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.”
Explanation:
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.
