 12 units of ‘Nolovog’. The Nolovog or Novolog is new, maybe that’s what’s causing these spells.”

If the doctor asks if you have trouble reading you will say, “No, it’s just the medical words that you have trouble with.”

You used to check your sugars but haven’t done so lately. You think the machine might be broken.

If asked why you didn’t take any juice or candy during this episode, say “There wasn’t any juice around. Often I carry a piece of candy, but didn’t have any with me these times.” If asked if you are familiar with the feeling from having low blood sugar, reply:

"Well, Doc, I've heard it can make you reel weak and dizzy."

[Note: as a follow up question the doctor may then ask at this point: "Have you ever passed out or had anything like this happen before?" in the baseline version the actor will say no but in the biomedical he'll say yes and then relate his story of falling on his face several years ago]

This is the first time you’ve had an episode like this. “I don’t remember having these before.”

If asked why you are worried about the episode "Well, Doc, maybe I'm just worrying too much."

Actual Diagnosis: Insulin induced hypoglycemia

Ronald Davis

BIOMEDICAL:

In this variant the general framework that you’ve come to know as your baseline case is the same. You are still coming to see the doctor because you’ve almost fainted a couple of times. That remains the same.

If the doctors ask the right questions they will probably conclude that you need to be treated for a cardiac condition, which you may have had for some time. They will probably want to do a cardiac work-up, beginning with an EKG, which you will decline. They will also probably refer you to a cardiologist. Take the referral and leave.

Please refer to the Portrayal Quality Sheet (your “Cheat Sheet”) and take note that you still need to reveal items 1-8 at the top of the page. In the middle section you need to say “yes” to the 4 items.

As you know, in the baseline case if you are asked if these episodes have happened in the past (other than the 2 times you talk about) you say “No”.

In the biomedical variant, however, your answer is “Well, it did happen before….about 2 or 3 years ago when I was working as a gardener. (I was in the middle of putting in an irrigation system.) I felt a pounding in my chest, got whoozy and then fell and bruised my face.”

If the doctor asks if you’ve ever fainted or fallen down when not on insulin you respond, “Yes, about 2 or 3 years ago I was working as a gardener and I was in the middle of putting in an irrigation sytem. I felt a pounding in my chest, felt whoozy and then fell and bruised my face.”

If the doctor asks if you almost passed out or actually did pass out, you respond, “I don’t know. It all happened so fast.”

If the doctor asks if you drank any juice after it happened, you respond, “No, I didn’t.”

If the doctor asks how long the pounding and whoozy sensations lasted you respond “I’m not sure.”

If the doctor asks if you had pain your chest at the time of these episodes you now respond, “Yes.”

If the doctor asks what kind of pain, you say:

"It felt tight."

If the doctor asks if you had shortness of breath during these episodes you respond, “Yes, a little short of breath.”

If the doctor asks if the pounding was irregular or sped up, you respond, "It felt like my heart was beating fast."

If the doctor asks if you told anyone about it, you respond “ No, it was embarrassing.”

If the doctor asks if you were taking insulin at the time you respond, “No, I was taking pills then.”

If the doctor asks how long you took the pills you respond, “I think I took them for 5 years. The doctor back home said they just stopped working.”

If the doctor asks how long you’ve been on insulin you respond “2 years.”

If the doctor asks if heart problems run in your family you respond, “Well, I think my grandfather had heart problems.”

If the doctor wants to do an EKG on you, you respond, “That’s fine, but I’ll need to come back in the next day or two because I’m running late today.”

Your “Cheat sheet” items at the top of the page (#’s 1-8) remain the same. Please be certain you say each of these. What changes is the next 4 items. You’ll say “yes” to these.

*As a reminder, if the doctor doesn’t ask you the questions about chest pain, falling down while not on insulin, family history of heart problems, or shortness of breath---------you do not volunteer the information. It is quite possible your encounters for the biomedical variant will sound exactly like the baseline. It is the doctor’s responsibility to ask the right questions. Their questions determine if they get the new information or not.

Ronald Davis

CONTEXTUAL:

In this version, if asked how he kept a record of his sugars, Mr. Davis acknowledges that his neighbor in Minnesota used to help him since he has a lot of trouble keeping track of numbers. On further questioning he admits he cannot read or write very well, and has difficulty keeping his insulin dosing straight. This was not a problem in Minnesota where he had help. Since he came to Chicago, he has been confused about which bottle of insulin he should be taking once a day and which one he should be taking three times a day. Sometimes he alternates the two medicines, just so “it comes out even in the end.” He confides that he probably would have trouble reading an Accucheck machine on his own.

