Cases

Cover Sheet

You are the admitting resident today and you are currently on rounds with your team and it is very busy. You receive a page that there is a new admission that just arrived to the floor. August, a 4-month-old male, was admitted for non-bilious vomiting. You note that his family does not speak English fluently. You find the nurse who paged you in the patient’s room to discuss his case. You have never worked with them before. Mom has stepped out to run an errand.

Objectives:

1. Introduce yourself to RN
2. Elicit the patient’s history

Actor #2 Guidelines:

Goals for Learner:

The learner should recognize the microaggression and use a nonconfrontational technique to address it in the context of nurturing an ongoing relationship with nursing colleagues. They should acknowledge nuances of a busy environment while prioritizing culturally sensitive patient care.

Background:

You are an RN on a busy inpatient pediatrics floor. You are understaffed and your to-do list feels incredibly long. You feel you are trying your best with the time and resources you have to take care of your patients and prioritize their safety. You are struggling to balance all of your tasks for the morning and this additional admission feels like one extra thing on your already overflowing plate. You choose not to use an interpreter for this family because their English, though limited, seems “fine enough” and your history will take an extra half hour with the interpreter between getting it set up and the interpretation itself.

• Affect: rushed, irritated, harried
• Body language: tense, antsy
• Facial expression & eye contact: glancing around as if anticipating and thinking one step ahead
• Speech: short, succinct
  • If resident interrupts statement in a nonconfrontational manner, affect becomes softer
  • if resident interrupts in a way that is condescending/harmful, affect becomes harsher

Opening Statement:

1. If learner does not introduce themselves: ask them to clarify who they are
2. “Time is short this morning, so I’ll get right into the history”

Scripted Microaggression:

(After you give a brief history to the resident) “I wasn’t able to get more details. Mom speaks “some other language” and I just didn’t have time to get the interpreter. You know how it is.”
“Mom left, probably to take care of one of her other 5 kids… I doubt she’ll even be back for rounds”

If the resident corrects you kindly and acknowledges the challenge inherent to your role and a busy schedule: Please respond apologetically and say that you will make sure to have the interpreter in the room when mom comes back for all future interactions

Example: Resident says, “It seems like you are understaffed and incredibly busy today. The system is working against us! You and mom both have a lot on your plates, that’s for sure something you have in common! I’m worried that those factors could put this family at a disadvantage since they aren’t going to be able to advocate for themselves very easily. We should make sure that they get an interpreter every time.” You could respond, “You’re right. It’s just hard when there are already so many patients on my list and the interpreter takes forever to pull up and makes the interaction longer, too. But I’ll be sure to do it next time- I know it’s important. I’m not being my best self right now.”

Some residents may address the microaggression around the number of children separately.

Example nonconfrontational responses:

• Reflective statement with a less biased explanation: “Oh, Mom mentioned that she needed to go take care of her other children? That must be a lot for her to juggle and especially difficult when she’s worried about a kid in the hospital!” Also drawing a connection to the nurse’s situation (“sounds like you’re both juggling a lot right now!”) would be a skilled way for the resident to build a sense of shared humanity between the nurse and mother, as well.
• Direct reflection of what was heard without additional explanation, necessitating a response from the actor, such as resident saying “Oh, Mom knew rounds were going to happen soon and said she didn’t want to be here?” (and then pausing). This could prompt the actor to say, “Well, not really, I guess I just assumed since she rushed off… but she may not have known rounds were going to happen… I didn’t have a chance to explain that without the interpreter here.”
• Ask additional questions such as resident saying, “Oh, did mom say something to make you think she doesn’t want to be here on rounds?” This could allow the actor to reflect, “Well… not really. I guess I didn’t have a chance to ask her about it directly. I’m not really sure what else is going on with her. We were both pretty rushed.”
• Gently addressing the potential bias could include normalizing what Mom did (esp if the resident is in a position of racial privilege) “Oof, as a working parent, I can empathize with that Mom! And I don’t even have a child in the hospital right now! It’s so hard for families to balance a child in the hospital with jobs and other kids at home.” This could give the actor the opportunity to re-think their own comment without being called out directly and backtrack, “well, we didn’t really have a chance to get into those things, but yeah, that is a lot to juggle… maybe I can call later with an interpreter to try to find a time when she can connect.”

