Wednesday, 21 November 2012

Usmle Step 1 MCQ's # 6

Title: Usmle Step 1 MCQ's # 6
 Subject: Behavioral Science

Q NO 6: A 67-year-old man is admitted to the hospital for a biopsy to confirm suspected lung cancer. The results of the biopsy, sent to his physician the next day, confirm the presence of cancer in an advanced stage. Although a number of treatments are available, life expectancy for patients with this type of cancer is less than 6 months. The physician decides to tell the patient the results of the biopsy immediately. After checking in at the nurse’s station, he walks down the hall towards the patient’s room. Outside the patient’s door, he is met by the man’s adult daughter, who is visibly upset, and asks to speak with the physician in private. “If it is cancer,” she says, “please don’t tell him!” At this point what should the physician reply?

A. “I do need to tell him what we know. Would you like to come in with me while I tell him?”
B. “I know you are concerned, but I have to ask you not to interfere.”
C. “I’d be happy to wait a little bit it you can tell me why I should.”
D. “I’m sorry, but I am required to tell my patient everything, even the bad news.”
“Talk with me about why you don’t want me to tell him.”
F. “Why don’t we go into a quiet room over here and talk about your father a bit.”
G. “Would you have me lie to my patient?”
H. “You seem upset. Please try to compose yourself and then we can talk about it.”

The correct answer is E. The patient needs to be told what the doctor knows, and told in a timely fashion, but something else has occurred that must be dealt with first. Confronted with the daughter’s pleading, the correct response is to seek some information from the daughter to discover if she has any information the physician should know. Be clear that there is nothing the daughter can say that will stop the physician from going into the room and telling the patient what he knows. Rather she may have information that changes they way that he approaches the patient or the method he will use to break this bad news. Notice that with this question the physician is asking for, but not giving information.
Along with these specifics, there is i more general rule here. Don’t get carried away by momentum. The doctor was on his way to talk to the patient. But when new events occur he must change his tack in order to deal with them.
The patient, not the physician should be the one to decide it the daughter should be present. Confidentiality is absolute and should not be violated by inviting the daughter into the discussion (choice A)
Choice B chides the daughter. At best, it misses the chance to seek information from her. At worst it sets up a confrontation that could escalate right outside the patient’s door.
The physician wants to know what the daughter thinks, but should not delay telling the patient (choice C) . The patient has the right to know the results of the test. The physician has no right to tell the daughter he will delay the necessary conversation.
The physician must tell the patient everything, but should take the opportunity to gain additional information about the patient from the daughter. Simply bypassing her (choice D) misses the opportunity.
The physician must respect the patient’s confidentiality. This means not discussing the patient’s health, even with family members, without the patient’s explicit permission. It’s OK to ask the daughter what she knows, but not to tell her about her father (choice F)
Choice C is very challenging and confrontative. It is more likely to lead to an emotional exchange than any useful conversation.
Choice H also misses the opportunity to find out what the daughter knows. In addition, it could be perceived as condescending, that is, treating the daughter like a child, rather than an adult.

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