DOC COM 5,6,7,8,14

Peter Erman is 18, a Caucasian high school student admitted to the hospital for internal injuries after driving a car into a tree. He was driving while intoxicated, and luckily no one else was injured. It is your responsibility now to address the drunk driving issue with him. Which of the following responses would best convey Support? A. State: "No more drinking and driving - please!" B. State: "I hope this was a good lesson for you - drinking and driving has horrible consequences. Actually, at your age you should not be drinking at all." C. State: "When I was your age I also liked partying. Of course, you can't drive home when your alcohol level is still elevated." D. State: "Let's brainstorm about how you can stay away from alcohol." E. State: "There are many situations that can result in someone driving while they are drunk. I would like to help you figure out what led to your accident so that you can avoid it in the future."

(E) is correct because it acknowledges the patient's emotional experience, and does not imply that she really hasn't been following the plan. This legitimizes her concern that the plan is not working for her. (the patient is likely to respond to "E" with additional useful information about details, and you will take the time to more fully explore the facts and her feelings.)

Carlos Rodriguez is 60, Hispanic, owns a neighborhood grocery store, and is in the hospital with a heart attack. His condition has improved and he wants to be released immediately, even contemplating signing out against medical advice. Mr. Rodriguez is in bed, with IV's running. He tells you he is concerned that his store is his wife's responsibility while he is in the hospital, and she is undergoing outpatient treatment for breast cancer. Which of the following responses would best convey Partnership? A. State "Many people in your situation would feel hesitant to stay longer in the hospital. Let's work together to make sure that you are stable enough to return home." B. State "Taking care of yourself is the most important thing for now." C. Lean towards the patient and state "You have a lot on your plate - your wife's cancer, the shop and now your illness. It must be tough." D. State "Do you have any relatives or friends who could step in?" E. Briefly touch the patient's arm in a friendly gesture and state "Are you concerned about the financial impact of your hospitalization?

A best conveys Partnership because there is an explicit invitation to work together. Options C and E include non-verbal behaviors that may not be appropriate to the situation--when patients are lying in bed, getting closer or touching could be seen as intrusive. Since the patient is somewhat agitated and wants to leave against medical advice it would be better to give him some more space and appear less pressuring. The statement in C is empathic, but not partnership.

Juanita Perez, 21, is a single college student of Hispanic descent. Juanita came in with gastrointestinal symptoms, you suspected pregnancy, and confirmed the diagnosis by lab test. You noticed arm bruises consistent with physical abuse. When you told Juanita she was pregnant, she started to cry. Which of the following responses would best convey Support? A. State: "I can see that being pregnant is very upsetting to you. How can I help you?" B. State: "I can see that being pregnant is very upsetting to you. Did someone force you to have sex?" C. State: "I can see that being pregnant is very upsetting to you. Is your partner abusive to you?' D. State: "I can see that being pregnant is very upsetting to you. Many options are available to deal with this situation." E. State: "I can see that being pregnant is very upsetting to you. I've had other patients in the same situation, and somehow things always work out."

A best conveys Support. D and E are impersonal and not relational. Of course exploring the possibility that Juanita is a victim of violence is important (B and C), but you should first affirm your personal availability and support.

Which one of the following is not one of the 7 cardinal features of a symptom? A. Attribution B. Quality C. Setting D. Location

A is correct. The 7 cardinal features of a symptom are Location/Radiation, Quality, Quantification, Chronology, Setting, Modifying Factors and Associated Symptoms.

Mrs. P. is a 25 year old, 5 months post-partum with her first child, who is in neurology clinic because of a severe headache, and says that she's had painful peri-menstrual right and left sided headaches since age 15. Last night an unusually severe headache associated with nausea, vomiting and some difficulty pronouncing words occurred; subsiding after several hours and multiple doses of Ibuprofen. She says she was very frightened, as she was home alone with the baby. Mrs. P has not experienced palpitations or other neurological symptoms, takes no other medications and does not drink alcohol, smoke tobacco, or use other drugs. On exam her BP is 120/80 and P is regular at 72. Her fundi are normal, and she has no carotid bruits, cardiac murmurs, or neurological deficits. Mrs. P says, "There's been a lot going on lately. It's been tough at home. Maybe this was just a bad migraine. I've had headaches for a long time." Which of the following do you prefer? A. "Migraine is definitely possible You mentioned there's been a lot going on at home lately. Can you tell me more about that?" B. "Migraine is definitely possible. In the past, have you ever had problems speaking during your headaches?" C. "Was this the worst headache you've ever had in your life?" D. "Migraine is definitely possible, and I think we need to be certain nothing new is happening and I'm sending you for an MRI scan of your head." E. "Migraine is definitely possible. Did you take any medications other than the Ibuprofen?"

A is correct. Your clarifying question functions as an invitation to share additional psychosocial or contextual information, which may be important in its own right, and your preface to the question responds directly to the patient's concerns and emotions at the time of their expression. B, C, D and E respond to important biomedical issues, but fail to respond to the patient as a person, and do not seek additional contextual information. They miss the "window of opportunity" Mrs. P has presented.

