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29 Cards in this Set
- Front
- Back
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CHAPTER 23: Clinical Practice and Difficult Situations
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CHAPTER 23: Clinical Practice and Difficult Situations
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The USMLE sometimes gives 'quote' questions asking you to pick something to say in a provider-patient interaction.
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In general, it’s usually a good idea to get more information, respect the patient’s autonomy, keep information confidential, and never lie
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What is the importance of rapport?
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The relationship and trust built between the doctor and patient greatly enhance the effectiveness of care.
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What are the most important things to do if a medical error is committed?
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Admit the mistake and apologize for it. Never try to cover up an error.
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What should you do if a patient tries to give you a gift?
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You should thank the patient for their thoughtfulness, but not accept it. Gift giving may be misinterpreted as 'buying better care'—equal care should be given to all.
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When is it appropriate to refer a patient to another physician?
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Only when the problem cannot be handled by yourself. This is rarely the answer on the USMLE—it is inappropriate to refer a patient to a psychiatrist just because they have a difficult situation to be dealt with!
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What would you say to a patient with a terminal illness who wants to die?
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Get more information about why they feel this way. Commonly, they are afraid of dying in pain; they may have seen a loved one die painfully. Reassure them that you will stick with them and that their symptoms will be well controlled. Also assess for untreated depression.
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Your fellow resident gets called in to work at night and you smell alcohol on his breath. He says he only had two beers and asks you not to say anything. Do you tell someone?
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Yes. It’s unethical to endanger patient care with a possibly impaired physician.
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A patient’s sibling asks you for information about their condition—do you give it to them?
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No. You must have formal permission from the patient to share their health information with anyone other than them.
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Can you tell information about a patient to someone uninvolved in their care?
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No. This is a violation of the Health Insurance Portability and Accountability Act (HIPPA). You should be careful where and with whom you discuss any patient information.
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You see a former patient at a bar, whom you treated briefly 10 years ago. Can you ask them out on a date now?
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No. It is never ethical to have a romantic relationship with a patient, former or current.
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When is it OK to withhold information about an illness from a patient?
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If the patient tells you they don’t want to know. It must be the patient that indicates this—not a family member.
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A patient asks you to do a procedure that is legal, but is against your belief system. Must you do it?
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No, you do not need to do anything nor treat anyone that would compromise your beliefs. However, you should refer the patient to someone who will treat them, as well as provide support in the meantime.
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What is a good general approach to an emotional patient—be it angry, sad, or scared?
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Label and validate their emotions, then offer support. Eg: 'You sound like you are scared—I don’t blame you, it’s OK to be scared about this procedure.'
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What if the patient starts to cry?
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Let them cry. Try to be comfortable with silence when appropriate. Offering a tissue is always a good gesture.
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What are the steps to giving bad news?
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① Set the stage—find a private place and ensure you have a proper amount of time free.
② Find out what the patient knows about his/her illness. ③ Find out how much the patient wants to know. ④ Tell the information. ⑤ Respond to feelings. ⑥ Make a plan for next steps. |
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Which of the steps above is most likely to be asked on the USMLE?
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Finding out how much the patient knows about their illness (no 2). It’s always good to get information first so you can frame the discussion.
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How do you use an interpreter?
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Speak to the patient, not the interpreter. Speak clearly, being sure to pause intermittently to allow the interpreter to convey information to the patient.
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Is it OK to allow a child or family member to act as an interpreter?
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No, not if it can be helped. Even if the family member is fluent, it is good to at least offer to get an interpreter for the patient. Family members may also have their own agenda that may unduly influence the patient.
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What is patient adherence (formerly called 'compliance')?
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The degree to which the patient follows the advice of the treating physician
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What are barriers to patient adherence?
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Complicated medical regimens
Poor physician-patient rapport Lack of patient involvement in the treatment plan Infrequent appointments Poor support structure/inadequate help at home |
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How might a physician make a treatment plan less complicated?
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The treatment plan can be simplified by limiting:
The number of medications the patient is taking The number of times the medications is taken per day The number of changes made at each visit |
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What is an open-ended question?
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A question that is intentionally left broad, such that the patient can say what is really on their mind—'What brings you into the clinic today?' or 'Tell me about your stomach pain.'
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What is a close-ended question?
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A very specific question with a discrete answer. Used to get more detail—'Did you have nausea?' 'How frequently do you have pain?' This is also useful with seductive or disorganized patients.
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What is the cone method of interviewing, or 'coning'?
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Starting with an open-ended question, then progressively narrowing down to more specific close-ended questions.
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CLINICAL VIGNETTES
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CLINICAL VIGNETTES
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A 79-year-old woman came into the hospital complaining of shortness of breath. After an extensive workup, you find that she has metastatic lung cancer. Her son finds you in the hallway and states 'In our culture our elders do not like to know about serious illnesses. It is my duty as a son to take care of my mother.' You are unclear about what cultural practices are appropriate to the patient. How do you approach this situation?
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It may very well be that there is a cultural aspect to discussions of terminal illness that is appropriate to consider in this case. If available in your institution, a 'cultural consult' may be appropriate with someone more versed than you in these issues. If not, it would be inappropriate to withhold information based solely on what the son of the patient says. The best case would be to sit down with the patient and ask her about her cultural beliefs around illness—'Some members of your culture prefer not to talk about their illnesses, but instead allow their children to make medical decisions for them. How do you feel about the discussion of illness?'
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A patient with known sickle cell disease comes into the ER. He states he is in 10/10 pain and requests 15 mg of morphine. The nurse says he is a 'frequent flier' and worries that he is an addict. He doesn’t look like he’s is in any pain. What should you do?
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Treat his pain. With known disease it is more important that he does not suffer than to distinguish his symptoms from malingering. Remember, sickle cell crisis can be extremely painful even without outward signs of pain.
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You call a family meeting for a chronically ill patient whom you just found out has leukemia. Everyone is comfortably sitting in your office. What do you say next?
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What do you know about your illness?' It is important to be open-ended and see what the patient’s thoughts are. Most likely he has been thinking about this much more than you and probably is very well informed; or he may have completely unrealistic views that would be good to learn about before the conversation. Probe a bit to understand this, and then to ascertain how much he wants to know before delivering the news.
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