medical humanities MCQ

Question 13 1 / 1 pts A 49-year-old man has asthma which is exacerbated when he uses tobacco. He visits his physician because he wants to quit smoking. He has tried unsuccessfully to quit multiple times in the past. Which of the following is the best patient-centered statement for the physician to make in counseling this patient? "I know how difficult this is and am glad you're willing to try again." "Are you ready to try a nicotine patch at this point; some of my other patients swear by them." "Quitting tobacco is hard. My husband quit after 20 years and he still craves nicotine a lot of the time." "Many of my patients have found a behavioral contract helpful in keeping them on track." "If you need some more motivation, let's review all of the nasty things smoking is doing to you."

"I know how difficult this is and am glad you're willing to try again" is the correct answer which provides acknowledgment of the patient's feelings and support for the patient's desire to change. This answer correctly identifies the patient's struggles with quitting smoking, is non-judgmental, and demonstrates compassionate support. "Are you ready to try a nicotine patch at this point; some of my other patients swear by them" and "Many of my patients have found a behavioral contract helpful in keeping them on track" jump immediately into problem-solving which is not as patient-centered initially as expressions of empathy. "Quitting tobacco is hard. My husband quit after 20 years and he still craves nicotine a lot of the time", might be seen as empathic, but it is discouraging and focuses on the experience of the physician's husband rather than the patient's experience. "If you need some more motivation, let's review all of the nasty things smoking is doing to you", is a good example of a doctor-centered statement: the physician is verbally trying to exert their influence over the patient by scaring him.

Question 12 1 / 1 pts A 70-year-old woman sees the physician for a refill of her antihypertensive medication. She mentions that she still misses her husband, who died of lung cancer a year ago. Which of the following best reflects a patient-centered response? "Socializing more might help you feel less lonely." "Well, are you having any trouble remembering to take your medication?" "Would you be willing to attend a grief support group?" "Losing a loved one is so painful; tell me more about what you are feeling." "You should be starting to feel better by now according to normal grieving processes."

"Losing a loved one is so painful; tell me more about what you are feeling", is the correct answer which effectively acknowledges the patient's felt experience and elicits the patient's perspective. "Well, are you having any trouble remembering to take your medication", is called a terminator - it completely shuts down any further conversation about feelings. "You should be starting to feel better by now according to normal grieving processes", this is paternalistic, invalidating the patient's feelings by telling her how she should be feeling at this point. "Would you be willing to attend a grief support group?" and "Socializing more might help you feel less lonely", are problem-solving and do not acknowledge the patient's feelings.

Question 10 1 / 1 pts During her annual physical examination, a 42-year-old woman diagnosed with multiple sclerosis (MS) 8 years ago, tells her physician, "I hate that my multiple sclerosis is ruining my marriage!" Which of the following best reflects a patient-centered response? "I can refer you to a good marriage counsellor who has helped a lot of my patients." "Tell me more about how your MS is affecting your marriage." "Why don't you bring your spouse in, so that we can talk about how challenging this disease can be?" "Chronic disease can be hard on any marriage; how can I help?" "Your spouse needs to be reminded of his marriage vows: 'in sickness and in health'."

"Tell me more about how your MS is affecting your marriage" is the correct answer, which elicits the patient's perspective. "Chronic disease can be hard on any marriage; how can I help", may seem like an empathic response; however, we really don't know what part of the patient's MS experience is problematic, and it pays to get more information. "I can refer you to a good marriage counselor who has helped a lot of my patients", "Why don't you bring your spouse in, so that we can talk about how challenging this disease can be", and "Your spouse needs to be reminded of his marriage vows: 'in sickness and in health' " all have underlying assumptions about how the patient's disease is affecting her marriage, focusing on her spouse's response to her disease. This may not be the problem at all. This question highlights a significant challenge in patient encounters: recognizing our own beliefs and assumptions as they arise and exercising extreme care in avoiding the biases they bring to our communication with patients.