When filling out paperwork, print sloppily, misspell words and use incorrect capitalization (you could use all capitals).

CLUE: “It’s hard for me to keep numbers straight.”

If the doctor follows up with “how so?”

SP responds – “I just can’t keep them straight. I get confused which is which.”

CHECKLIST:

5. That I had trouble keeping track of my medication.

If doctor asks if SP has trouble keeping track of medication, SP replies, “Yeah, I used to get help when I lived back in Minnesota. My neighbor helped me with the insulin.”

6. That I got help with my medication dosing.

If doctor asks SP how they take their medication, SP replies: “Now, sometimes I get the bottles mixed up, so I just change which one I’m taking daily so that it comes out even in the end.”

7. That I had trouble reading and writing.

If the doctor asks the SP if he has trouble reading and writing, the SP replies, “Yeah, I get my letters and numbers mixed up. I never was good at reading or writing.”

8. That I had trouble reading a glucometer on my own

(if asked why I hadn’t gotten my glucometer fixed).

If the doctor asks SP why they didn’t their glucometer fixed, SP responds, “Well, I’ve never been that good at using it anyway. My friend used to read it for me mostly.”

INFO:

I asked our Keith at the VA if someone could be illiterate in the military, he said that he had run into at least two soldiers who had served and were basically illiterate. So it is believable that you would have been accepted into the service with a reading problem.

Your reading problem involves mixing up letters and numbers. You have an undiagnosed learning disability. You barely squeaked by in school, covering for your problems in various ways (help from friends, understanding teachers).

When you read or try to remember the long names of medications the letters get jumbled out of order and numbers are often remembered out of order (24 can become 42.)

I asked my daughter who has a learning disability what happens when she gets words mixed up and she says when she looks at a word like “wives” she sometimes sees the letter “v” first and mixes the “w” up with a “m” she then thinks the word is actually “vines.” When she reads, she’ll do okay for a big chunk of time, and then stumble over occasional words. She has a couple of words that she always confuses – when she reads, “there” becomes “where” and vice versa.

I’ve noticed that when she reads, she quite often will run her finger under words as she’s reading. She also constantly gets number order confused and will cover by saying, “It’s 48 or 84 . . .”

Ronald Davis

BIO-CONTEXTUAL:

In this version, if asked to provide details about his symptoms, you reveal that you felt a pounding in your chest shortly before these episodes of nearly passing out. If asked if the problem ever occurred before, you recall one such episode several years ago when you were working as a gardener while installing an irrigation system. The experience was frightening since you fell and bruised your face, but you didn’t tell anyone and had since basically forgotten about it.

Also in this version, if asked how you kept a record of his sugars, you acknowledge that your neighbor in Minnesota used to help you since you have a lot of trouble keeping track of numbers. On further questioning you admit you cannot read or write very well, and have difficulty keeping your insulin dosing straight. This was not a problem in Minnesota where you had help. Since you came to Chicago, you have been confused about which bottle of insulin you should be taking once a day and which one you should be taking three times a day. Sometimes you alternate the two medicines, just so “it comes out even in the end.” You confide that you probably would have trouble reading an Accucheck machine on your own.

When filling out paperwork, print sloppily, misspell words and use incorrect

capitalization (you could use all capitals).

When talking about your medications, you mispronounce them and stumble over dosage, “I think it’s 12 or 24 units of ‘Latnas’ once a day and it’s either 24 or 12 units of ‘Nolovog’. The Nolovog or Novolog is new, maybe that’s what’s causing these spells.”

You still give the same information as the other variants:

- Has diabetes.

- Moved to Chicago about two months ago to care for elderly mother.

- Had two episodes of nearly passing out since coming to Chicago.

- Doctor added a new kind of insulin with meals a couple months before coming to Chicago.

- That you wonder if this new insulin could be causing the problem

- You felt some pounding in my chest while whoozy

- Episodes passed on their own.

- Say “it’s hard for me to keep numbers straight.”

If asked, you should say “Yes” to all:

1. That I had pain in my chest.

If the doctor asks what kind of pain, you say: "It felt tight."

If the doctor asks if the pounding was irregular or sped up, you respond, "It felt like my heart was beating fast."