Your patient, Dr. Singh, a 28 year old internal medicine resident, comes in 3 weeks after a trip home to India. She opens by complaining of rigors and fever to 103 degrees F, and then says, "This is exactly how I felt the last time I had malaria!" What is the recommended next statement? A. I understand you're having chills and fever. Have you noticed anything else? B. Were you taking malaria prophylaxis? C. Have you noticed a sore throat, cough, skin abscesses or problems when you urinate? D. How long ago did you have malaria? E. Has anyone else in your family been ill?

A is recommended, as it keeps the exploration open and avoids premature narrowing of hypothesis generation. B, C, D, and E are all closed questions, each of which probes for important details, but are best delayed until the patient tells her story.

Question 4 "I know that you are concerned about losing weight. I'd like to be sure I know the other things that are on your mind." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

A. Survey symptoms

Gary Brown is a 27 year old single man of Nigerian descent, in your office for the first time because he has been experiencing diarrhea and night sweats and generally feeling unwell for the past month. You thoroughly explore his complaints and the story of his illness, and have just begun asking more about his sexual history. Mr. Brown maintained good eye contact until you asked about sexual orientation, and then looked down and noticeably lowered his voice. He answered "I'm straight." Which of the following options is recommended to help address the mixed message? A. State: "Talking about sex is uncomfortable for many people, and in this situation it is important for me to fully understand your current life situation." B. Say, "Let's move on to other details and I'll return to this issue a bit later." C. Lean forward a bit, and remain silent to give him time to elaborate further on this sensitive topic. D. State: "Understanding your sexual preferences and activities is a key part of making a good assessment of what might be going on here.." E. Rest your head on your hand to mirror the patient's non-verbal behavior and ask for more details.

A. is recommended. Legitimizing (m6) verbally the discomfort the patient is expressing non-verbally might put him more at ease about disclosing his sexual history. Mirroring (E) may not work since the patient has withdrawn significantly, is looking at the floor and may be less aware of your nonverbal cues. Shifting the topic temporarily (B), or just waiting (C) might work, but does less to assist with his discomfort as expressed in a mixed message. D is "just the facts" and does not acknowledge verbally or non-verbally the emotional content of the situation.

Tom Pawlak is a 48 year old of Polish descent, in the ER because he was "spitting up blood." As you go into the cubicle, Mr. and Mrs. Pawlak look up anxiously and quietly say hello. Mr. Pawlak has his arms crossed over his chest and his hands are gripping his elbows. Mrs. Pawlak is sitting in a chair at the foot of the stretcher, resting her right elbow on the stretcher while her left hand is gripping her handbag in her lap. Which behaviors are recommended for establishing rapport with both Tom and Mrs. Pawlak? A. Fold your arms and quietly introduce yourself. B. Hold out your hand to Tom and clearly say hello. C. Hold out your hand to Mrs. Pawlak and clearly say hello. D. Wave hello and clearly introduce yourself. E. Put your hands into your pockets and quietly introduce yourself.

A. is recommended. When receiving non-verbal clues that a new patient does not feel "safe" it is useful to match the patient's behavior. In Tom's case matching his crossed arms is appropriate, along with a friendly but toned down introduction. Initiating a touch or being too friendly upfront (as in B. C. and D.) is likely to feel inappropriate if patients are in physical or emotional pain and distressed (as with Mr. and Mrs. Pawlak, or if you are about to reveal bad news.

"What did you notice experiencing when this first began?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

A. open question.

Francesca Chen is 35, a Chinese American hairdresser with diabetes. Her glucose and HgbA1C indicate poor control. As you speak, she hesitatingly reveals that since the last visit two months ago, she broke up with her boyfriend of 10 years, started a new job and registered for classes at the local community college. Which of the following statements would show that you understand and empathize with her likely emotional state? A. State "A lot has been happening since I last saw you, and you still seem to be managing well." B. State "As you speak, I get the sense that the many changes in your life are very stressful." C. State "With so many life changes happening all at once it would be difficult for anyone to stay on top of their diabetes." D. State "Let's work on adjusting your diabetes treatment plan." E. State "Why do you think your diabetes is not better controlled?"

Among these empathic responses, B most directly expresses your understanding of her situation. A summarizes and adds a statement of respect; C is an example of legitimation, D of partnership, and E seeks her perspective (see Module 9).

James King, 70, is a patient of your colleague on vacation and a retired African American postal worker. His daughter brings him in today because of difficulty breathing and a fever. You recommend hospitalization, but Mr. King wants to wait until his regular physician returns in a few days. Which of the following responses would best convey Attentiveness and Warmth? A. State: "There is no need to be afraid about going into the hospital. I'll be here to assist in any way I can." B. State: "I can see that you are anxious about going into hospital without having your regular physician at your side. Please tell me more about your concerns." C. State: "Your daughter understands the urgency of getting hospital treatment now." D. State: "Mr. King, I'm worried that you are quite sick and we need to start antibiotics, fluids and other treatments before you get any sicker." E. State: "I'm sure your doctor would insist that you get hospital treatment right away."

B best conveys Attentiveness and Warmth because it acknowledges Mr. King's emotions right away and warmly invites his participation. (Further, when covering for someone else, always openly acknowledge the relationship the patient and your colleague have built up over time.)

