Ethics/communication

[#1] Family #1: which members belong to the “Patient communication” family?

Members: Patient communication: emotions, bad news, interpreters.

[#1] A patient cries, is angry, or is sarcastic. What is the most appropriate response by the physician?

'It must be very difficult to hear this' / 'You sound upset. Tell me more.' (#1 Patient communication: emotions, bad news, interpreters)

[#1] A patient asks, 'Why did this happen to me?' or wants an alternative remedy or a test. What is the most appropriate initial response by the physician?

'What are your thoughts about that?' / 'What have you heard about…?' / 'Tell me what you understand…' (#1 Patient communication: emotions, bad news, interpreters)

[#1] Nonadherence is suspected: missed insulin, poor BP control, or uncontrolled asthma. What is the most appropriate response by the physician?

'Most people find this hard. How has it been for you?' (#1 Patient communication: emotions, bad news, interpreters)

[#1] A physician must disclose a positive HIV test, cancer, or ALS. What is the most appropriate statement by the physician?

'I have some upsetting news. Your test is positive.' / 'You have ALS. Have you heard of this disease?' (#1 Patient communication: emotions, bad news, interpreters)

[#1] A patient asks directly whether the news is bad, or 'Is it cancer?' Which topic does this scenario test?

1 Patient communication: emotions, bad news, interpreters

[#1] A non-English speaker has a bilingual daughter or receptionist available. What is the most appropriate next step?

Use a trained interpreter to determine his preferences (#1 Patient communication: emotions, bad news, interpreters)

[#1] The family asks that a capable patient not be told the diagnosis. What is the most appropriate next step?

Use a trained interpreter to determine his preferences (#1 Patient communication: emotions, bad news, interpreters)

[#1] An adolescent has a chronic illness, or a parent speaks for the patient. What is the most appropriate approach by the physician?

Speak with the adolescent (and parents) directly; give time alone with the physician; teach age-appropriate self-management (#1 Patient communication: emotions, bad news, interpreters)

[#1] A patient expresses strong emotion; the best first response validates the feeling and hands the floor back before giving information. Which is more likely: Reassurance ('Don't worry') or Empathic acknowledgment?

Empathic acknowledgment. reassurance ('Don't worry, it's nothing') → correct option acknowledges the feeling and hands the floor back before informing

[#1] Before giving information, the physician first needs to learn what the patient already knows or fears. Which is more likely: Pamphlet, referral, or test first or Ask what the patient knows?

Ask what the patient knows. pamphlet, referral, or test as first step → first find out what the patient knows or fears ('Tell me what you know about…')

[#1] A non-English-speaking patient needs interpretation, and in-person, phone, or video services are available. Which is more likely: Family member as interpreter or Trained medical interpreter?

Trained medical interpreter. family member as interpreter → a trained interpreter (in person, phone, or video) is always correct

[#81] Family #81: which members belong to the “Stages of change and motivational interviewing” family?

Members: precontemplation · contemplation · preparation · action · maintenance.

[#81] A smoker or drinker doesn't think he has a problem. Which stage of change is the patient in?

precontemplation (#81 Stages of change and motivational interviewing)

[#81] The patient is not ready to change. Which is more likely: Ask about pros, cons, concerns or Set a quit date?

Ask about pros, cons, concerns. prescribing or setting a quit date → don't hand a plan to someone not ready; ask pros/cons or concerns first

[#81] A patient says he knows he needs to change but lacks the willpower right now. Which stage of change is the patient in?

contemplation (#81 Stages of change and motivational interviewing)

[#81] A smoker wants to quit eventually but is not ready now. Which stage of change is the patient in?

contemplation (#81 Stages of change and motivational interviewing)

[#81] The patient acknowledges the problem but is ambivalent. Which is more likely: Precontemplation or Contemplation?