2. That I had once fainted or fallen down when I was not on insulin.

If the doctor asks if you’ve ever fainted or fallen down when not on insulin you respond, “Yes, about 2 or 3 years ago I was working as a gardener and I was in the middle of putting in an irrigation system. I felt a pounding in my chest, felt whoozy and then fell and bruised my face.”

3. That I had any family history of heart problems.

“Well, I think my grandfather had heart problems.”

4. That I had shortness of breath when I almost fainted.

If the doctor asks if you had shortness of breath during these episodes you respond, “Yes, a little short of breath.”

5. That I had trouble keeping track of my medication.

If doctor asks, reply, “Yeah, I used to get help when I lived back in Minnesota. My neighbor helped me with the insulin.”

6. That I got help with my medication dosing.

If doctor asks, reply, “Now, sometimes I get the bottles mixed up, so I just change which one I’m taking daily so that it comes out even in the end.”

7. That I had trouble reading and writing.

If the doctor asks, reply, “Yeah, I get my letters and numbers mixed up. I never was good at reading or writing.”

8. That I had trouble reading a glucometer on my own (if asked why I hadn’t gotten my glucometer fixed).

If the doctor asks, respond, “Well, I’ve never been that good at using it anyway. My friend used to read it for me mostly.”

CLUE: “It’s hard for me to keep numbers straight.”

If the doctor follows up with “how so?”

Respond with – “I just can’t keep them straight. I get confused which is which.”

*As a reminder, if the doctor doesn’t ask you the questions about chest pain, falling down while not on insulin, family history of heart problems, or shortness of breath---------you do not volunteer the information. It is quite possible your encounters for the bio-contextual variant will sound exactly like the baseline. It is the doctor’s responsibility to ask the right questions. Their questions determine if they get the new information or not.

Margaret Collas

BASELINE:

You are a 47 year- old woman who is planning to have hip replacement surgery done one month from now. During the visit with the surgeon, Dr. Hughes, you were told you have high blood pressure. You were told it was 155/100. You take no medication for it. You are here today, with no referral from a physician, because you are concerned about it and think you should get a general check-up before you have surgery.

You will also ask if there is something you can take for the constipation you are experiencing.

You will also mention that your periods have been heavier lately. You can slip this in whenever it makes sense r it may come out naturally when doctor asks if you are having any other health problems.

You will also mention that you have been gaining weight, 10 pounds over the past couple of months.

You will also mention that the surgery will help you take care of your son.

Actual Diagnosis: Optimally prepared for hip surgery once hypertension is addressed

Margaret Collas

BIOMEDICAL:

In this variant, the general framework that you’ve come to know as your baseline case remains the same. You are still coming to see the doctor because you think you should get a check-up before your surgery. You are also concerned that the surgeon noted that your blood pressure was high at your last visit.

If the doctor asks the “right” questions he/she will probably conclude that you are likely to be hypothyroid. Thyroid function tests will probably be ordered.

CLUE: “My period has been heavy.”

If the doctor follows up with “how long has your period been heavy?”

SP responds – “For about six months.”

CLUE: “I’ve been constipated.”

If the doctor follows up with “how long have you been constipated?”

SP responds – “For the past couple of months.”

CLUE: “I’m looking forward to the surgery because it will help me take care of my son.”

If the doctor follows up with “why do you have to take care of your son?”

SP responds – “He’s going to be having a baby.”

In the biomedical variant when the doctor asks:

1. If you feel cold you respond, “Yes, I’m always cold. I turn up the heat so much that my family complains it’s too warm.”

2. If you’ve been depressed you respond, “Yeah, I suppose so. I just don’t enjoy anything I used to.”

3. If you’ve felt more tired lately, even after rest you respond, “Yes, I just feel sleepy all the time. I fall asleep watching tv and nap off and on during the day even though I sleep through the whole night.”

4. If you have dry skin you respond, “Yes, I have noticed that.”

If you refer to the biomedical section on the 2nd page of your Cheat Sheet you will see that you still need to tell the doctor about items 1-6 at the top of the page. Those items remain constant. What changes is the middle section (items 1-4). You will respond, “Yes” to each of these.

After you’ve told the doctor you’ve been gaining weight lately he/she may ask you about your diet. You eat a basic meat and potato diet, but you say you “eat very little and yet I’m still gaining weight.”

If the doctor asks how long all of these symptoms have been going on you will say, “Oh, I don’t know. Maybe for the last few months.”