Renata Bowen, an 80 year old widow and retired antiques dealer was brought to the hospital for a hip fracture. Her rehabilitation is going more slowly than usual, and she will clearly need long-term care for an uncertain period. Ms. Bowen has maintained her independence throughout life, and the idea of going to a nursing home (even temporarily) seems unacceptable. Her mood has been depressed, and her social worker reported that Ms. Bowen cried when he brought up the issue. After greeting her, what statement would best demonstrate Respect , as you begin today's conversation? A. State: "Ms. Bowen, I realize this is a difficult subject, but soon you will no longer require hospitalization and I want to help you make plans for your future." B. State: "I am so impressed with your ability to lead a remarkably independent life until now." C. State: "The idea of longer term care, even temporarily, must be very frightening." D. State: "I've had other patients in this situation, and they are always reluctant to sign up for longer term care." E. State: "This is complicated; given that you can't get around that easily yet. Lets' work together to find the best possible living arrangements."

B best conveys Respect because you simply name a strength and leave the floor wide open, giving Ms. Bowen permission to respond, or not respond. Whatever she says (or doesn't say) will give you clues as to how to be most helpful to her. The other responses demonstrate other aspects of empathy: A. shows Understanding of her emotions (a Reflection of what she has previously stated) and Partnership; C shows Understanding of her emotions; D demonstrates Legitimation, and E again stresses Partnership.

Ms. Dole, 25, an executive assistant, is in Urgent Care with left ankle pain and swelling following a fall 10 days ago. She says she simply lost her footing going downstairs from her apartment, and has not felt dizzy or blacked out. The clinic notes show that she had a right wrist injury following another fall at home a few months ago. Otherwise, she is healthy; takes only an oral contraceptive And her x-rays show no fracture. The waiting room is packed with patients waiting. Which option is recommended as your next action? A. I'm going to give you an air cast, crutches, and Ibuprofen. Elevate your leg as much as possible, and come back for more evaluation if you do not improve in this coming week. B. I'm concerned that you've had two recent falls and I'm wondering if you have any ideas about why this is happening. C. How much alcohol do you drink? D. I'd like to do a more complete physical exam. E. Do you have other symptoms, problems or concerns we have not yet discussed?

B is preferred. An open invitation to speak more about her life is helpful here. A ignores the two-fall fact; C is relevant, but too abrupt and if she has a substance abuse problem may lie or respond defensively; D is important but not yet, and E asks several questions at once, a poor strategy.

Dr. Singh (from prior Question) says she had shaking chills and fever without any other focal symptoms. She had malaria a year ago that was successfully treated and has been asymptomatic since that time. Her trip to India was for a month and she took appropriate chemoprophylaxis before, during and after the trip. She says she is quite concerned about P. falciparum infection, because she knows P. falciparum may carry drug resistance. What is the recommended action now? A. Say, "I'd like to send you to the lab for a malaria smear, as well as blood cultures and other appropriate blood and urine tests." B. Say, "I can understand your concern about P. falciparum infection, given your past history and recent travel." C. Say, "Even though P. falciparum may be resistant, its prevalence is low and you were so conscientious in taking the prophylaxis that it is unlikely you have malaria." D. Say, "Let's complete an appropriate physical, checking carefully for splenomegaly, then decide on next steps." E. Say, "I'm eager to work with you until we get to the bottom of this."

B is recommended at this choice point in the interview because it immediately acknowledges her illness concern. This legitimation/ validation of her emotions tells her you have heard not only her history, but its emotional significance and context. This keeps you and the patient on the same page. Failing to respond right away may be interpreted as a lack of interest, and distract her. A and D seek appropriate information, but should be delayed until you respond to her feelings. C is premature reassurance. E is helpful, but a less direct response to her emotions than B. NOTE: Her urine showed 50-100 white cells and grew out > 100,000 E. coli, with positive blood cultures. Malaria smears were negative. Treatment for pyelonephritis led to recovery without problems or recurrence.

In the Emergency Department, you are directed to see a 30 year old man who will be admitted to assess the presence or absence of a heart attack, then write the admitting orders and page your supervising resident. Bob L. is a 30 year old software engineer who appears concerned but not in distress. Bob reports left sided chest pain intermittently since yesterday, and the nursing notes state that he has an elevated cholesterol and family history of coronary artery disease. What is your preferred next statement? A. Was the pain sharp or dull? B. Can you describe your chest pain? C. Have you ever had this type of pain before? D. On a scale of 0 to 10 with 10 being the worst, how bad was this pain? E. Would you tell me a bit more about your family and your current life situation?

B is recommended, as an open question with a focus on the primary symptom, and a question that will help you determine the urgency of the situation. A, C, and D are important, but they are closed questions that do not invite the patient to tell the full story and may limit your ability to perform a full assessment if asked too early. E is equally important, but also a closed question and should be asked later if the patient does not spontaneously include sufficient detail after your open invitation.

For your patient who is concerned about chest pain, which informational statement will be included in the History of Present Illness (HPI)? A. Eating strawberries gives me hives. B. This burning chest pain started after I had a bowl of chili. C. My children and I live with my long-time partner. D. I have had chest pain since last night. E. I haven't had any fevers.

B is the correct response, as it expresses the beginning of the presenting illness. A is part of Past Medical History. C is part of Psychosocial History. D is the Chief Complaint. E is part of the Review of Systems.

