Monday, 17 December 2012

Usmle Step 1 MCQ's # 11

Title: Usmle Step 1 MCQ's # 11
Subject: Behavioral Science

Q NO 11: A 29-year-old man comes to see his physician for treatment of a sinus infection. From previous medical history, the physician knows the patient often has sexual relations with other men. In the course of the physical examination, the patient tells the physician that he has “had a difficult time lately” since the death of his “life partner” due to AIDS several months ago. He reports difficultly sleeping, waking time anxiety, and a weight loss of 10 to 15 pounds. His appearance is gaunt and his face is strained. When asked it he had ever been tested for HIV, the patient becomes angry and says,” No, and I’m never going to get tested. Don’t tell me you’re one of those doctors who think that all gay men have AIDS!”. At this point the physician’s best reply would be which of the following?

A. ”Don’t be so sensitive. It just seemed like the obvious question to ask given your circumstances 11
0B.1 have quite a few gay patients and i get a long well with allot them. I’m sorry that l upset you.”
C. “I’m going to prescribe an antibiotic for your sinus infection and something else to help you feel a little better.”
D. “l’ m sorry if I upset you. I want to make surely give you the best care possible and with currently available medications, early detection for AIDS is essential.”
E. “I’m sorry that you feel that way about me. Would you rather I refer you to another physician?”
F. “If you want me to help you, I have to ask these types of questions.”
G. “OK, sounds like that is a sensitive subject. Sorry that I bought it up.”
H. “You seem to be distressed at the loss of your partner.”
I. “You seem upset. Let’s talk a little bit about how things have been going for you in the past several weeks.”

The correct answer is D. The issue of testing is a legitimate, and even necessary one. The anger of the patient should be defused, and the reasons for the question explained, but the matter should not be left to drop just because of the patient’s emotional response. The physician first takes responsibility, and acknowledges that he is the cause of the patient being upset by apologizing. Alter addressing the emotional issue, the physician proceeds to explain the reason for the question. This answer keeps the lines of discussion open, and focused on the health matter at hand. This answer is best because it deals with the patient’s anger AND keeps the discussion on the health issue of concern.
This response is defensive--the physician feels attacked and defends himself by justifying his actions (choice A) . Un fortunately, this response is likely to heighten, not reduce, the patient’s anger. Further, the discussion now centers on the patient’s response with the focus on the need for testing and treatment lost. Note that in this response, no reason for raising the testing issue is given. It is merely asserted.
This is also defensive and opens up a discussion about how the physician feels about and deals with homosexual men (choice B), not the core health issue, which needs to be addressed. The issue is the patient’s HIV status, not how the physician feds about gay men.
This may be a reasonable treatment for the sinus infection (choice C); however, it is not responsive to either the patient’s expressed anger or the health need of testing. Note that the veiled offer of antidepressant medication is also incorrect. yew likely the patient is grieving. Correct response to grief is listening, support, and allowing the patient to go through the grieving process.
The rule” never pass off H applies here. The physician can and should, resolve this issue with his patient. There is simply no reason for a referral (choice E)
This is not bad answer, just not best. The tone is sufficiently non-confrontative. However, the physician takes no responsibility for the patient’s response and provides no rationale for raising the topic of testing (choice F).
This response backs away from the subject because of the patient’s response. The apology is correct, but the subject raised is important, one might even say central to the ongoing health of the patient, and cannot be dropped just because the patient is uncomfortable with it (choice G)
Acknowledging the patient’s emotional state is a good idea (choice H). Leaping to an interpretation as to why he is distressed is not. This statement is an interpretation. Physicians should remember that interpretations are almost always perceived as hostile, even if correct. This response is likely to escalate the patient’s anger and detracts from the health issue at hand, the need for testing.
This option reflects back to the patient that he is upset (choice I), a good technique. However, the discussion is then turned to the patient’s life in general, and the focus on testing as the important health issue is lost. Allowing a grieving patient to talk about what they have been doing with their day is good and appropriate, but should be pursued after the discussion about HIV testing is concluded. By raising these issues now, the physician is avoiding the main topic at hand.

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