A 56-year-old man reports to his family physician for a follow-up of his type 2 diabetes. He states if only there is a way to stop his wife from nagging him. He is not checking his blood sugars regularly as directed by a physician. He also admits that he occasionally forgets to take his diabetic medication. Fasting blood sugar in the office is 325 mg/dL (normal 70-100 mg/dL). Which of the following is the most patient-centered response by the physician? "Is your wife nagging you about checking your blood sugars and taking your medicine, too?" "Would working with a different doctor help you to stay motivated?" "I'm worried that your poor diabetes control is going to cause complications." "Let's send you back to the diabetic educator again and see if that will help you." "Tell me what is getting in the way of checking blood sugars and taking medicine."

"Tell me what is getting in the way of checking blood sugars and taking medicine", is the correct answer. An example of eliciting the patient's perspective for the struggles they are experiencing. "Is your wife nagging you about checking your blood sugars and taking your medicine, too?" is a clumsy attempt on the part of the physician to identify with the patient, this can backfire if the patient feels the need to defend his wife against the physician's implied criticism. "Let's send you back to the diabetic educator again and see if that will help you", is problem-solving, the physician might decide to do this as part of the management plan, but it will not work if the patient's perspective on his illness is not explored. "Would working with a different doctor help you to stay motivated?", sounds defensive and is a doctor-centered response, implying that the physician is anxious to "get rid" of the patient. "I'm worried that your poor diabetes control is going to cause complications", might be OK, after a therapeutic relationship is established, but as an initial response, it is doctor-centered.

Question 11 1 / 1 pts A 26-year-old patient sees her physician for an annual physical exam. She mentions that she has just separated from her husband of two years and she is feeling really stressed and sad. Which of the following best reflects a patient-centered response? "I've been through it, too, and the process follows stages of grieving." "I presume you tried marriage counseling?" "If you are depressed, I can prescribe something." "That sounds really painful and difficult." "You're young and once you start dating again, you'll find someone else."

"That sounds really painful and difficult", is the correct answer which is a truly empathic response, acknowledging the patient's felt experience or her separation. "You're young and once you start dating again, you'll find someone else." is based upon an assumption that the patient's marriage is over - it may or may not be! - and is an attempt to offer reassurance without acknowledging the patient's felt experience. "I've been through it, too, and the process follows stages of grieving", is also an attempt to be reassuring but it is very doctor-centered. So, when is it OK to share personal experiences with a patient during a medical encounter? Though not "forbidden", sharing personal experiences with patients should not shift the focus of the encounter to the physician's feelings and experience. I recommend avoiding this strategy until one receives additional counseling and communication training (available in some residency curricula!). "I presume you tried marriage counseling" and "If you are depressed, I can prescribe something" are aimed at problem-solving and fail to acknowledge the patient's emotional experience.

Question 3 1 / 1 pts A 42-year-old man is referred to an otolaryngologist because of a tickle sensation in his throat. Direct laryngoscopy is performed during the office visit and a tumor is seen necessitating an evaluation for laryngeal cancer. After telling the patient that he has a tumor and a biopsy procedure should be performed, which of the following best reflects patient-centered communication? "Try not to worry about this being cancer until we get the biopsy results." "This is a great opportunity to practice living in the present moment." "This can be scary news; let's let it sink in for a few moments before we talk about the next steps." "Don't start looking up information on the internet; it will only frighten you." "The sooner we get this biopsied, the sooner we'll know what we're dealing with."

"This can be scary news; let's let it sink in for a few moments before we talk about the next steps" is the correct answer. It is always a good idea to leave a little space after breaking bad news, to allow the patient to process the information. A reasonable strategy is to break the news and then wait for a patient response, which will then guide further discussion. The time spent in silence may be really uncomfortable for the physician, so be prepared for these feelings, but don't succumb to the need to fill in the silence. Think about what all of the other answers are trying to communicate/accomplish; they are doctor-centered and/or paternalistic in tone. Paternalism is generally communicated by phrases that are directive and often include: "you should", "you shouldn't", "you must", "you mustn't", "don't" (do something), "do" (do something), etc. Paternalistic responses emphasize the physician's point of view and authority over the patient's point of view and autonomy and are very doctor-centered.