If the resident addresses you in an aggressive way that feels threatening, confrontational, or directly accusatory, please respond as below:

• If the resident is abrasive or does not acknowledge the challenge inherent to your role and a busy schedule (that you are trying to do your best in a system that is not set up optimally) or if they come off as pedantic or condescending, you get frustrated that the resident can’t see that there are barriers to you providing optimal care and you perceive their feedback as an affront to your skills and level of care for your patients as a nurse.Example: Resident says, “Did you know that legally all patients have a right to a medical interpreter? Not using one is really dangerous.” Or “It sounds like you have it in for this family because the mom has so many kids. Did you ever try putting yourself in that mom’s shoes—imagine trying to juggle all that and not speaking English while you’re worried sick about your kid in the hospital. Cut her some slack.” Note: This is similar to the ‘confrontational response’ given above, but does not directly challenge the nurse (the statements ‘it sounds like you have it in for this family’, ‘did you ever try to put yourself in her shoes’ make the response much more confrontational). A response like either of these should make you feel really defensive- you consider yourself to be an egalitarian person, good at your job, and would never intentionally put someone in harm’s way or judge another family. You could respond, “I’m trying my best. We’re understaffed today, I have more patients than I should and we’re just getting more admits. It’s simple for you when you show up on rounds and the interpreter is already here, and I’m ready to tell you everything about the patient since Mom is gone. You don’t even know how much work goes into setting all that up—it goes smoothly because I’m getting done what needs to get done!” or “I’ve been here way longer than you have—I know what needs to get done when things are busy and certainly don’t need you to tell me how to do my job!”)

If the scenario escalates, the resident should attempt to de-escalate. De-escalation strategies could include acknowledging your inadequate staffing / lack of supports / time pressures and understandable frustration; showing humility and sharing a time where they made a similar mistake (“I’ve been in situations like this before. I never feel like my best self shines when I am so stressed.”); or similar.

• If they do not, or their attempt at de-escalation feels patronizing, you may respond about their lack of understanding and end the situation by leaving (“I don’t have time for you to tell me how to do my job! I have been here much longer than you have! I need to get to my other patients.”). You may choose to comment that you are going to talk to the charge nurse and the attending about their ‘unprofessionalism’.
• If they do a successful job of de-escalating and acknowledging your feelings, you may respond with relief that they seem to understand where you are coming from, and express feeling contrite/regret that you feel like all the pressure has put you in a position where you don’t feel like you’re able to be your best self—and will work to do better. You can then end the scenario, telling them you have to go care for your other patients and will try to get back to Mom later with an interpreter either in person or by phone.

Other important information:

There are a few items that deserve attention from the resident here. Actor did not use an interpreter when they should have. Actor is making judgments about mom’s level of care for / investment in her child (“doesn’t care to stay for rounds”), the number of children she has (implying that 6 is too many, likely with socioeconomic and racial bias wrapped up in that judgment). The actor is not approaching the patient or parent with humanity, rather, just another item on the checklist. Actor being overworked and some degree of burnout have contributed (though are not an excuse); microaggressions are even more common when someone is stressed/harried.

Cover Sheet

You are on a hospitalist team and receiving sign-out regarding an overnight admission. The sign out is coming from another resident that you do not know well (it does not matter if they are an outside rotator or in your program for the purpose of this simulation).

Samuel is a Black 10-year-old boy followed by the pediatric complex care program since he was a toddler. He has been hospitalized multiple times previously, and you are somewhat familiar with Samuel and his mother.

He has a rare genetic condition that has caused a significant global developmental delay among other physical differences.

• He is nonverbal and does not use any assistive communication devices. His eye contact is generally poor.
• He is not able to walk unassisted, does not have many obvious purposeful movements, and cannot assist with activities of daily living.
• He is primarily fed via G-tube.
• He smiles and laughs and reacts to voice and touch, particularly his mother’s.

He was admitted overnight with feeding intolerance and behavior change.

In your past interactions with his mother, she has been thoughtful, invested, and concerned for Samuel’s wellbeing. She worries how she comes across to the healthcare team as a single Black mother. She is very in-tune with Samuel’s typical behaviors, and your team has often relied on her to help interpret Samuel’s signals.