What exactly do you mean by shortness of breath? Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

B. Clarification.

Question 6 "Headache, backache, difficulty sleeping, tiredness." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

B. List concerns

A new patient in your office, Mr. Smith told you his concerns, and said that his biggest concern is a recent episode of chest pain; he appears quite anxious. Your next best step toward completing the history of present illness is to say A. "When did your chest pain start?" B. "You look worried." C. "Did your parents have heart disease?" D. "You must be under a lot of stress." E. "What goes along with your chest pain?"

B. The process of obtaining an accurate and thorough history of present illness is usually facilitated by addressing emotion, even very briefly, as soon as it appears. When we notice emotion, we can easily assist the flow of the interview if we name it, or make an understanding statement, or respect the patient through acknowledging it, or offer support (NURS pneumonic). Regarding A, C, and E: Patients generally go into a "fact" mode if this is your next question; and many of them will feel ignored or "depersonalized" by your early failure to acknowledge their manifested anxiety in some way ("I'm a person, not an ailing machine"). When this kind of "shutdown" occurs, it diminishes their ability to be fully present, attentive, and responsive and effectively participate to help plan next steps Regarding D: If you mean to say, "you seem distressed", you need to be clearer. Some patients will be forgiving and respond as if you had named their emotion, but most will experience your drawing a conclusion about their life situation this early as your going into a "fact" mode, as in A, C and E, above.

Sharon Cane is an 8 year old girl of German descent, in your office with her parents. You borrowed an extra chair from the next office, and Sharon positioned herself near the window. As you begin the interview her parents lean forward and explain that Sharon has been having stomach aches, and that something needs to be done because she is missing school so often. They interrupt one another and escalate in volume to almost shouting. Which intervention best demonstrates "matching and leading" in relation to the parents? A. Walk over to Sharon, stand next to the window and ask her: "How are you feeling?" B. Lean forward, look each of the parents in the eye, and softly say "Let's let Sharon talk first." C. Ask Sharon to sit next to her parents since the discussion is all about her. D. Walk over to Sharon and gently guide her to the empty chair, asking her to sit down. E. Lean back in your chair and softly say "Let's give Sharon a chance to describe the problem.

B. is correct. By leaning forward (as the parents do) the clinician can "match" their behavior. Changing the tone of voice to softly is "leading." Clearly Sharon is the focus, but her parents have an important role and should not be excluded by ignoring them (A. or D). E is a second best strategy if "matching and leading" does not work, with A,D or C less appropriate non-verbal interventions.

Which of the following statements about disease and illness is most accurate? A. Disease is a patient's experience of illness. B. Disease is a subjective expression of illness. C. Illness is a patient's experience of disease. D. Illness is an objective expression of disease.

C is correct. Disease is a biological process, and illness describes the effect of disease on an individual. Disease may be cured with medications, surgery and biotechnology. Illness may be healed through words and relationships.

Integrated patient-centered and doctor-centered interviewing: A. Is less scientific than isolated doctor-centered interviewing B. Is unnecessary now that we have advanced diagnostic tests C. Provides more accurate medical diagnoses than isolated doctor-centered interviewing D. Will make most patients uncomfortable

C is correct. Integrating patient-centered and doctor-centered interviewing skills is actually more scientific than isolated doctor-centered interviewing because it provides a more complete and accurate database. Advanced diagnostic tests will not help you understand the patient's experience of illness, which can play a major role in negotiating a therapeutic plan. Studies show that doctors who integrate patient-centered and doctor-centered interviewing skills arrive at a more correct and more complete diagnosis. Patients usually want to share their story and appreciate their doctor knowing how a symptom is affecting them and making them feel.

Mr. Jones, age 50, comes to the office and says he is worried about his cough. You ask "Please tell me more about this?" Which of his statements about his situation is likely to emerge earlier than the others? A. I am allergic to penicillin so I hardly ever take antibiotics. B. I was in the hospital for a pneumonia when I was three C. I was treated with antibiotics last month for this cough and it didn't help. D. My father died of lung cancer when he was in his 80s. E. My sister has multiple sclerosis, discovered when she had trouble seeing."

C is correct. This information is most current, and likely to be a high priority concern about his cough, and be stated early. A, B, D, or E may emerge as an important factor, and in the unlikely event that this is a major issue for him, may come out first; however, it is more likely to be discovered later, during your more doctor-centered inquiry about relevant details.

Ms. Dole tells you that she really doesn't know why she's been falling. You then tell her you're happy she's come in to see you, but you're wondering why now, ten days after the injury rather than earlier. She replies, "I couldn't come in until today because it's just been hard to get away from work and home. My husband's out of town today so it was more convenient." At this point, choose the recommended response statement. A. It sounds like your schedules are pretty busy. B. It's best to come in soon after this kind of injury so you can avoid further damage. C. Sometimes when I've heard symptoms or seen problems like yours, I've learned that the patient is being hurt or hit at home. Could that possibly be happening to you? D. I'd like to refer you to a primary care physician for follow-up if you don't already have one. E. Is someone hurting you?

C is preferred because you are following up on the "red flag" about her husband being out of town before she comes in. A ignores the red flag (an empathic response might be good here, but to be effective should address the red flag- example: "You had to wait until your husband was away.") B and D are important, but both ignore the red flag. E is likely to provoke shame or guilt, and would be vastly improved by adding a preface and including your thinking, as in C. NOTE: Mrs. D. did disclose her husband's abuse. Alcohol and drug screening questions showed no risky behaviors. Physical exam showed additional bruises on her torso and back. You express concern for her safety and assure her that she doesn't deserve to be hurt or abused. She agrees to speak with the social worker on call for further assessment and counseling. (M 28 has more on Domestic Violence.)

