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