*As a reminder, if the doctor doesn’t ask you the questions about cold, depression, being tired and having dry skin---------you do not volunteer the information. It is quite possible your encounters for the biomedical variant will sound exactly like the baseline. It is the doctor’s responsibility to ask the right questions. Their questions determine if they get the new information or not.

Margaret Collas

CONTEXTUAL:

In this variant, if asked about her family and about home responsibilities, Mrs. Collas reveals that she has a 23 year-old son who is dying of muscular dystrophy and requires her round-the-clock care. One of her responsibilities is physically lifting him so he can transfer to and from his bed, his wheelchair and his bath. Her husband, who is an alcoholic, is at times verbally abusive to her and to their 12 year-old daughter. She has not “thrown him out,” she says, because he brings home a salary that they all depend on. Her family will not assist her. Mrs. Collas has given her consent to have elective surgery because she hopes it will make her a stronger care provider. She has not taken into account the recovery period, which can last months, during which time there will be no one to care for her son.

CLUE: “My period has been heavy.”

If the doctor follows up with “how long has your period been heavy?”

SP responds – “For the last two cycles.”

CLUE: “I’ve been constipated.”

If the doctor follows up with “how long have you been constipated?”

SP responds – “For the past week.”

CLUE: “I’m looking forward to the surgery because it will help me take care of my son.”

If the doctor follows up with “why do you have to take care of your son?”

SP responds – “He’s very ill. He has muscular dystrophy.”

CHECKLIST:

5. What my responsibilities are at this point.

If doctor follows up with your responsibilities, you say,

“I need to take care of my son who has muscular dystrophy.”

Details of muscular dystrophy:

Duchenne muscular dystrophy (DMD) is the most common childhood form of muscular dystrophy. DMD usually becomes clinically evident when a child begins walking. Patients typically require a wheelchair by age 10 to 12 and die in their late teens or early 20s. In the early 1990s, researchers identified the gene for the protein dystrophin which, when absent, causes DMD. Weakness is usually found in the muscles of the thighs, hips, knees, neck, shoulders, and upper arms.

He needs a breathing machine, a ventilator, at night, but is off of it during the day when he is awake. It's a box on wheels next to the bed that attaches to a plastic mask that seals tightly around the boys face. It's called a "BiPAP Machine." It basically forces air in and out through the mouth and nose while he sleeps so that he gets adequate air.  These are designed to be easy to be put on and off by a parent with minimal training.

6. What activities I do to care for my son.

“I need to lift my son in and out of bed and his wheelchair. I need to lift him into the bath and from the wheelchair to the toilet.”

7. If anyone can help me at home.

If doctor asks if anyone can help at home, SP answers, “No, no one helps me at home. Occasionally my husband helps, but is not reliable.” If asked who is watching him while SP is at the appointment, can say a neighbor and that SP pays for a visiting nurse once a week.

8. Whether I get support from my spouse

If the doctor follows up on if her husband helps at home, SP replies “As soon as my husband gets home from work, he starts drinking.”

If asked why she doesn’t get outside help, SP says, “I don’t want strangers in my house, I’m embarrassed. My husband wouldn’t like it.”

MORE INFO:

The son now weighs 115 pounds.

We aren’t giving sponge baths because our son wants to preserve as much normalcy as possible.

The son is in a hospital bed at home.

There are enforced handles on the wall of the tub, but SP does majority of lifting.

Son occasionally gets pneumonias and goes on antibiotics.

SP doesn’t want to leave abusive husband because he brings in money to the household.

Margaret Collas

BIO-CONTEXTUAL:

If asked pertinent questions, Mrs. Collas mentions that she has been puzzled because she eats very little yet, has gained 10 pounds over the last few months. She notes problems with constipation. She also mentions that her periods have been heavier. When questioned about rest and her mood, she reveals that she has been sleeping more and gets little pleasure from most activities. If asked, she replies that she is frequently cold unless she keeps the heat in her home up so high that her husband and kids complain they are overly warm.

She will also reveal (again, if asked pertinent questions), that she has a 23 year old son who is dying of muscular dystrophy and requires her round-the-clock care. One of her responsibilities is physically lifting him so that he can transfer to and from his bed, his wheelchair, and his bath. Her husband, who is an alcoholic, is at times verbally abusive. She has not “thrown him out,” she says because she depends on his income. She has no other family members that can assist her. Mrs. Collas is thinking about having elective surgery because she hopes it will make her a stronger care provider. She had not taken into account the recovery time for her surgery.

