You are a 20-year-old male, presenting with a headache

Photo by David Billings on Unsplash

The first sentence in the case file is also the second thing to tell the standardized patient (SP) when we brief him on his new scenario.

The first thing is his opening statement:

“I’m having trouble concentrating. It’s really affecting my grades.”

I am writing a case with a focus on mental health. I mentioned in an earlier post that students in health sciences, such as medicine, chiropractic, and nursing, demonstrate a decline in empathy as quickly as a few months into a program (Junod Perron et al, 2015). In a high-stakes OSCE (Observed Standardized Clinical Examination), stations related to mental health and communication and empathy are included at many schools– not for the diagnosis, but for the process.

The other cases being developed at this training have a strong clinical base; I have no clinical experience or education, but I encountered many students over the years who needed support and a sympathetic ear. They sometimes didn’t get what they needed, even though resources existed. I learned a lot of difficult lessons, and I also learned what not to do. I’m hoping to draw on all that experience to write this case.

A good SP case needs to be complex, but not unsolvable. It needs to be detailed, but only as much as necessary. An SP needs to remember essential details, but should not be overwhelmed by them. Our trainer indicates that cases work better if they are based on a real case and the developer is familiar with the medical details. I don’t have a real case, nor do I have clinical experience. So, one of our biggest challenges is to make this case believable.

The patient presents at the clinic with a headache and concentration problems.

Our case objective: ensure the medical student engages in a conversation about mental health with the patient; make a referral to an attending physician; correct diagnosis not necessary.

We have to address these items in the case development:

Patient’s medical history
Family medical history
Patient’s social history, including recreational drug use
ADHD drugs and their known side-effects
Drug dosages for people matching the case description
Differential diagnoses (e.g. depression, bi-polar disorder)
Diagnosis
Miscellaneous details which come up in the course of a simulation (e.g. sports, location of school, names of family members)
Physical findings
Presenting behaviours
A clear timeline for the patient
Patient file
Complete case history
SP narrative

Case development mimics instructional design: we work backwards from the diagnosis. A lot of our work gets discarded, but the process is important to get to this point:

Our SP will play a 20-year-old male college student who exhibits early signs of schizophrenia, but has convinced himself that he needs to increase his ADHD medication. He uses his inability to focus (real) and his headache (also real, but a distractor for this case) to visit the clinic.

This was all we managed to achieve on our first day. It doesn’t seem like much, but the following details informed those 47 words:

Individuals can often begin experiencing symptoms of schizophrenia in college;
Males are diagnosed with schizophrenia more often than females;
ADHD can mask symptoms of schizophrenia;
Schizophrenia can be misdiagnosed as ADHD;
Pediatricians in some areas of North America treat patients up to 20 years of age and they do not screen for mental health conditions such as schizophrenia; pediatricians may not catch signs of mental health in young people;
Young people diagnosed with ADHD have to change health care providers if they move to go to school;
Some of the side effects of some ADHD drugs can be similar to symptoms of schizophrenia;
If not taken correctly and regularly, ADHD drugs can cause symptoms that mask schizophrenia;
Some individuals may drug-seek in order to cope with symptoms of schizophrenia;
Individuals in early stages of schizophrenia are aware that something is not right but may also convince themselves it is something else;
Individuals diagnosed with schizophrenia in early stages can have their condition monitored, and, with medication, can live a fulfilling life.

All of this makes for a challenging encounter and a (maybe) difficult conversation with the patient.

In my Mental Health First Aid training, a certificate provided by the Mental Health First Aid Commission of Canada, the steps we covered were: recognize (a change in behaviour); respond (with confident conversation); and guide (to appropriate resources and support). (Mental Health Commission of Canada, 2019). These steps express my personal goal for this case. I hope neither the case nor the scenario unravel.

My case partner and I engaged with two nurses (one experienced in mental health) as well as the SP trainer to gather relevant data for the scenario. No place for egos as we kept filling information gaps, researching, revising, reviewing, removing, and returning back to the case template to revise again and resave. Day 2 felt less messy than Day 1. The team could identify gaps in the previous day’s work and we began to talk about Jordan. Our made-up case began to feel real. Last step: who would this case be assigned to? A quick interaction with the SP trainer revealed that mental health is not covered until a student’s third year at SIU, so we assigned it to a fourth year student.

* * * * *

Spoiler alert: I am not going to describe how it all played out.

I debated whether to share how the case unfolded. I’ve decided to refrain from specifics. I don’t want to objectify schizophrenia into a description of symptoms presenting in a patient. It’s a complicated condition with difficult consequences for real people. I will tell you that training our SP required a lot of sensitivity and we put a lot of thought into presenting the case to him so that he could embody Jordan for 20 minutes. He delivered in spades. The medical student assigned to our case was a joy to observe. He was sensitive to the patient’s condition. He collected all the data relevant to making a diagnosis. When we debriefed with him, he described his strategy for interacting with Jordan. Briefly: it went well.

Next post: “I’m really having a problem with all these headaches.” My turn as the standardized patient.

References:

Junod Perron, N., Sommer, J., Louis-Simonet, M., & Nendaz, M. (2015). Teaching communication skills : Beyond wishful thinking. Swiss Medical Weekly, 145(0708).

Mental Health Commission of Canada (2019). Mental Health First Aid Canada: Big Picture. Retrieved from https://www.mhfa.ca/en/big-picture