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:
- 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."
- 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.”
- 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.”