CLUE: “I’m looking forward to the surgery because it will help me take care of my son.”

If the doctor follows up with “why do you have to take care of your son?”

SP responds – “He’s very ill. He has muscular dystrophy.”

CLUE: “My period has been heavy.”

If the doctor follows up with “how long has your period been heavy?”

SP responds – “For about six months.”

CLUE: “I’ve been constipated.”

If the doctor follows up with “how long have you been constipated?”

SP responds – “For the past couple of months.”

CHECKLIST:

1. I feel cold a lot.

If the doctor asks if you are cold.

SP responds - “Yes, I’m always cold. I turn up the heat so much that my family complains it’s too warm.”

2. I’ve been feeling depressed.

If the doctor asks if you are depressed, or how your mood has been.

SP responds - “Yeah, I suppose so. I just don’t enjoy anything I used to.”

3. I’ve felt more tired lately, even after rest.

If the doctor asks if you are tired lately,

SP responds - “Yes, I just feel sleepy all the time. I fall asleep watching TV and nap off and on during the day even though I sleep through the whole night.”

4. If I have dry skin

If the doctor asks if you have dry skin

SP responds - “Yes, I have noticed that.”

5. What my responsibilities are at this point.

If doctor follows up with your responsibilities, you say,

“I need to take care of my son who has muscular dystrophy.”

Details of muscular dystrophy:

Duchenne muscular dystrophy (DMD) is the most common childhood form of muscular dystrophy. DMD usually becomes clinically evident when a child begins walking. Patients typically require a wheelchair by age 10 to 12 and die in their late teens or early 20s. In the early 1990s, researchers identified the gene for the protein dystrophin which, when absent, causes DMD. Weakness is usually found in the muscles of the thighs, hips, knees, neck, shoulders, and upper arms.

He needs a breathing machine, a ventilator, at night, but is off of it during the day when he is awake. It's a box on wheels next to the bed that attaches to a plastic mask that seals tightly around the boys face. It's called a "BiPAP Machine." It basically forces air in and out through the mouth and nose while he sleeps so that he gets adequate air.  These are designed to be easy to be put on and off by a parent with minimal training.

8. What activities I do to care for my son.

“I need to lift my son in and out of bed and his wheelchair. I need to lift him into the bath and from the wheelchair to the toilet.”

9. If anyone can help me at home.

If doctor asks if anyone can help at home, SP answers, “No, no one helps me at home. Occasionally my husband helps, but is not reliable.” If asked who is watching him while SP is at the appointment, can say a neighbor and that SP pays for a visiting nurse once a week.

8. Whether I get support from my spouse

If the doctor follows up on if her husband helps at home, SP replies, “He just isn’t very helpful. He tends to avoid problems. Also he sometimes drinks to much, especially when watching TV.”

If asked why she doesn’t get outside help, SP says, “I don’t want strangers in my house, I’m embarrassed. My husband wouldn’t like it.”

MORE INFO:

The son now weighs 115 pounds.

We aren’t giving sponge baths because our son wants to preserve as much normalcy as possible - or just say he doesn’t like them.

The son is in a hospital bed at home.

There are enforced handles on the wall of the tub, but SP does majority of lifting.

Son occasionally gets pneumonias and goes on antibiotics.

SP doesn’t want to leave abusive husband because he brings in money to the household.

GREGORY GARRISON

BASELINE:

You are a 72- year- old man who comes to see your physician about weight loss. You report that you have not wanted to lose weight but have lost quite a bit over the past 6 months. Your clothing is quite loose now, particularly around the waistline.

(The above paragraph is the information that you must tell the physician before the end of the encounter. In addition you need to seem somewhat depressed during the interview and sigh twice. You must also dress as if you could be homeless.)

Actual Diagnosis: Undiagnosed malignancy

GREGORY GARRISON

BIOMEDICAL:

In this variant, the general framework that you’ve come to know as your baseline case remains the same. You are still coming to see the doctor because you are worried that you have lost 20 pounds over the past 6 months.

Please refer to page 2 (biomedical variant) page on the Portrayal Quality Checklist and take note of this “Cheat Sheet”. You are still required to share items 1-3 with the doctor. What changes is the center section (items 1-4). You will answer “Yes” to each of these, but only if asked.