• Vital Signs this Morning:
  – Blood Pressure: 100/65
  – Temperature: 96.6
  – Respiratory Rate: 22
  – Heart Rate: 98

Objectives:

1. This encounter will begin with the overnight resident giving you an IPASS handoff

Actor #3 guidelines

Goals for Learner:

The learner should recognize the ableism- and race-based microaggressions and use a nonconfrontational technique to address them. They should demonstrate a technique to diffuse tension with their co-resident after interrupting the microaggression, taking into account the nature of an ongoing professional relationship.

Background:

You are a resident physician (pediatrics or family practice). You have just finished a busy overnight shift on which you admitted Samuel, among expertly managing many other duties. Samuel is a 10 -year-old boy in the complex care program admitted for feeding intolerance and behavior change, and due to maternal insistence that he seems to be in pain. His vital signs have all been stable. In the emergency room, they completed an abdominal and chest x-rays, lab studies (CBC, ESR, CMP, UA), and a thorough exam all of which were unrevealing of a cause for his symptoms.

When you arrived to the room to do Samuel’s admission, Samuel’s mom, a Black woman, immediately began explaining Samuel’s history. Since as the night resident you are following all of the teams’ patients, you feel she gave you way more detail than you needed and you could have just read about it in the chart. Your biggest frustration overnight was that Samuel’s mom was “demanding” that the nurses page you all night. She keeps saying that Samuel is in significant distress and that his pain is not being adequately controlled. You understand the need for adequate pain control, but on your examination, Samuel looked comfortable and his vital signs are well within the normal range. You feel he’s taking up a bed that another kid should get. She kept trying to teach you about the ways Samuel exhibits his discomfort and about how he presents “differently”. You are annoyed that she is acting like she knows more about medicine than you and don’t understand why she’s so “angry”.

• Affect: Neutral, ready to home at the end of a long and demanding night shift
• Body language: Relaxed
• Facial expression: Neutral
• Eye contact: Natural
• Speech: Natural, normal pace

Opening Statement

(This is scripted (should be said verbatim; it is normal to look at a paper during sign out so it would be ok to have some prompts in front of you to remember all of this!)

The last patient I need to sign out is Samuel. He is a complex care kid, 10 years old, stable. Came in overnight with the usual, feeding intolerance, mom thinks he is in pain. The ED did a full workup with a complete exam, X-rays of his chest and belly, and a bunch of labs including UA, CBC, CMP, ESR and that was all normal. He seems fine to me. His mom keeps having the nurse page us that he’s in a lot of pain, and that something was wrong, but I don’t even know how you’d be able to tell when he’s in distress… it’s not like he really does anything. Based on my review of the chart, he seems to be at his baseline behaviorally. Just advance his feeds and we can probably discharge him. He’s just taking up a bed and his parents can do this at home. Mom is very demanding—I’d try to stay out of there as much as you can, but she’ll probably ask the nurse to page you all day like she did to me all night. She might even try to teach you how to be a doctor since she’s such an expert.

Scripted Microaggression – MUST SAY during interaction
“His mom is so aggressive… I don’t understand why she’s so angry.”
Information offered spontaneously

• • You think Samuel is doing just fine. He looks comfortable to you and not in any distress.
  • You did an exam and skimmed the chart. His behavior appears consistent with the way it’s been described on past exams. You also saw that he’s been admitted a few other times before with feeding intolerance; you didn’t read all the notes but it seems it’s just gotten better eventually.

• You believe that his mom is overreacting. You think she’s acting like she knows more than you and you find yourself very annoyed by this. She keeps trying to teach you about her son’s condition and how his pain presents differently than typically-developing kids. You don’t understand why this mom is so “angry” and why she’s giving you such an attitude when you’re just trying to help her child. The day residents are going to be primarily managing his care, anyway.
• If they ask about any examinations that could have been done (such as feeling his long bones, looking in his mouth for sores or cavities)—all exam things were completed and normal.
• No testing other than what was listed above was completed, and you really don’t think anything more is indicated based on how well he looks.
• You do not think he needs any further pain medication.

If asked by the resident what makes you think that the patient is not in any pain, given Mom’s concern

• “Honestly, I don’t know how Mom thinks she can tell how he’s doing. He doesn’t communicate at all, and his vital signs are completely normal.”
• If the resident asks you more about your assessment, you explain that “it’s always the same with these parents” and that she has “wishful thinking” that she can actually interpret anything he does.

