Anesthesiology APPLIED Exam › OSCE: communication and professionalism

Barriers to access, disparities and allocation of resources

OSCE: communication and professionalism·~5 min read· Physician-reviewed✓ Sourced · 11

Stem

Station prompt: Ms. Ramírez, a 27-year-old woman in her second pregnancy, is at 39 weeks in active labor, 5 cm dilated. She speaks mostly Spanish. Overnight her 13-year-old son interpreted, and the nurse charted "declines epidural." She is now crying through contractions, and a video medical interpreter is connected. She has no contraindication to neuraxial analgesia. Your task: discuss her options for labor pain relief and confirm her decision.

Question

(Through the interpreter) My son said the epidural costs a lot, and I don't have insurance. The nurse said it's only if I ask. Is it true I can't have it?

Ideal answer

Headline"You can have an epidural if you want one; insurance doesn't decide that. Let's go through your choices with the interpreter so the decision is truly yours."

Interpreter, eyes on her (concern, removes the barrier). "Ms. Ramírez, I'm Dr. Reyes, the anesthesiologist. I'm speaking with you through a medical interpreter so nothing is lost. Your son shouldn't have to carry this. How bad is the pain right now?"
Find out what she was told (gather information). "What did you understand last night? Did anyone explain the choices to you directly?"
Options in plain words (clarify options). "The epidural is a thin tube in your lower back that gives the strongest relief; you stay awake and can still push. Common effects are itching or lower blood pressure, which we treat; a bad headache is uncommon, and serious nerve injury or infection is rare. Medicine through your IV is another choice, but weaker."
Cost, answered honestly (barrier to access). "Your care tonight does not depend on insurance or on papers. I can't tell you the bill, but a financial counselor can help later. Please don't choose your pain relief because of money."
Her decision, without pressure (decide). "What would you like? You can also wait and decide later." I correct the chart with the interpreter's ID and tell her nurse.

Breaking down the answer

Why this is an ethics station — the outline lists barriers to access and allocation of resources, graded on gathering information, clarifying options, determining preferences, negotiating and deciding.¹ Social determinants include language and health coverage.² Changes if: she lacks capacity; a surrogate decides.
Qualified interpreter, not family — federal rules bar relying on a minor child except as a temporary emergency measure,³ and ASA says family or friends should not interpret.⁴ Changes if: she privately asks for an adult relative with a qualified interpreter present, documented.³
The documented gap — Black and Hispanic women receive neuraxial labor analgesia less often than non-Hispanic white women, and Spanish-speaking Hispanic women less often than English-speaking ones.⁴ Changes if: nothing; this is why I ask directly.
Request is the indication — absent a contraindication, maternal request is sufficient medical indication for labor pain relief.⁵ Changes if: a contraindication appears, such as coagulopathy; I offer the safest alternative.
Check my own assumptions — about half of white medical students and residents endorsed a false belief about biological differences by race; those endorsing more rated Black patients' pain lower.⁶ Changes if: I catch myself guessing her preference; I ask.
Emergency care regardless of coverage — hospitals must screen and stabilize labor whether or not she has insurance, can pay or is a citizen;⁷ EMTALA does not itself require an epidural, but maternal request is the indication, and payment questions must not delay her care.

Follow-up question

As you leave, the charge nurse stops you: "Pharmacy says the premixed epidural bags are short nationally. Save the last ones for the private patients; they're the ones who complain." How do you respond?

Follow-up answer

Headline"No. Scarce drugs go by clinical need, through the hospital's allocation process, never by insurance or who complains."

I say it calmly and privately, then call pharmacy. ASHP calls for a resource allocation committee, including pharmacy, nursing, social work, medicine, ethics and a patient representative, with criteria set in advance so nobody rations at the bedside, applied to all regardless of the type of patient.⁸ Meanwhile pharmacy prepares an equivalent solution, and we keep treating by need. Patients whose care changes are told; in one survey 64% were not.⁹

Pitfalls that cost points

Accepting "declines epidural" as an informed refusal when it came through her child.
Turning to the interpreter with "ask her whether..." in the third person.
Promising "it's free"; I promise care, and route billing questions to a counselor.

Rapid-fire

Q: May a bilingual nurse interpret? A: Only if she is a qualified interpreter or qualified bilingual staff; otherwise no.³

Q: Can I use machine translation for a consent form? A: Only if a qualified human translator reviews it, because accuracy is essential.³

Q: Ventilators run short. May a triage plan exclude by age or disability? A: No; OCR rejected exclusion for intellectual disability and blunt age cutoffs without individualized assessment.¹⁰

Q: What makes a rationing process fair? A: Transparency, relevance, appeals and revision, enforcement, and fairness to every patient.⁸

Q: What should my department measure? A: Accurate race, ethnicity and language data, and disparity dashboards stratified by them.⁴

Numbers to know

Item	Value
Station time	8 min, 4-min read, warning at 6 min¹¹
ABA ethical principles	6, including social and distributive justice¹
Trainees endorsing a false racial belief	About half⁶
Patients not told of a shortage change	64%⁹
Fair-process conditions (ASHP)	5⁸

Sources

1.APPLIED Examination OSCE Content Outline · ABA · theaba.orgSection A.3, Ethical issues: lists allocation of resources and barriers to access to healthcare; principles include social and distributive justice.
2.Initial Certification Content Outline · ABA · theaba.orgSections II.E.7 (bias, implicit bias) and II.E.8 (social determinants including language and health coverage; maternal healthcare disparities, pain management).
3.45 CFR 92.201, Meaningful access for individuals with limited English proficiency (Section 1557) · Electronic Code of Federal Regulations · ecfr.gov
4.Statement on Reducing Maternal Peripartum Racial and Ethnic Disparities in Anesthesia Care · ASA Committee on Obstetric Anesthesia, 2021 · asahq.orgApproved by the ASA House of Delegates October 13, 2021.
5.ACOG Practice Bulletin No. 209: Obstetric Analgesia and Anesthesia (Obstet Gynecol 2019;133:e208-e225) · ACOG Committee on Practice Bulletins-Obstetrics (abstract via Penn State research portal), 2019 · pure.psu.edu
6.Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites (Hoffman et al., PNAS 2016;113:4296-4301) · AHRQ Patient Safety Network (summary), 2016 · psnet.ahrq.gov
7.You have rights in an emergency room under EMTALA · CMS · cms.gov
8.ASHP Guidelines on Managing Drug Product Shortages (Am J Health-Syst Pharm 2018;75:1742-1750) · ASHP (Fox, McLaughlin), 2018 · wwwtest.sop.pharmacy.wisc.eduUniversity-hosted copy of the published guideline.
9.How Should Critical Medications Be Rationed During Shortages? · AMA Journal of Ethics (Fox, Wynia), 2024 · journalofethics.ama-assn.org
10.OCR Reaches Early Case Resolution With Alabama After It Removes Discriminatory Ventilator Triaging Guidelines · HHS Office for Civil Rights, 2020 · hhs.gov
11.What to Expect for Your APPLIED Exam (APPLIED Exam Manual) · ABA, 2026 · theaba.org

Facts on this page were checked against these sources on Oct 25, 2026. Guidelines change; confirm doses against current institutional protocols.