Question 9 1 / 1 pts A 45-year-old man visits the physician to receive the results of his colon biopsy. The physician informs him that the biopsy was positive for cancer. The patient begins to cry. Which of the following is the most appropriate response by the physician? "Would you like to see a therapist who specializes in working with cancer patients?" "This is hard news to receive; we'll take as much time as you need." "We can treat this and you're still likely to live a normal lifespan." "My father had the same cancer but he's doing great after treatment." "I'm going to step out for a bit and give you time to pull yourself together."

"This is hard news to receive; we'll take as much time as you need", which allows the patient time to process bad news and then respond in a way that provides the physician a direction to follow to address the patient's questions, concerns, and needs. "I'm going to step out for a bit and give you time to pull yourself together", is avoidant and clearly reflects the physicians' discomfort with emotion. "We can treat this and you're still likely to live a normal lifespan", is reassuring and the physician might say this at some point in the encounter, but it is not the best first response. "Would you like to see a therapist who specializes in working with cancer patients", is problem-solving and again gives the impression that the patient's expression of emotion needs to be taken elsewhere. "My father had the same cancer but he's doing great after treatment", is offering a kind of reassurance but is very doctor-centered, focused on sharing the physician's personal experience rather than "being" with the patient in the midst of his shock and discomfort!

Question 4 1 / 1 pts A 62-year-old man visits the physician to receive the results of his prostate biopsy which shows a cancer. Which of the following statements best reflects an expression of empathy by the physician? "The 5-year survival rate for this cancer is 99%; so don't waste time being depressed." "Most men with prostate cancer will die of something unrelated to the cancer." "Treatments for this cancer just keep getting better and better." "Treatment might affect your sex life, but there are ways to work around that." "This is hard news; let's sit with it a few moments before discussing treatment options."

"This is hard news; let's sit with it a few moments before discussing treatment options", is the correct answer. Again, letting bad news sink in by providing silence for the patient to process the news, is important. Once the patient responds, the physician can then specifically address any questions or concerns that are most important to the patient at that moment. All of the other responses here might be statements a physician would make after the patient asks specific questions. "The 5-year survival rate for this cancer is 99%; so don't waste time being depressed", also contains a directive that is very paternalistic "don't waste time being depressed".

Question 2 1 / 1 pts A 48-year-old woman visits her physician because of insomnia. She recently lost her job as a manager in a fast food franchise. She has type 2 diabetes and states she will be unable to pay bills and eat properly. She has little social support. Which of the following best reflects an expression of empathy by the physician? "Our dietician is great at helping people on a limited budget with meal plans." "Try not to worry so much; the stress will only make your diabetes worse." "I'll refer you to a social worker, who can help you connect with community resources." "Getting away from fast food on a daily basis may actually be a blessing in disguise." "This sounds really hard and I can see why you are worried about your health."

"This sounds really hard and I can see why you are worried about your health", is the correct answer. An empathic response acknowledging the difficulties in this patient's life. "I'll refer you to a social worker, who can help you connect with community resources" and "Our dietician is great at helping people on a limited budget with meal plans", are problem-solving in nature; jumping to them right away in this encounter essentially denies and minimizes the patient's stated concerns and terminates any further discussion about her struggles. "Getting away from fast food on a daily basis may actually be a blessing in disguise" and "Try not to worry so much; the stress will only make your diabetes worse." minimizes or denies the patient's stated concerns about her situation. All responses, except for the correct answer, are doctor-centered.

Question 7 1 / 1 pts A 37-year-old man sees his physician because of insomnia. He recently lost his job as a manager of a convenience store. He states that he is a single dad with three young children at home and his life has revolved around working and taking care of his kids. He adds that he just doesn't know what he will do. Which of the following statements best reflects an expression of empathy by the physician? "Let's get you hooked up with social services to see if they can help." "You have to take care of yourself despite the stress, or it will only get worse." "Lack of sleep can make anyone pessimistic; let's fix the sleep problem first." "This sounds really hard and it must be scary to think about." "Have you thought about driving for Uber during the day while the kids are at school?"