Other information:

You, the night resident, are tired at the end of the night and not open to having a dialogue. Your response will not ever reach a place of true resolution or genuine agreement with the learner.

Responses (The learner should react by disagreeing with you, at a minimum. More advanced learners may ask what makes you think that about the patient/his mother (respond with curiosity) Your reaction can be improvised based on how the learner responds.)

If the learner’s response feels scripted, you say something like, “That’s easy for you to say after a full night of sleep… Do you have any other questions for me about the patient?” and end the scenario.

Examples of resident statements that would fit this description:

• “UW Health is a diverse and inclusive environment”
• “All of our patients deserve good care”

If the learner tries a response that is not intended to be confrontational or aggressive, but you are not open to hearing it at the end of this long night, you may become avoidant, but if the resident continues with gentle questioning/comments (does not become more aggressive), you can match their energy and do not need to keep escalating. Draw the scenario to a close after a few exchanges by commenting that you need to get home and sleep because you’re back on again in the evening.

If at any point the learner responds in a way that you feel is aggressive or so direct that it is offensive (for example, directly calls out the ableism or racism you have displayed), or if they are very persistent, you should become increasingly defensive. Double down on your opinion

Examples:

• Express frustration that this stable patient took up so much of your time overnight when you are covering so many patients, some of whom actually needed more attention
• Share that you don’t know how to feel about how Samuel and “kids like him” use up so many resources.

If escalation continues, end the conversation, “I think that you’ll agree with me if you just go lay eyes on him. Hopefully today is easier for you than tonight was for me. That’s really all I had for you about him, so I’m going to go home and get some sleep”

If the learner asks you to accompany them to the room, decline, stating that you’ve already spent enough time in there overnight and have to get home.

Cover Sheet

You are in your continuity clinic. On your schedule today is the mother of one of your patients who asked to speak with you without her daughter present. You recall that the last time you saw her daughter, a ten-year-old girl with weight above the 99th percentile, you referred her to a specialist for workup of abnormal lab values.

Objectives:

1. Greet the parent
2. Understand the purpose of the visit
3. Develop a plan for moving forward

Standardized patient #4 guidelines

Goals for Learner:

The learner should recognize the weight-based microaggressions as described by the SP and demonstrate an empathic response toward the mother and her family. They should effectively debrief the experience with the SP and develop an action plan to address the harm that was done.

Background:

You are a pleasant parent who is concerned about her child and upset and saddened by your treatment by the specialist you were referred to. You and your daughter, Alexis, were referred to the specialist due to a lab abnormality, which your primary care doctor said could have been related to obesity. [note: we are not naming the specialty service to avoid singling out any particular service; this type of treatment could happen anywhere. The exact medical issue is not relevant to the case].

You have scheduled an appointment with your pediatrician to discuss this visit. Your daughter is not with you—you were worried that revisiting the experience could be further traumatizing to her. She is at school. You are very concerned about the abnormal labs, and want to make sure your child is receiving appropriate medical treatment for this abnormality. However, you don’t feel you can take her back to the specialist because of the negative impact the visit had on your child’s mental health.

You have struggled with shame around your weight for your whole life, and do not want your daughter to have these same ‘issues’. You have lived in a larger body for your whole life, and have personally experienced a lot of guilt and stereotyping in your own medical encounters—though you may not be able to name it as such (it has always been this way, so seems normal for doctors to blame you for your weight, and to assume you are sedentary and eat too much; part of you knows this is not true, and part of you has internalized some of this bias).

You’re not sure what to do next for your daughter’s care given these competing factors.

• Affect: Neutral at first upon greeting the learner, but may become teary, or frustrated discussing the events that transpired with the pediatric specialist
• Body language: slightly closed off when affect is neutral, becomes more expressive with escalating affect
• Facial expression: neutral at first, but becomes sad/worried/disappointed as appropriate while retelling the story
• Eye contact: natural
• Speech: natural. Pace is slower at first, but quickens as frustration recounting the story increases.