Bob (from previous question) tells you the pain is moderately severe and feels like a stabbing sensation in his left chest, and he reveals that he's worried about a possible diagnosis of heart attack. At this point, which statement below is recommended? A. Can you show me where it's hurting you? B. Go back to the beginning. What were you doing when this began? C. What worries you the most? D. Have you had any shortness of breath with this? E. So, who in your family has had a heart attack?

C is recommended, because it addresses his concerns, is an open invitation that allows him to disclose as much or as little as he chooses, in whatever direction he chooses. This moment is often called a "window of opportunity" and keeping it open usually makes interviews more efficient, addresses patients' concerns in the moment, and improves clinical outcomes. His responses to the other questions are very important, and if he does not give data that answers them in response to C, you will need to ask each of them—but do so after respond to his concern. Bob says that what worries him most is that a heart attack that might preclude his continuing as a committed amateur weight-lifter! Then he reveals that he suddenly had a sharp pain in his lateral chest while bench pressing, and since then has had pain off and on when he twists a certain way or externally rotates his left shoulder. Except for point tenderness in a small area in the lateral pectoralis, exam is normal, his EKG is normal and there is no pneumothorax on chest s-ray. You summarize for the resident and decide to not admit him- Bob is relieved.

This is your first encounter with Margot Gwen, a 20 year old single Caucasian collegian with Crohn's disease whose previous physician just moved out of town. Her responses to your open-ended questions ("Tell me a little about yourself;" or "I've looked at your medical record, how can I help you today;" etc.) are consistently one or two word answers, and she looks down at her hands and twists her fingers during the interview. Which of the following responses would best illustrate Empathy? A. State: "Before we continue, I'd like to let you know why I am asking you questions about your health." B. Connect non-verbally by moving your chair closer, maintaining good eye contact, and gently touching her shoulder to supply reassurance. C. State: "You seem uncomfortable with our conversation, so far." D. State: "Is there anything in particular that you would like to tell me now? I am here to help you with your health." E. Back up in your chair and state: "It seems that now is not a good time for us to get to know each other. What should we do next?"

C is the most Empathic response, using Reflection to simply demonstrate your understanding of her discomfort, leaving the floor wide open and giving Margot permission to respond, or not respond. In B and E, not knowing what the trouble is and responding to your own assumptions by moving closer or moving away unnecessarily puts your relationship with her at risk. A and D are supportive but less direct expressions of empathy, and questions put Margot more on the spot, potentially increasing her discomfort. A, B, D, and E may help with relationship building as well but the simpler response is less risky at the start of a relationship.

Mr. J has come to your office for a new patient visit. The process of patient-centered interviewing suggests that early in the interview, after introducing yourself and ensuring that he is comfortable, you should say: A. "I see that you told the nurse you are here for a cough. When did that start?" B. "Tell me about your past medical history." C. "Tell me what is on your mind today. ... What else?" D. "What do I need to know about your family history?" E. "What medicines are you taking?"

C, initially obtaining a list of the patient's concerns helps you jointly set the agenda for the visit, and facilitates your agreeing on priorities regarding what can be addressed during this visit. If Mr. J does not spontaneously offer information about A, B, D, E, you will ask him specifically these doctor-centered questions.

2) Your patient, a 54 year old woman, returns to your office for a blood pressure follow-up. In response to your opening question, "What concerns do you have today?" the patient mentions back pain and begins to give details about the most recent painful episode. You can best facilitate addressing all of the important concerns for the visit today by which of the following: A. Ask, "Can you tell me more about your back pain?" and facilitate the patient's description, including frequency, precipitating events, quality of pain, neurological symptoms, and alarm features. B. Say, "Let's focus on your pain and blood pressure today." C. Allow the patient to complete her statement about the recent painful episode, then ask "In addition to your back pain, is there anything else?" D. Summarize the patient's description of her back symptoms to check for accuracy and begin the physical examination. E. Say, "Let's talk about your blood pressure and then you can tell me about your back pain."

C. Allow the patient to complete her statement about the recent painful episode, then ask "In addition to your back pain, is there anything else?"

Typically, clinicians begin interviews by inquiring about what concerns brought the patient into the office. On average, clinicians interrupt the patient's opening statement after 18-23 seconds, and seldom return to asking the patient for a complete list of concerns. The most likely result of this pattern of limiting the list of concerns in opening the discussion is to: A. Enhance the efficiency of the time spent in the visit B. Assure that the patient's most important concern is voiced since it was mentioned first C. Increase the frequency of late-arising concerns. D. Obtain the most important information early in the visit E. Enhance diagnostice accuracy

C. Increase the frequency of late-arising concerns.

Question 5 "You mentioned that your wife is having health problems. Let's get back to how that is affecting you." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

C. Redirect patient

Mandira Das is a 33 year old married woman from India, your patient for 2 years. You just confirmed that she is 8 weeks pregnant and Mrs. Das is elated. She has suffered because of 5 early miscarriages, and never before made it to 8 weeks, so she is hopeful that this time she will have a baby. Unfortunately, given her medical history, you feel you've an obligation to caution her. You are sitting at your desk and she is sitting at the side of your desk, with her right hand on her left shoulder. What is the recommended approach? A. Get up and put your arm around her shoulders stating "I'm glad you are so happy but we are not quite out of the woods yet." B. Move closer and hold her left hand which is resting in her lap and tell her "I'm glad you are so happy but we are not quite out of the woods yet." C. Smile at first and then transition to a more serious facial expression stating "I'm glad you are so happy but we are not quite out of the woods yet." D. State simply, "I'm glad you are so happy but we are not quite out of the woods yet." E. Lean backwards, cross your arms and state "I'm glad you are so happy but we are not quite out of the woods yet."

