Cultural Competence OSCE

Scenario:

A 33 year old male with history of autism, domiciled at a group home, presents to the ED brought in by EMS complaining of abdominal pain. While interviewing him, he denies ever feeling abdominal pain and is now complaining of foot pain. When asked if he has any medical history or takes any medications, the patient stares blankly at his shoes. While trying to perform an abdominal exam, the patient becomes aggressive and yells that he hates being touched. The patient is new to the hospital and is a poor historian, unaccompanied by any other person familiar with him. 

“Cultural” factors that need to be considered:

• Patients with autism spectrum disorder have neurodevelopmental deficits including deficits in social communication and social interaction, and have restrictive repetitive behaviors. In this case the patient’s autism is likely the reason he is a poor historian unable to provide a clear chief complaint (he switches his complaint from dizziness to abdominal pain), medical history, medication list, and is opposed to anybody touching him making taking an appropriate history and performing a physical exam extremely difficult. 
• Adult patients with autism, who lack support from family members, typically end up residing in an adult day care or other assisted living / group home facility. In some cases, the patient may have difficulty interacting with and forming healthy relationships with the staff and other residents of the group home, resulting in the patient looking for shelter elsewhere  (i.e. a nearby hospital). It should be determined whether the patient himself or the staff from the home called 911, and the provider should try to speak with the EMT directly to obtain a clear and full story. Maybe the true reason he was brought to the ER was for aggressive behavior toward his roommate; this needs to be determined. 
• The patient is not accompanied by any family or friend. It is not uncommon for adult patients with autism to lack an adequate support system, since being the caretaker of an adult with a neurodevelopmental disorder can be physically, emotionally, and financially tasking. While the family of patients with autism should be viewed without judgement, this makes it even more difficult to obtain a complaint history on the patient
• Patient’s with autism typically have an insistance to sameness or resistance to change. Since the ED can be a fast paced and overwhelming environment crowded with many unfamiliar places, an autistic patient in the ED may act more aggressively or with poorer communication skills than usual. Additionally, the provider should keep in mind that handing the patient off to another provider and switching the patient’s care will only worsen the situation and the patient’s mental state. 
• Aside from resistance physical touch, people with autism may also have other abnormal responses to physical stimuli, such as preoccupation with shiny objects, lights, or odors. This can make it even more difficult to get the patient’s attention. Additionally, this could also include indifference to pain. This is important because perhaps the patient’s abdominal pain is no longer apparent to him and did in fact exist this whole time. Thus an abdominal exam is still important to try to perform. It’s also important to keep in mind during the patient’s hospital stay in general, since the patient may not react when in pain like other people would, but should still be monitored with the same vigilance. 
• Autism can also manifest as intellectual and language impairments. The provider should therefore be conscious of using simple vocabulary when speaking with patient, and giving the patient a chance speak at his own pace and to recall certain things that he cannot remember at the moment. 
• Patients with autism may also have anxiety disorders, which should be considered. 

Unique considerations that care of this patient might require:

• Speak clearly to the patient, in a non-judgemental manner and with simple vocabulary. 
• Be aware of any behaviors that make you feel uncomfortable, and calmly leave the room if you feel uncomfortable. Try to have another provider you feel comfortable with present in the room with you if you feel necessary (but avoid having multiple people in the room at once, as this may overwhelm the patient). Try to maintain a judgement-free view of the patient, and keep in mind that the patient does not mean any real harm. 
• If the patient is sitting in the hallway, and the ED is crowded and noisy, take the patient into a separate room. When seeing the patient, turn the ringer off on your phone, since loud noises might be especially irritating to the patient. 
• To make communication easier, try showing the patient images or using hand gestures to indicate what you are referring to or asking. For instance, while asking the patient about his belly pain, try pointing to your belly or bending over and clutching your abdomen as if acting out a belly ache. 
• Be aware of the patient’s mental state, such as whether he seems anxious. He might require anxiety medications. 
• Again, try to speak with the EMS team who brough the patient in. The more information you could gather on the patient the better, since he is a poor historian. However, keep in mind that you must abide by HIPAA guidelines.  
• If the patient requires immediate medical attention, which includes an urgent physical exam, ultrasound, or other imaging (e.g. CT scan or MRI which require remaining still in confined spaces), make sure to clearly explain what will be happening to the patient before you do anything. Don’t touch the patient or try to perform any procedures without telling him what and how you are doing it. 
• If the patient says or does anything inappropriate, act professionally and leave the room, and report the incident to your supervisor. Do not yell at the patient and do not stay in the room with him if you feel unsafe. 
• Don’t deny the patient food or standard care, even if you feel he is only here for malingering purposes. 
• In many cases, contacting/consulting with social services is a good idea. Perhaps they’ll have information on the group home the patient is residing at and deciding whether the home is still a good fit for the patient. 

Areas where conflict might develop:

• Again, conflict may develop when trying to perform a physical exam, any procedures such as blood draws, or imaging. 
• Conflict may also develop if the patient is surrounded by multiple people at once (i.e. in a crowded ER hallway, or by multiple providers in a small room). 
• Conflict may develop if the patient endures too much change at once, such as switching providers or moving him to different floors or sections of the ED. 
• Conflict may develop if the patient is triggered by abnormal sounds or flashing lights (could be a good idea to keep him away from the ambulance bay)
• Conflict such as poor communication may develop if advanced vocabulary or medical jargon is used with the patient. 
• Medication, such as anxiolytics and sedatives, should be given as necessary and appropriately! It’s important to keep in mind that people with autism may have difficulty sleeping or severe insomnia, or anxiety, and may require these medications to an extent. 

What would be expected of the student in demonstrating Cultural Competence/Humility – what things would the student be expected to say/do/avoid/suggest/consider in this scenario (these may not all be relevant).  These would be the elements on which the student taking the OSCE would be graded:

• The student should demonstrate respect and patience toward the patient, and treat him with the same level of care as any other patient. This should include trying different measures to take a history (e.g. using hand gestures) instead of giving up after the first try.
• The student should speak calmly toward the patient even if he yells, and explain exactly what she is going to do and where she will touch him before she does. Her language should use simple and easy to understand words/terms. 
• The student should never laugh at the patient. 
• The student should ask for help from an additional provider if necessary, but should avoid inviting multiple people into the patient’s room at once. 
• The student should bring the patient into a private room, and out of the crowded hallway. 
• The student should demonstrate on herself first what she will be doing for the physical exam. If the patient refuses the physical exam, do not try again. Let the patient relax, leave the room, and return a few minutes later and ask if it would be ok to try again. 
• The student should ask the EMS personnel for any other additional information they can gather, however do not violate any HIPAA laws by discussing details of the patient’s case with those outside of the patient’s direct team of providers. 
• The student should avoid overwhelming the patient by getting too close to him. 
• Although the patient may be intellectually disabled, the student should still take each of his complaints seriously. This means assessing for both abdominal and leg pain, and taking the rest of the evaluation from there. 
• The student can also ask for a social services consult for help in contacting the group home.