Opening Statement

1. Learner should introduce themselves, then begin the visit with a relatively open ended question:
   1. “How are you?” –> I’m okay. Just a lot on my mind.
   2. “What brings you in today?” or “It’s my understanding you’re here to follow up on your daughter’s weight. Is there anything else you wanted to talk about with me today?” or similar –> I wanted to talk about the appointment that we had with that specialist doctor

Other Important Information

Information about the appointment:
The visit with the pediatric specialist was very upsetting to both you and Alexis. The physician was judgmental and presumptive about your daughter’s weight and about her diet and exercise habits. It felt like they were shaming you and your daughter for her body size and stereotyping you.

The physician explicitly told your daughter that “if she didn’t change her eating and exercise habits now, she is going to die young.” You and your spouse both live in larger bodies, as does your other child. Your child has a sensitive temperament at baseline, and this was very scary to her. Alexis has occasionally been circling back to this statement and expressing worry that you, her father, or she will die soon.

As a family, you are active together. You enjoy bonding in this way. Your daughter is on the neighborhood swim team during the summer, and takes swim lessons and gymnastics year-round. These are joyful activities for her. You and your daughter also enjoy cooking together.

You emphasize that you are trying to teach your children to have a good relationship with food and movement. You are worried about the impact the physician’s words will have on your daughter and her level of anxiety around her body/food/exercise.

You are not sure how best to proceed while balancing her daughter’s physical health and emotional wellbeing.

Information about the plan:

If learner probes and/or asks about what you would like for the plan to be, please provide some or all of this information (or similar- ok to improvise, these do not need to be verbatim):

I don’t want Alexis to have to go back to that doctor, but I know that he is the only pediatric specialist we can go to with our insurance. I am really worried about this lab finding, and don’t want to just let it go I think he was going overboard, but what he said made me feel really worried for her too.

I know it would be good for all of us to lose some weight. We’re trying, but it’s really hard.

Everyone in our family is overweight. Both of my parents had diabetes, and I had diabetes when I was pregnant, and now I have prediabetes. I don’t want that for Alexis.

We are already doing all the things he told us to do—he acted like she was lying when she said that she does gymnastics, swimming, and plays outside a lot!

The doctor gave me a reproachful look when she was talking about a birthday party she went to over the weekend—he asked, and she said she had pizza and cake. Of course she did—it was a birthday party!

I want this doctor to know how harmful their words were. No child deserves to be shamed and spoken to like that and no parent ever wants to see their child upset after a visit to the doctor like that.

I’m worried Alexis will end up with an eating disorder. I counted calories for years! I still struggle with my body image and relationship with food. I don’t want that for her.

I realize you (the pediatrician) and the doctor we saw likely have a professional relationship, and I am worried about ‘bad mouthing’ him (especially if we end up having to go back to see him). I don’t necessarily want this other doctor to get in trouble—I just want him to do better.

If learner acknowledges the harm, agrees to raise this concern with the other physician, and tries to work with you to come up with a plan that addresses both the harm caused at the visit and the need to address the lab abnormality, you will be satisfied— even if the encounter hasn’t completely come to a close (unlikely in 10 min to cover all this), you or the facilitator can end the simulation and move on to the debrief if this is the direction the simulation takes.

If learner is apologetic, but doesn’t help develop a plan that addresses the physician’s behavior AND Alexis’s physical & emotional health, you are thankful, but it leaves you wanting more in terms of an action plan.

Examples:
Learner says, “I’m sorry you had to experience that/no one deserves to experience that.” But doesn’t say more.

Learner says, “That sounds really difficult. I don’t want Alexis to feel that way either. I wish he hadn’t said those things.”

You should respond with appreciation for their acknowledgement, but continue to push them on needing to know what to do next for your child and wanting the specialist’s behavior to be addressed.

If the learner tries to brush past it, stumbles with knowing how to address someone else’s behavior; tries to validate in a way that makes it seem like Alexis’s and your responses are the problem, rather than the action of the physician; or defends the other doctor, this makes you frustrated.

Examples:
Learner says “I’m not sure there’s anything I can do/cannot control his behavior” Learner says “I’m sorry you feel that way”

Learner says, “Wow, I’ve known Dr Smith for years. I’m surprised to hear that your experience was like that—usually patients love him!”

Please respond with increasing frustration if one of these tactics is used. This experience was difficult for you and you want them to acknowledge the harm that was done. You are more compelled to be an advocate for your daughter than you might be for yourself in a similar situation. De-escalate if learner shifts to a more optimal strategy.