C. is recommended. "Match" the patient with a smile about the good news and then non-verbally "lead" into a more serious aspect of the conversation with a new facial expression, in order to stay in rapport. Putting an arm around her shoulder or taking her hand (A,B) are undesirable at this time, as by crossing her chest with her arm the patient has taken assumed a protective posture.. E may be interpreted as withdrawal from the patient or her situation, and experienced as unsupportive. D is "just the facts" and does not utilize any non-verbal cues to show your concern and involvement.

Ken Maloy is the husband of a 30 year old Caucasian woman who was in a car accident and died as she arrived at the hospital. As soon as her identity was established, Mr. Maloy was told that his wife had a very serious accident and that he should come to the hospital immediately. He was not informed that she died. You must give him the bad news, and have introduced yourself and quickly led him into an empty office. You asked him to take a seat, moved your chair a bit closer, slightly leaned towards him and then said, "I'm sorry I have bad news for you. I have to inform you that your wife was in a serious car accident and died just before she arrived at the hospital." He sits back and screams. What is the recommended way to proceed? A. Reach out, hold his hand and gently say, "I understand that this is a great shock for you." B. Touch his upper arm and state softly, "This must be terrible for you." C. Continue to slightly lean towards him and remain silent until he has a chance to fully express his initial shock. D. Stand up, put your hand on his shoulder and say, "I'm ready to help you in any way that I can, in this terrible moment.". E. Continue to slightly lean towards him and ask, "Is there anyone I could call for you?"

C. is recommended. Mr. Maloy is in shock and needs time to collect himself. Leaning towards him in an attentively and waiting for him to indicate his readiness for more interaction with you is likely to be helpful. Many people feel a strong inclination to comfort him, both verbally and non-verbally, but chances are good that he will feel this as intrusive, or be entirely unable to perceive comforting of any kind, until he indicates readiness. Many people will experience these attempts as invasive.

An empathic response to a patient distraught about a new diagnosis of breast cancer might be: A. It's all part of God's plan. B. I'm sure everything will turn out OK. C. My grandmother had breast cancer. D. I can understand; this news is devastating for you.

D is correct. Empathy is not about fixing, it is about being with and seeking to understand a patient's emotional state. A. does not acknowledge the patient's distress, but attempts to explain it away. This answer could also be devastating to a patient if you do not have a complete understanding of her spirituality. B. tries to "fix" the patient's distress. C. shifts the focus from the patient to the doctor. D. communicates an understanding of the patient's emotional state without attempting to fix it or falsely reassure. It could be followed with a heartfelt statement of respect for the patient's plight (e.g., "You sure weren't expecting this." or "I wish it could be different."- see Module 33) and a statement of support (e.g., "We'll get through this together.")

Mrs. P.(from previous question) shares additional information, revealing that her husband's job requires travel, so she is left alone frequently with the new baby and little support. She's uncomfortable with how much he drinks when he's at home, although he's not been abusive. She feels "down in the dumps," and cries frequently, has been sleeping poorly, awakening at 4-5AM even when the baby is quiet, and feels fatigued most of the time. She's lost 10 pounds more than the weight she gained while pregnant, and says that taking care of the baby is always effortful rather than pleasurable.. Which diagnosis seems the least likely based upon Mrs. P's history? A. Complex migraine B. Post-partum thyroiditis C. Major depressive episode D. Transient ischemic attack

D is correct. Given the patient's age, the absence of predisposing risk factors such the use of tobacco and contraceptives, valvular disease, or arrhythmia. A is highly likely based on this clinical presentation. B is plausible, and a TSH would be helpful. C is also plausible, and she does meet DSM criteria for major depressive disorder, single episode, moderate, with melancholic features, and with post-partum onset. In both B and C, you might not have discovered an important additional diagnosis that needs careful management without your follow up of the cues she gave about her situation.

Which of the statements below is most accurate about the process of patient-centered interviewing? A. It keeps patients focused on the chief complaint B. It keeps patients from talking about emotion C. It occurs at the beginning of a medical interview D. It prompts patients to offer psychosocial details E. It uses only open-ended questions

D is correct. The patient-centered process encourages patients to tell their stories - not only the symptoms, but also whatever else seems important or relevant to them, including the psychological and social spheres of their lives. Many important aspects (such as, my father died suddenly at my age; or, my 32 y o autistic son moved out from our home to independent living this week) might never be guessed or asked about in a doctor-centered interview. Additional comments for options A,B,C,E: A. Both doctor-centered and patient-centered skills may be used to keep patients focused, and both can be distracting from the chief complaint if not used skillfully. B. Generally speaking, a doctor-centered approach does not facilitate patients' expression of emotion, and leaves most patients feeling not heard, misunderstood or ignored. C. Patient-centeredness may occur throughout the interview, in the same manner that open- and close-ended questions interweave throughout an interview. E. Reflective statements, brief summaries, closed questions, and other strategies are also aspects of patient-centered interviews.