"This sounds really hard and it must be scary to think about" is an empathic response that is acknowledging and correctly identifying the feelings the patient is experiencing. "You have to take care of yourself despite the stress, or it will only get worse", is a paternalistic response (typically these responses are characterized by "you should", "you must", or "you ought to" type of directives). "Let's get you hooked up with social services to see if they can help", "Have you thought about driving for Uber during the day while the kids are at school?" and "Lack of sleep can make anyone pessimistic; let's fix the sleep problem first." are focused on problem-solving, missing the opportunity to acknowledge and support the patient's feelings and experience.

Question 17 1 / 1 pts A 40-year-old woman has been diagnosed with pre-diabetes. She states that she hopes there is something she can do to avoid taking medication. Her BMI is 30. Which of the following is the most appropriate next response by the physician? "Tell me what you eat on a daily basis." "What do you know about the relationship between prediabetes and body weight?" "You know, you really need to lose some weight." "It's going to be hard to change old habits; medication will be a lot easier for you." "You'll have to start exercising right away and don't give up."

"What do you know about the relationship between prediabetes and body weight" is the correct answer. This answer elicits the patient's perspective with the initiation of a very effective technique called "ASK-TELL-ASK": ask the patient what they know about something; identify knowledge gaps based on their response; fill in the knowledge gaps with facts, advice, and motivating statements; ask the patient what they now understand after receiving the information. Telling the patient she needs to lose weight is direct and honest, but it is not going to motivate the patient and may actually alienate her. "Tell me what you eat on a daily basis", is not a bad response, but it does not use relationship-building to help the patient with change. "You'll have to start exercising right away and don't give up", is also true, but again, telling the patient what to do before building the relationship is often useless. "It's going to be hard to change old habits; medication will be a lot easier for you", is also true but it is discouraging.

Question 5 1 / 1 pts A 72-year-old woman with type 2 diabetes that is well-controlled with diet and medication has been optimistic and doing well during physician visits every 3-6 months. Today she appears unhappy and tells the physician that she's "ready to be sent to the glue factory, just like an old horse who's no longer good for anything else". Which of the following best reflects a patient-centered response to the patient? "I'll order some lab work and see if something is going on to make you depressed." "You're not thinking about suicide, are you?" "If you are getting depressed, an antidepressant can work miracles!" "Diabetes is hard to manage; I'm surprised you've been upbeat for so long." "What do you think has caused this big change in perspective for you?"

"What do you think has caused this big change in perspective for you", is the correct answer. This response is eliciting the patient's perspective on a change in her mood and attitude. All of the other answers assume the patient is depressed. However, the reason for her change in perspective may have to do with situational stress (e.g., the recent loss of a beloved pet or a dear friend) for which an antidepressant would not be indicated! We don't know until we ask!

Question 6 1 / 1 pts A 74-year-old woman with chronic obstructive pulmonary disease (COPD), who is usually quite content, now complains to her physician that her life seems hopeless. She denies any suicidal ideation and has no past history of depression. Which of the following is the most appropriate patient-centered response by the physician? "Is your breathing trouble interfering at all with your sleeping?" "Would you be open to talking this through with a good counselor?" "Everyone feels "blue" now and then, perfectly understandable with a chronic disease." "What do you think has happened to make you feel hopeless?" "I want you on an antidepressant before this gets any worse."

"What do you think has happened to make you feel hopeless", is the correct answer. Eliciting the patient's perspective for the change in her situation and feelings. "I want you on an antidepressant before this gets any worse" and "Would you be open to talking this through with a good counselor" are jumping to problem-solving, not a helpful initial response. "Everyone feels "blue" now and then, perfectly understandable with a chronic disease" is true, but not helpful, and it does not increase rapport nor help explore this patient's unique reasons for feeling hopeless. "Is your breathing trouble interfering at all with your sleeping" is exploratory but does not empathically acknowledge or address the patient's change in feelings.

