Observed Structured Clinical Examinations:

Instructions for the Residents:

Introduction: You are a physician working in the clinic this afternoon. You are
about to see a newborn brought in by her mother.
Brief Summary: Madeline Cuncha is a 19 day old F brought into the ER by her
mother, Maria Cuncha, to be seen for fussiness, decreased oral intake and increased
sleepiness. Her vitals and physical examination are as listed below (no physical
examination is needed during this encounter.)
Physical Exam: T100.9; HR 170; RR 50; 80/50. Weight: 4kg
Gen: sleepy, irritable, fussy
HEENT: AFSF, NCAT, PERRL, TMs pearly bilaterally, MMM
CV: RRR no murmur, strong femoral and brachial pulses, CR <2 seconds
Pulm: LCTA-B
Abd: soft, ND +BS, no mass
GU: normal female
Derm: no rash
Neuro: fair/good tone, sleepy, irritable, positive moro, fair suck
Tasks for the resident: You will have 25 minutes to:
1. Take a history.
2. Negotiate an evaluation and management plan that the patients mother
agrees to.

Material to read prior to the standardized patient encounters:

Rust, G., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., Woody, R., Daniels, E.,
Herbert-Carter, J., Aponte, L., Strothers, H. (2006) A Crash Course in Cultural
Competence. Ethnicity & Disease.16:S3-29-S3-36. http://www.ishib.org/journal/162s3/ethn-16-2s3-29.pdf

Instructions to give the residents prior to the start of the cases:

1.)This is formative onlyto provide you with feedback to develop as a
physician.
2.)There are two casesif you have seen one, then stand outside the door to
wait for the second one. At the end of the second one, wait in the waiting
room for the attending to find you to discuss the cases with you. One
attending will be providing you with feedback.
3.)Both cases occur in the KU Peds clinic.
4.)Anything you need will be available to you in the patient room, but you do
need a stethoscope.
5.)If you need an interpreter, the interpreter will be waiting for you outside the
exam room.
6.)

Cultural Competence Standardized patient Encounter: Madeline Cuncha

Goals:
1.) The resident will develop an appropriate management plan for neonatal fever.
2.) The resident will respect parental autonomy.
3.) The resident will negotiate the plan with the mother.
4.) The resident will educate the patients family on reasons for recommended
medical treatments.

Standardized Patient Instructions

Demeanor: The mother (Maria) believes that her baby is a little fussy but generally
ok. When she was hospitalized for her babys birth, the newborn team told her to
bring her baby to the clinic if she had a fever and thats why shes here. She lived
in South America when she had her second baby. That baby developed a fever at 2
days old and was placed on oral antibiotics and got better, so that is what shes
expecting when she arrives in the clinic today. She doesnt have much money. She
wants her baby to be seen and she needs to get back home to take care of her
other children. She is quite confident and assertive and has a thick accent. The
mother will become more agitated and loud during the encounter if the resident
doesnt respect her and the challenges shes facing, but if the resident uses
negotiating techniques, the mother will agree on an appropriate medical treatment
plan. She plans to give her baby chamomile tea to treat her baby at home, and she
wants to talk with her husband on the phone before agreeing to any testing or
treatment plans.
History of Present Illness: 19 day old F is brought to the ER by her mother for
fussiness, decreased feeding today and increased sleepiness. Mom says she has
felt warm today but was fine until today. Usually has 10 voids and 10 stools/day
and breastfeeds 10x/day for 25 minutes each time, but today has only breastfed
twice for 5 minutes each time. Has had 2 voids and 2 stools so far today. No
vomiting, diarrhea, cough, congestion or other concerns.
Birth Hx: 40 WGA, Vaginal Delivery, normal pregnancy and delivery, APGARS 8/9.
GBS negative. Birth Weight 3.5 kg. Had a newborn check in clinic at 3 days old and
another at 10 dayseverything was normal and the infant was gaining weight.
Past Medical History: negative. No hospitalizations or surgeries.
IMM: Up to date (Received the Hep B immunization after delivery)
Meds: None
All: no known allergies

ROS: negative except as per HPI.

