Friday, 21 December 2012

Usmle Step 1 MCQ's # 12

Title: Usmle Step 1 MCQ's # 12
Subject: Behavioral Science

Q NO 12: A 15-year-old boy has been treated on an ongoing basis by his physician for type 1 diabetes. During a regularly scheduled evaluation, the patient appears sullen and non-responsive. He slouches in his chair and will not make eye contact with the physician. When questioned about how he is feeling, the boy mumbles something unintelligible and stares at the floor. When told that he was not understood, the boy blurts out, “This treatment is not working. It’s such a pain. I don’t want to come here anymore. I don’t think you know what you are doing.” In response to this out burst the physician’s best reply would be which of the following?

A. "Are you having trouble with the other kids at school?"
B. "I know this is a bother, but your parents have decided on this course of action and they know what is best for you."
C. "If you would be more comfortable with a different doctor, I’ll try to arrange it for you."
D. "I’ll make a deal with you. Keep on with your treatment for six more months, and we’ll see where you are at that point."
e. "In what way is the treatment not working?"
F. "Tell me a little bit about what life has been like for you lately."
G. "When I was younger, I had to do a lot of things that I did not want to, but looking back, I’m glad I did."
H. "When you are old enough, you will get to make these decisions. Until that time, I’m going to do as your parents request."
I. "Without this treatment you will die. Do you understand that?"

The correct answer is E. The key issue here is that the physician does not know exactly what is bothering the boy when he says the treatment is not working. Does he think he should be cured? Does he find the monitoring and treatment regimen to be onerous? Is he subject to criticism from his peers? Or is he just tired of having a medical problem? The physician does not know, and so should ask. When you don’t know exactly what the patient is talking about, ask!
Choice A is not directly responsive to the boy’s outburst and leaps to an assumption about the reason he is upset. Guessing correctly may make the physician seem omniscient, but guessing wrong simply makes him seem foolish. Don’t assume, ask.
Choice B brings the parents, and their authority to make medical decisions for the boy into the discussion. It complicates the gathering of information from the boy, and stresses the authority relations, something that is likely to heighten, not soothe the boy’s anger.
Choice C is incorrect. The physician must form a relationship and solve the presented problem. Getting rid of the problem by getting rid of the patient is nothing more than a dereliction of duty.
Choice D is not a bad tactic for negotiating adherence. Often, seeing treatment stretching out interminably makes patients despair. Breaking it into a bounded time frame makes it seem more manageable. The problem here is that this discussion is premature. The physician is negotiating the solution before having a clear sense what the problem is.
Choice F is a great way to get a sense of how the disease and treatment might be affecting the boy and his relationship with others. But, again, this is premature. Find out what the problem really is before talking about how it has affected the boy’s life.
Choice 0 is meant as fatherly advice, but risks being perceived as condescending and un empathetic. At the very least, find out what the problem is before regaling the boy with what life was like when you were young!
Choice H tells the boy that he has no say, and that the physician is not interested in what he has to say. True, the parents are the ones making the decisions, but there are other reasons to talk to the boy. Only he knows how the treatment makes him feel, and what impact it has on his life. And he is likely to be the first one that knows if something is truly wrong. Don’t lecture ask.
Choice I is a bit harsh, but statements like this can be excellent motivators to foster adherence with treatment. The Health belief model tells us that engendering fear, and then providing a simple solution is empirically a very good way to motivate adherence. But here again, we need to know what the problem is before we seek to work on adherence issues.

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