Contemplation. precontemplation vs contemplation → precontemplator denies a problem; contemplator acknowledges it but is ambivalent

[#81] A patient has made lifestyle changes for 2 months with improved labs. Which stage of change is the patient in?

action (#81 Stages of change and motivational interviewing)

[#81] A smoker comes for a routine visit, or a sedentary new hypertensive has a poor diet. Which condition is this?

81 Stages of change and motivational interviewing

[#81] A relapsed patient previously succeeded with weight loss or a dialysis diet. Which condition is this?

81 Stages of change and motivational interviewing

[#81] An adolescent smoker ignores health warnings. Which condition is this?

81 Stages of change and motivational interviewing

[#81] An adolescent is best engaged with an open-ended, nonjudgmental approach that targets how he looks. Which is more likely: Discuss appearance effects or Warn about long-term health?

Discuss appearance effects. fear tactics or long-term health warnings → open-ended nonjudgmental question wins; adolescents respond to appearance effects

[#97] Family #97: which members belong to the “Informed consent, capacity, and refusal” family?

Members: Informed consent, capacity, and refusal.

[#97] A student or uninvolved resident is asked to get a consent form signed. What is the most appropriate action?

Ask the resident/attending; student may accompany (#97 Informed consent, capacity, and refusal)

[#97] Risks and the procedure are explained to a patient before consent. Which topic does this scenario test?

97 Informed consent, capacity, and refusal

[#97] A patient refuses treatment, with possible confusion or grandiose ideas. What is the most appropriate next step?

Determine decision-making capacity first (#97 Informed consent, capacity, and refusal)

[#97] A competent patient asks to stop the ventilator, and the family disagrees. What is the most appropriate action?

Respect refusal (withdrawing life support is legal and ethical); state your recommendation (#97 Informed consent, capacity, and refusal)

[#97] A patient wants to cancel surgery or leave the hospital after signing consent. What is the most appropriate initial response?

Open-ended exploration of concerns; offer accommodation (#97 Informed consent, capacity, and refusal)

[#97] An unconscious Jehovah's Witness has a documented refusal, and the spouse wants a transfusion. What is the most appropriate action?

Do not transfuse (#97 Informed consent, capacity, and refusal)

[#97] An emergency occurs in a child or unconscious patient with no surrogate available. What is the most appropriate action?

Treat under implied consent (#97 Informed consent, capacity, and refusal)

[#97] Confusion is suspected in a patient who refuses treatment. Which is more likely: Assess decision-making ability first or Explore the patient's concerns?

Assess decision-making ability first. Capacity assessment as the first step → only when confusion is suspected; otherwise first explore the patient's concerns

[#97] A patient understands and appreciates the decision but makes an unwise choice. Which is more likely: Has decision-making capacity or Lacks decision-making capacity?

Has decision-making capacity. Disorientation or psychiatric diagnosis = incapacity → capacity depends on understanding/appreciating the decision; an unwise choice is not incapacity

[#97] A physician refuses to give lethal medication while controlling pain. Which is more likely: Beneficence or Nonmaleficence?

Nonmaleficence. Beneficence → refusing lethal medication while controlling pain is nonmaleficence

[#122] Family #122: which members belong to the “Professional duties: reporting, colleagues, boundaries” family?

Members: Mandated reporting (adult protective services, health department) · MedWatch / phase 4 reporting · Conflict of interest disclosure · Conscientious objection · Chaperone and limit setting · Physician health program.

[#122] A dependent adult (e.g., Down syndrome) has signs of neglect or financial exploitation. What is the most appropriate next step?

Mandated reporting (adult protective services, health department) (#122 Professional duties: reporting, colleagues, boundaries)

[#122] A patient with contagious TB pleads for confidentiality. What is the most appropriate next step?

Mandated reporting (adult protective services, health department) (#122 Professional duties: reporting, colleagues, boundaries)

[#122] A patient with abuse/neglect, TB or an adverse drug event asks that it be kept private. Which is more likely: Keeping confidentiality or Mandated reporting?