Bill, a 22 year old college student comes to emergency at 2AM on a busy Saturday with pain in the left side of his chest. You are the supervising physician tonight, and the resident tells you the history- including that he had an injury to his left calf and left chest during a rugby game 2 weeks ago. Tonight he was awakened with the pain, which increased with inspiration. The resident's exam was normal, except for mild left rib tenderness, and his chest x-ray was normal, and the resident suggests that he sign the patient out with a diagnosis of left sided rib injury, possible occult rib fracture, after you see him. At this point, choose the recommended statement. A. After you examine Bill's heart, lungs and chest wall counter-sign the resident's note and discharge Bill with the diagnosis of rib contusion. B. Review the chest x-ray and then ask the resident to order spot rib films. C. Ask the resident to check on the possibility of transferring Bill to the college infirmary for overnight observation. D. Ask Bill to tell you more about his symptoms and their evolution over time. E. As supervisor, ask the resident to share his thinking about the case with you before you decide on the next step.

D is recommended. Bill might indeed have a rib contusion, but the onset of pleuritic pain many days after the injury is unexplained by what the resident told you. When there are unexplained elements in the patient's history, you must take the time to get the story directly from the patient. The question "Why is the patient coming in at this moment?" is always relevant. Neither A nor C fulfills your professional responsibility in this case. B and E may be appropriate, but getting the story straight first is the most important next step. When you got more detail, Bill revealed that after the rugby game his rib was sore, and he had a "bad bruise" and swelling of his left calf, and that both had improved. Tonight's awakening was entirely unexpected and different. Bill was evaluated with D-dimer and CT angiography and had a left lower lobe pulmonary embolus.

Ken Fortek is a 40 year old divorced Caucasian book keeper who complains of persistent headaches. You've done a careful history, physical exam, and ordered laboratory tests. Your exam and lab results are normal. You convey this good news but your patient continues to look worried. He asks, "How can you be sure that these headaches are not related to a brain tumor?" Which of the following responses would best illustrate Attentiveness and Warmth? A. State in a confident tone, after briefly touching the patient's arm: "Let me reassure you once again. There is no evidence of a brain tumor." B. State "Nothing is ever 100% certain, but in your case we can be sure that you do not have a brain tumor. The odds of a brain tumor are very small." C. Lean forward and state "The chances of your having a brain tumor are extremely low. I think we can move on to treating your headache pain, and you will feel a lot better." D. State "I can see that you are still worried about the possibility of a brain tumor. Help me understand why that is the case." E. State "You want to be positive there isn't a brain tumor. While I'm sure there is nothing to worry about, I can arrange a referral to a neurologist for another opinion."

D is the most Attentive and Warm response because it responds to the patient's emotional state, summarizes his main concerns and invites participation. Since your exam and test results were not convincing to him it is important to further explore the origin of the patient's worry before moving on. Touching the patient or moving closer in this instance may be viewed as too intrusive.

Francine Bacon is a single mother of 3 school-aged children. She is 38, African American, overweight and has hypertension. She is an office manager and some of her supervisees are performing poorly. Balancing home and work demands is difficult. You have discussed weight loss strategies and she agreed to start a medication for her blood pressure. When you tell her that today neither her blood pressure nor her weight has changed, she responds "I have been following your instructions and made a lot of changes. But this plan clearly does not work for me." Which of the following responses would best illustrate Partnership? A. State "Before we explore other treatment options, I need to know whether you gave it a fair chance because we know that it is effective in most people." B. State "Between your job, your children and your health, you have a great deal to do. Perhaps you can get some support for managing all these things." C. State "I appreciate that you have been doing your best. However, I'm guessing that that you have had difficulty following the care plan." D. State "You are coping with a lot of challenges. Let's see if we can devise a new plan that won't add to your stress levels." E. State "I can see that you are frustrated that our initial plan did not work. Most people in your shoes would feel the same way."

D most clearly promotes Partnership because it invites the patient to work together with you to devise a less stressful plan. Some of the other statements exemplify other relationship skills: B begins with an empathic reflection, C is a statement of respect, and E is an empathic reflection and a statement of legitimation.

3) Ms. S., a 23 year old, returns to your office for an oral contraceptive follow-up visit. She has been having increasingly frequent headaches with nausea and vomiting, and tells you she thinks she has a brain tumor. She also has low back pain. She wants an MRI of her brain and her back, pain medications, a note for her supervisor, a referral to a neurologist at another hospital, and a refill of her oral contraceptives. She indicates her agreement with your summary of her complete list of concerns for this 20 minute office visit. What is your best statement to Ms. S. to help you reach agreement on the agenda for the remainder of the visit? A. "Before we do anything else, let's agree to stop your oral contraceptive pills because they are contraindicated with headaches." B. "Let's focus on what's causing your headaches because they sound like migraines and I'm not worried about a brain tumor. C. "I'd like you to make an appointment with a neurosurgeon to talk about your concerns." D. "Let's start with more discussion about your headache symptoms and an exam so we can decide what tests and referrals might be needed." E. " I can't address all of your requests today. What is your top priority for today's visit?"