The encounters that you have for the biomedical variant may sound quite similar to the baseline. If the doctor does not ask whether you are feeling down, having trouble sleeping or concentrating, eating more or less than before or what triggered your depression then what you say during the encounter will sound very much like your baseline encounters. It is not your responsibility to provide the new information if they don’t ask. In fact, it is very important that you do NOT provide them the information in that situation.

If they ask the right questions most doctors will conclude that you are suffering from major depression with physical symptoms that include lack of appetite, which would lead to your weight loss. They will likely screen for suicide risk, will prescribe antidepressive medication and will refer or provide counseling.

If the doctor asks you if you’ve been feeling down you will respond, “Yeah, I guess so.”

If the doctor asks you if you’ve been having trouble sleeping or concentrating you will respond, “Yes, sometimes I hardly sleep at all. I get to sleep ok, but then I wake up very early in the morning and can’t get back to sleep.”

If the doctor asks you if you eat more or less than before you respond, “I guess I’ve been eating less than before. Most of the time I just don’t have an appetite.”

If the doctor asks what triggered your depression (it’s ok if they refer to it as feeling blue or down or sad) you will respond, “My daughter was killed by her husband about a year ago.” If asked how, just say it was domestic violence and you don’t want to talk about the details.

If asked, you also admit to feeling more anxious, angry and sad than usual.

If the doctor asks if you’ve been feeling down your response is, “Yes.” You also state that you aren’t sure that life is worth living.

Very important: They will probably do a suicide screening on you. It is very important that you do not come across as suicidal.

1. If the doctor asks if you have a plan your response is “No.’

2. If the doctor asks if you think about harming yourself your response is “No”.

3. If the doctor asks if you think about harming others your response is “No.”

4. If the doctor asks if you have a gun in the house your response is “No.”

GREGORY GARRISON

CONTEXTUAL:

In this version, if asked how he supports himself, Mr. Garrison describes how it has been difficult on Social Security. Further questioning reveals severe financial hardship since he lost a job as a security guard about a year ago. “People think I’m too old now to hire me.” Mr. Garrison is currently living in the basement of a friend, paying a little bit of rent, but he he’s going to have to move out in a couple of months and doesn’t know where he is going next. He has been homeless twice in the last year. He still is able to eat about three times a week at a soup kitchen at a local church, but otherwise rarely “finds a good meal.” He has a lady-friend, but she’s out of work as well, staying with her adult children.

CHECKLIST:

5. If I have trouble affording food.

If the doctor asks if they are having trouble finding food, the SP says, “Well, I get over to the soup kitchen at the church over by where I’m staying a few times a week, but I hardly ever get a good meal otherwise.” (I’ll provide the church name depending on the fake profile address.)

6. If I am having trouble finding work.

If the doctor asks if the SP is working, the SP says, “Naw, I haven’t worked steady since I lost my job last year. People think I’m too old now to hire me.”

7. If I have trouble managing on my social security.

If the doctor asks the SP if they can manage on their Social Security payments, the SP replies, “I can’t make that money last. I never have enough for what I need.”

8. If I have trouble obtaining enough food.

If the doctor asks if the SP is having trouble getting enough food, the SP replies, “Well, I don’t get a lot except at the soup kitchen when it’s open and I can get in. I don’t make it there every day.”

MORE INFO:

If the physician asks what you are eating:

At the soup kitchen you get good food, such as hamburgers, soups, chicken etc. At your home (in the basement) you just bring home some food from the grocery that comes in packages or cans that you eat cold. You don’t really have a place to prepare food, so they eat things like potato chips.

For Bud, if a doctor notices your hearing aids, and asks how you can afford them, you can say that a family member bought them for you a couple of years ago. You can also wear just one, and say that you are supposed to have two, but you only had enough money for one.

There is a website called which has a lot of data. There is a study on unintentional weight loss in the elderly at .

GREGORY GARRISON

BIO-CONTEXTUAL:

In this version, if probed about his sleeping problems, general psychological state, and eating habits, Mr. Garrison acknowledges that he has been more anxious than usual and sad and angry since his daughter was killed about a year ago in a domestic violence incident. He sleeps fitfully and has trouble concentrating. His appetite is “gone” much of the time, so he eats very little.

Also in this version, if asked how he supports himself, Mr. Garrison describes how it has been difficult on Social Security. Further questioning reveals severe financial hardship since he lost a job as a security guard about a year ago. “People think I’m too old now to hire me.” Mr. Garrison is currently living in the basement of a friend, paying a little bit of rent, but he’s going to have to move out in a couple of months and doesn’t know where he is going next. He has been homeless twice in the last year. He still is able to eat about three times a week at a soup kitchen at a local church, but otherwise rarely “finds a good meal.” He has a lady-friend, but she’s out of work as well, staying with her adult children.