Family Hx: Hypertension in grandfathers on both sides of the family, otherwise
negative. All siblings were born full term and all are healthy and are up to date on
their immunizations. The second oldest had fever at 2 weeks of age, was treated
with oral antibiotics and improved. No children have had any hospitalizations.
Social: Lives with mom and dad, and 4 older siblings (ages 8, 6, 4 and 2.) The
family owns the Big 6 Motel in Wichita; mom stays at home with the children. No
tobacco exposure. No pets. Moms mother lives in Wichita as well.
Development: lifts her head a little bit, looks at her mother, moves arms and legs
equally.
Background: Mom thinks her child probably has a common virus but brought her
into the clinic because after delivery, when her doctor gave her discharge
instructions, she told her to have her baby seen if she wasnt eating as much as
usual and was fussy. She wants the doctor to determine the cause of the fussiness
and prescribe treatments and send her home. She doesnt want to make any
medical decisions without talking with her husband. She is worried about the cost of
the medical treatment (however, the baby will have Medicaid insurance although
the parents are undocumented.) If the physician suggests that the child be
admitted, the mother will resist admission, saying that her baby is fine and saying
they will go back home and follow-up in clinic tomorrow. If asked why she doesnt
want to be admitted, the mother refuses admission because of the cost and
because of a lack of childcare for her other children and because she doesnt think
her baby is that sick. If she is reassured that the bill will be paid for by Medicaid,
(and has found childcare as discussed below) she will agree to the admission, to
blood draws and to the use of antibiotics and an antiviral medication. Another
barrier to admission is her lack of childcare for her other children. If this problem is
addressed as well, she will agree to the admission. This can be addressed by asking
the mother if she knows someone else who can watch her other children. She can
ask the grandmother, who will agree to come and watch the other children for a
couple days. She also will refuse the admission unless she understands the reason
why its important. All three conditions must be met in order for the mother to
agree to the admission.
If the provider requests a catheterized urine specimen, the mother is to refuse it,
saying the child is not voiding because shes not eating, but otherwise doesnt have
any voiding problems. If the provider explains that UTIs are the most common
source of fever in a child without other symptoms, and explains that the way to
diagnose a UTI is through a catheterized specimen, the mother will agree to the
procedure.
If the provider requests a CXR, the mother is to refuse it, saying xrays are harmful
and its unnecessary. If the resident says its required, the mother is to become

angry and say she wants to talk with her husband. She will not allow a CXR and if
its forced upon her, she will leave the clinic with her baby. If she is allowed to talk
with her husband (it will only be a 30 second conversation), and if the resident
explains why its necessary, she will agree to the procedure since her husband will
agree with the procedure.
If the provider requests a lumbar puncture, the mother is to refuse it, saying that
the child is just barely sick, just for one day, and doesnt need an LP. If the provider
explains that neonates sometimes are very ill without localizing signs of infection,
and that a fever in a neonate under 28 days is an emergency, the mother will agree
to it after she understands the reasoning. If the provider forces the mother to allow
the LP without her agreeing to it, the mother is to staunchly refuse it, although she
will still allow whatever they have agreed to up til this point (i.e. admission,
antibiotics, UA/M and culture, etc.) If the provider still insists upon the LP, the
mother is to say that shes leaving the clinic and plans to go home. If the provider
explains the reasoning to her, she will agree to stay, but otherwise she will walk out
of the encounter with her baby. The mother is to be defensive, although she will
listen if the provider takes the time to explain the situation to her. If the resident
tells the mother she cant leave the clinic and take her baby home, the mother is to
become extremely angry and call for help outside the room, at which point the
encounter would be terminated unless the resident is able to backtrack and
effectively deescalate the situation. If the mother decides to leave the clinic, she
will agree to having the infant take oral antibiotics if the resident suggests them.

Here is an article (with the link at the end) on cultural competence that the
residents will be asked to read before the standardized patients.
Rust, G., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., Woody, R., Daniels, E.,
Herbert-Carter, J., Aponte, L., Strothers, H. (2006) A Crash Course in Cultural
Competence. Ethnicity & Disease.16:S3-29-S3-36. http://www.ishib.org/journal/162s3/ethn-16-2s3-29.pdf

Faculty Members:
While you are observing the cases, please observe for anything that could be
improved upon in the patient-resident interactions, including aspects within medical
knowledge, patient care, communication/negotiation and professionalism. At the
end of the two back to back cases, the resident will meet one-on-one with the
faculty member who has been observing the interactions for feedback. Please start
by asking the resident if (s)he would like feedback, and open the discussion by
asking the resident how (s)he felt the encounters went. Discuss their comments.
Then move on to discuss anything additional you noted during the encounters that
could be improved upon. Please let Dr. Kroeker or Dr. Wittler know if there are any
concerns about a residents performance noted during the standardized encounters.
You may want to discuss the LEARN or CRASH methods for negotiation with the
resident.
LEARN
Listen to the patients perspective sympathetically to gain understanding
Explain your perceptions of the problem
Acknowledge and discuss the differences and similarities
Recommend treatment
Negotiate agreement.
CRASH-course in cultural competency skills
Culture: The importance of shared values, perceptions, and connections in the
experience of health, health care, and the interaction between patient and
professional.
Respect: Understanding that demonstrations of respect are more important than
gestures of affection or shallow intimacy, and finding ways to learn how to
demonstrate respect in various cultural contexts.
Assess: Understanding that there are tremendous within-group differences, ask
about cultural identity, health preferences, beliefs, and understanding of health

conditions. Assess language competency, acculturation-level, and health literacy to

meet the individuals needs.
Affirm: Recognizing each individual as the worlds expert on his or her own
experience, being ready to listen and to affirm that experience. Re-framing cultural
differences, by identifying the positive values behind behaviors we perceive as
different.
Sensitivity: Developing an awareness of specific issues within each culture that
might cause offence, or lead to a breakdown in trust and communication between
patient and professional.
Self-Awareness: Becoming aware of our own cultural norms, values, and hotbutton issues that lead us to mis-judge or miscommunicate with others.
Humility: Recognizing that none of us ever fully attains cultural competence, but
instead making a commitment to a lifetime of learning, of peeling back layers of the
onion of our own perceptions and biases, being quick to apologize and accept
responsibility for cultural mis-steps, and embracing the adventure of learning from
others first-hand accounts of their own experience.