D. "Let's start with more discussion about your headache symptoms and an exam so we can decide what tests and referrals might be needed."

Question 7 "Let's see if I have this right: you'd like to talk about your blood pressure, your biggest worry is side effects of the medicine, and you'd like to talk about alternatives." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

D. Summarize

"I'd like to ask a few more questions about your past medical history." Which of the following correctly names the question/ statement above? A. Open question B. Clarification C. Closed question D. Verbalize transitions E. Summarization

D. Verbalize transitions.

Kim Park, a 25 year old woman of Korean descent, is in for an initial visit, and needs a physical for her new job as a kindergarten teacher. When you asked about heart disease in the family, her mood changed dramatically, and she told you that her father is still in intensive care, after a heart attack a week ago. Her voice is almost a whisper, her hands are crossed in her lap, and she is staring at the floor. You would like to hear more about this situation. What body posture is recommended, as you quietly tell her that you are sorry to hear bout her father's illness? A. Slightly lean back. B. Stand up, reach out and touch her shoulder. C. Move your chair closer and lean towards her. D. Slightly lean towards her, cross your hands and rest them in your lap. E. Slightly lean forward and place the tissue box right next to her.

D. is recommended. Leaning forward and mirroring her non-verbal gesture will likely strengthen rapport. Pushing for emotional expression by providing tissue before she is crying (E) could be felt as intrusive. For personal or cultural reasons many patients do not feel comfortable showing strong emotions, especially at an initial "routine" visit.

Israel Wasserman, a 50 year old Caucasian teacher, was brought to the hospital after experiencing a seizure while shopping. You found that he has a benign brain tumor and recommended that he start treatment immediately to prevent further seizures. Israel has trouble accepting the diagnosis and wants to postpone treatment because he fears that any delay in launching a big project at school may derail the entire project. Which of the following statements best conveys Respect? A. State: "It must be very frustrating to get sick just in the midst of starting an exciting project." B. State: "Given your condition it is really essential to get treatment now; another seizure will only cause more delays." C. State: "There is probably someone else working on this that you could trust to start the project for you." D. State: "I want to get you treated quickly so that you can go back to work as soon as possible." E. State: "I admire your devotion to your work, and I'm sure your students appreciate all you do for them."

E best conveys Respect because it acknowledges and appreciates the patient's strengths. The statement of your respect for his strengths tells him that you take his ambitions seriously, and gives him a chance to reflect and respond to you about how his illness and his work intersect. This will improve your conversations about establishing a plan that is medically sensible and acceptable to him. Statement A shows empathic understanding and may build relationship, while B C and D are attempts (more or less veiled) to persuade him to follow medical advice—he may agree, but they do not build relationship.

Joshua Reynolds is a 35 year old married man of British descent, in your practice for over 3 years with puzzling stomach problems, here today to follow up on the GI series he had last week--the results are within normal limits. He gave a mixed message when you asked him about how things are at home, quickly saying "Fine," but lowering his voice and crossing his arms. Which of the following options would be recommended for your response? A. Say, "I'm glad things are going well at home but let me know if there are any changes." Then move on. B. Attribute the posture and tone to his physical discomfort because he has had a stable home life all along, and then move on. C. Say, "If you are having troubles at home it would be good for me to know," and then wait for him to respond. D. Lean forward and say, "Tell me a bit more about what's been happening at home." E. Cross your arms, lean forward and say, "You are telling me that home is fine but you look rather concerned. Can you tell me a bit more about what's been happening at home?

E is recommended. Within mixed messages, the non-verbal aspect is more likely to be accurate than the verbal one. Verbalize your observation about the mixed message and match the patient's behavior in order to build rapport and more swiftly enhance understanding. A and B ignore the non-verbal component. Mr. Reynolds may not understand why the physician expresses doubts in C and D, and therefore may be reticent to share underlying concerns.

Maria Correa is a 86 year old widow of Cuban descent, whose pneumonia has responded well to treatment in hospital, and you think she may be able to go home soon. You need more information about her living situation at home to plan for home health care, and remember that she has already said she does not like strangers in her house. You also need to check her lungs and other physical findings to be certain that she is ready; right now she seems very relaxed and clearly feels "safe" with you. What is your recommended position/ posture when asking about her home situation, an issue that may be difficult for her? A. Stand next to the bed and hold her hand. B. Stand at the foot of the bed so that the patient can look straight at you. C. Lean against the window sill to signal that you expect a lengthier conversation. D. Move the chair at the head of the bed so that so that both of you are looking in the same direction and sit down. E. Move the chair at the head of the bed so that so that you look at Mrs. Correa and sit down.

E. Is recommended. Sitting down so you are at eye level eliminates a power differential. Sometimes, looking in the same direction (D) is advantageous, but here it would be awkward for Mrs. Correa to maintain eye contact with you, and it would limit your opportunity to observe her non-verbal reactions. Sometimes, patients feel more comfortable if you hold their hand (A), but that is more risky when you are having a complex discussion, and could be felt as a pressure tactic.

Question 8 "Tell me what is on your mind today." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

E. Open-ended inquiry

"What inhaler did you use?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

c) Closed question

"So my understanding so far is that you developed shortness of breath and wheezing yesterday that didn't respond to your usual inhalers." Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

e) Summarization