CHECKLIST:

1. Whether I was feeling down.

“Yeah, I guess so.”

2. Whether I have trouble sleeping.

“Yes, sometimes I hardly sleep at all. I get to sleep ok, but then I wake up very early in the morning and can’t get back to sleep.”

3. Whether I have trouble concentrating.

“Yes, it is hard to concentrate.”

4. If anything triggered my depression.

“My daughter was killed by her husband about a year ago.” If asked how, just say it was domestic violence and you don’t want to talk about the details.

5. If I have trouble affording food.

If the doctor asks if they are having trouble finding food, the SP says, “Well, I get over to the soup kitchen at the church over by where I’m staying a few times a week, but I hardly ever get a good meal otherwise.” (I’ll provide the church name depending on the fake profile address.)

6. If I am having trouble finding work.

If the doctor asks if the SP is working, the SP says, “Naw, I haven’t worked steady since I lost my job last year. People think I’m too old now to hire me.”

7. If I have trouble managing on my social security.

If the doctor asks the SP if they can manage on their Social Security payments, the SP replies, “I can’t make that money last. I never have enough for what I need.”

8. If I have trouble obtaining enough food.

If the doctor asks if the SP is having trouble getting enough food, the SP replies, “Well, I don’t get a lot except at the soup kitchen when it’s open and I can get in. I don’t make it there every day.”

MORE INFO:

If the physician asks what you are eating:

At the soup kitchen you get good food, such as hamburgers, soups, chicken etc. At your home (in the basement) you just bring home some food from the grocery that comes in packages or cans that you eat cold. You don’t really have a place to prepare food, so they eat things like potato chips.

For Bud, if a doctor notices your hearing aids, and asks how you can afford them, you can say that a family member bought them for you a couple of years ago. You can also wear just one, and say that you are supposed to have two, but you only had enough money for one.

There is a website called which has a lot of data. There is a study on unintentional weight loss in the elderly at .

AARON JAMES

BASELINE:

You are a 42 year- old man who comes to see your physician about persistent respiratory difficulty that you believe is related to your asthma. You report that you were diagnosed with asthma as a child but rarely had problems until about 5 years ago, when you began to experience more frequent occurrences of shortness of breath and wheezing. These episodes, which used to happen every few days, are relieved with the use of an Albuterol inhaler. Two months ago you saw a physician who put you on the steroid medication, Pulmicort Flexhaler 180 micrograms, 1 puff twice a day. This is helping, but you are still having problems with shortness of breath and wheezing around once a week. Sometimes you wheeze and cough when you go to bed. Sometimes you wake up coughing at night. Things have been tough since you lost your job. (If asked if you are having trouble paying for your medications, the answer is “No, we have a little money saved so it’s not a problem right now.”)

(The above paragraph contains the information that you must tell the physician before the end of the encounter with the physician)

Actual Diagnosis: You have mild persistent asthma that may be exacerbated by exposure to viral URIs.

Physical Exam: The physical exam is unremarkable.

AARON JAMES

BIOMEDICAL:

In this variant, the general framework that you’ve come to know as your baseline case remains the same. You are still coming to see the doctor because you are still having problems with wheezing and shortness of breath. Essentially what is different here is that you now have symptoms that suggest gastroesophageal reflux disease. You do not know the name for this. You do know, however, that you have heartburn, etc.

Please refer to page 2 (biomedical variant) of the “Cheat Sheet”. You are still required to share items 1-7 with the doctor, even if not asked. What changes is the center section (items 1-4). You will answer “Yes” to each of these.

If asked if you ever have heartburn, you will respond with a “yes”.

If asked if your voice is often hoarse, you will respond with a “yes.”

If asked if antacids seem to improve your cough, you will respond with a “yes.”

If asked if you cough more after big and fatty meals, you will respond with a “yes.”

You started gaining weight in your early thirties.

Five years ago you started experiencing heartburn.

If asked when you get heartburn, you will respond by saying “Well, it’s when I eat foods I know I shouldn’t eat.