Question 8 1 / 1 pts A 26-year-old woman who has been in good health visits her physician because of symptoms of a "cold". She states that she is miserable and cannot eat or sleep comfortably. Which of the following physician behaviors is most likely to improve her immune response to her infection and shorten the duration of her symptoms, based on research evidence? Validating her concerns by ordering a blood count and throat swab. Creating rapport and listening attentively to all of her concerns. Reassuring her that a cold is, indeed, miserable but not deadly. Suggesting an over-the-counter cold medicine, rest, and self-care. Providing an informational pamphlet on the common cold and care strategies.

Creating rapport and listening attentively to all of her concerns, is the correct answer. Patient-centered communication skills, when performed expertly, have been shown to improve patient immune response to the common cold virus and shorten the duration of cold symptoms (Barrett, et al, 2007). In essence, excellent patient-centered skills turn physicians into effective placebos, able to invoke a positive therapeutic biological response in the patient. Though some of the other answers here may be part of a patient-centered response, none of them alone have evidence of efficacy.

Question 14 1 / 1 pts A 72-year-old man with Type 2 Diabetes, well controlled with diet and medication, has been doing well during his visits with his doctor every 3-6 months. Today he complains to his physician that his life seems senseless and that he ought to be "put down, like an old sick dog". Which of the following is the most important next step for the physician working with this patient? Refer the patient for psychotherapy Prescribe antidepressant medication Elicit family history of depression, anxiety, and psychosis Elicit the patient's perspective and reason for the change in his feelings Set up a "no harm" contract as a suicide precaution

Elicit the patient's perspective and reason for the change in his feelings is the correct answer. Again, answers "Prescribe antidepressant medication", "Refer the patient for psychotherapy", and " Set up a "no harm" contract as a suicide precaution" are problem-solving in nature and may be part of the final treatment approach to the patient's problem which appears to be depression in this case. A family history is an important part of the medical history and should be reviewed at some point. However, effective patient-centered care encourages that we first elicit our patient's perspective and reasons when he has a shift or change in mood or feelings or disease status.

Question 16 1 / 1 pts A 14-year-old girl has had Type 1 diabetes since she was 10 years old. Recently she has been "forgetting" to take her insulin, and consequently, she has had 3 episodes of diabetic ketoacidosis in the last 6 months. Her family physician meets with her and says, "Tell me what has gotten tough about taking your insulin on schedule." The patient states that she gains weight when she takes all of her insulin and she does not want to get fat. Which of the following best describes the patient-centered technique used by this physician? Conflict resolution Reflection of meaning Eliciting the patient's perspective Creating rapport Demonstrating empathy

Eliciting the patient's perspective is the correct answer. It takes empathy to back off from telling people what they need to do for their own good, but such a statement does not have strong empathic elements. Creating connection happens when we communicate effectively, however, it usually happens at the beginning of a relationship and this vignette implies a longer-standing relationship between the doctor and patient. Eliciting the patient's perspective is often the beginning of conflict resolution and creating workable solutions. However, we don't stop there. There is no reflection of meaning in this statement; rather it is soliciting perspective (and likely meaning) from the patient.

Question 15 1 / 1 pts A 53-year-old man with a 48-pack-year history of cigarette smoking develops a chronic cough. His physician orders a chest x-ray and a "spot" is seen on his lung. He undergoes bronchoscopy and biopsy. He returns to the clinic to discuss the biopsy results. When the physician enters the exam room, the patient looks up and states "It is bad news, isn't it?" Which of the following is the most appropriate patient-centered response by the physician? "It's important to stay hopeful and positive." "You know, we can get you into a drug trial." "I'm so sorry. My father had lung cancer, too." "Yes, it is." "I want to refer you to our university cancer center."

The correct answer is "Yes, it is." People need the truth and time to absorb bad news. "I'm so sorry. My father had lung cancer, too", is a doctor-centered response, even though, on the surface, it may appear as an attempt to connect. "It's important to stay hopeful and positive", "You know, we can get you into a drug trial", and "I want to refer you to our university cancer center." are rushing into advice and problem-solving. These responses make us, as physicians, feel less helpless, but they do not create some space for the patient's own process of dealing with the bad news and all of its meaning. Better to be silent. When the patient is ready, he will break the silence. At that point, what he says will guide the physician's response in a way that is focused on meeting the patient's precise needs.