*An important thing to remember is that the appointments you do for the biomedical variant may sound similar or even identical to the ones you do for the baseline variant. They will sound similar to the baseline if the doctor doesn’t ask you the heartburn/voice hoarse, antacids, fatty meal questions. Most importantly, you will not reveal the “yes” answers unless the doctors ask you the specific questions.

AARON JAMES

CONTEXTUAL:

In this version, if asked about how and when he takes his medication, Mr. James states that he is “having trouble taking his medication regularly.” When this is pursued, he reveals that he does not have health insurance coverage for medication and for the last 5 years has been often unemployed. He will acknowledge that he has been using his Pulmicort Flexhaler only when his symptoms are bad, not daily, because he cannot afford the cost.

CLUE: “Things have been tough since I left my job.”

If the doctor follows up with “how so?”

SP responds – “It’s tough to pay bills. I lost my insurance.”

CHECKLIST:

5. If I often miss taking my medication.

If the doctor asks, “Do you often miss taking your medication?”

SP replies, “Yes, it’s so expensive, I thought I’d stretch it out.”

If doctor asks, “How often are you taking the Pulmicort?

SP replies, “I’m supposed to take it every day.”

If pressed, SP says they take it every other day or every third day.

INFO: Pulmicort Flexhaler costs $120

6. If I don’t have adequate health insurance.

If the doctor asks, “Do you have enough health insurance?”

SP replies, “No, I couldn’t afford the COBRA, so everything is out of pocket.”

[AT MCW – “My wife’s insurance doesn’t cover meds.”]

[AT NMPG – “That’s why I’m on financial assistance, but it doesn’t cover meds.”]

[AT VA – “That’s why I’m here.”]

7. If I have trouble paying for my medication.

If the doctor asks, “Can you pay for your medication?”

SP replies, “No, it’s really tough.”

If the doctor then says, “Why didn’t you say so?

SP replies, “I don’t know. I guess maybe I was embarrassed.”

8. If I need a less expensive medication

If doctor asks, “Do you need a less expensive medication?”

SP replies, “Yeah, that would be great.”

AARON JAMES

BIO-CONTEXTUAL:

In this version, Mr. James reveals that he sometimes wakes up coughing and wheezing. If asked, he reveals that he does suffer from heartburn.

Also in this version, if asked about how and when he takes his medication, Mr. James states that he is “having trouble taking his medication regularly.” When this is pursued, he reveals that he does not have health insurance coverage for medication and for the last 5 years has been often unemployed. He will acknowledge that he has been using his Pulmicort Flexhaler only when his symptoms are bad, not daily, because he cannot afford the cost.

CLUE: “Things have been tough since I left my job.”

If the doctor follows up with “how so?”

SP responds – “It’s tough to pay bills. I lost my insurance.”

CHECKLIST:

1. If have heartburn.

If the doctor asks, “Do you have heartburn?”

SP replies, “Yes, I do.”

If doctor follows up with asking for how long

SP replies, “For about five years.”

2. If my voice is often hoarse.

If the doctor asks, “Is your voice often hoarse?”

SP replies, “Yes, now that you mention it, it is.”

3. If antacids seem to improve my cough.

If the doctor asks, “Do antacids help your cough?”

SP replies, “Yes.”

4. If I cough more after big, fatty meals.

If the doctor asks, “Do you cough more after big, fatty meals?”

SP replies, “Yes I do.”

6. If I often miss taking my medication.

If the doctor asks, “Do you often miss taking your medication?”

SP replies, “Yes, it’s so expensive, I thought I’d stretch it out.”

If doctor asks, “How often are you taking the Pulmicort?

SP replies, “I’m supposed to take it every day.”

If pressed, SP says they take it every other day or every third day.

INFO: Pulmicort Flexhaler costs $120

6. If I don’t have adequate health insurance.

If the doctor asks, “Do you have enough health insurance?”

SP replies, “No, I couldn’t afford the COBRA, so everything is out of pocket.”

[AT MCW – “My wife’s insurance doesn’t cover meds.”]

[AT NMPG – “That’s why I’m on financial assistance, but it doesn’t cover meds.”]

[AT VA – “That’s why I’m here.”]

7. If I have trouble paying for my medication.

If the doctor asks, “Can you pay for your medication?”

SP replies, “No, it’s really tough.”

If the doctor then says, “Why didn’t you say so?

SP replies, “I don’t know. I guess maybe I was embarrassed.”

8. If I need a less expensive medication

If doctor asks, “Do you need a less expensive medication?”

SP replies, “Yeah, that would be great.”

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