Mandated reporting. keeping confidentiality when the patient asks → mandated reporting (abuse/neglect, TB, adverse drug events) overrides confidentiality

[#122] A newly marketed drug causes unexpected liver toxicity in several patients. What is the most appropriate next step?

MedWatch / phase 4 reporting (#122 Professional duties: reporting, colleagues, boundaries)

[#122] Harm is detected after the drug is marketed. Which is more likely: Phase 4 postmarketing surveillance or Phase 3 trial?

Phase 4 postmarketing surveillance. phase 3 trial → harm detected after the drug is marketed = phase 4 postmarketing surveillance

[#122] A physician has a financial stake in a recommended treatment. What is the most appropriate next step?

Conflict of interest disclosure (#122 Professional duties: reporting, colleagues, boundaries)

[#122] A physician morally objects to a legal service (e.g., emergency contraception). Which ethical principle applies?

Conscientious objection (#122 Professional duties: reporting, colleagues, boundaries)

[#122] A patient becomes sexually suggestive during an exam, or calls excessively. What is the most appropriate next step?

Chaperone and limit setting (#122 Professional duties: reporting, colleagues, boundaries)

[#122] A physician has alcohol use disorder. What is the most appropriate next step?

Physician health program (#122 Professional duties: reporting, colleagues, boundaries)

[#122] Two specialists give a patient conflicting advice. Which condition is this?

122 Professional duties: reporting, colleagues, boundaries

[#122] A patient complains about another physician, or a spouse calls with new safety concerns. Which condition is this?

122 Professional duties: reporting, colleagues, boundaries

[#122] A patient demands opioids for back pain with a normal exam. Which condition is this?

122 Professional duties: reporting, colleagues, boundaries

[#122] A concern arises about another physician, and no patient is in imminent danger. Which is more likely: Speak directly with the physician or Escalate to risk management first?

Speak directly with the physician. escalating to risk management, ethics committee or licensing board → speak directly with the involved physician (or have the patient do so) first, unless patients are in imminent danger

[#180] Family #180: which members belong to the “Confidentiality and minors” family?

Members: Confidentiality and minors.

[#180] A spouse or relative calls asking about a competent adult's diagnosis. What is the most appropriate response?

Decline without the patient's permission (#180 Confidentiality and minors)

[#180] A genetic test result has implications for at-risk relatives. What is the most appropriate action by the physician?

Encourage the couple to inform them (#180 Confidentiality and minors)

[#180] Residents discuss an identifiable patient in an elevator. What is the most appropriate action?

Remind them immediately (#180 Confidentiality and minors)

[#180] A family wants a diagnosis hidden from a patient who can still decide. What is the most appropriate next step?

Discuss with the patient privately (#180 Confidentiality and minors)

[#180] A physician wants a sexual history from a teen whose parent is in the room. What is the most appropriate next step?

Ask the mother to leave the room (#180 Confidentiality and minors)

[#180] A 16-year-old with gonorrhea doesn't want her parents told. What is the most appropriate management?

Treat without notifying parents (ceftriaxone + chlamydia coverage) (#180 Confidentiality and minors)

[#180] A comatose minor needs emergency surgery, and the parents cannot be reached. Which ethical principle justifies proceeding?

Beneficence (#180 Confidentiality and minors)

[#180] An adolescent seeks STI care. Which is more likely: Treat and encourage telling parents or Require parental consent?

Treat and encourage telling parents. notifying parents or requiring parental consent → minors consent to STI care; treat, test for other STIs, encourage (don't force) telling parents

[#180] A patient's genetic result puts relatives at risk. Which is more likely: Physician informs relatives directly or Patient informs relatives themselves?

Patient informs relatives themselves. physician informs relatives directly → encourage the patient/couple to inform relatives themselves

[#180] An unconscious patient needs emergency care with no surrogate available. Which is more likely: Autonomy or Beneficence?

Beneficence. autonomy in the unconscious patient → no surrogate in an emergency → beneficence

[#197] Family #197: which members belong to the “End-of-life care, advance directives, and surrogates” family?

Members: End-of-life care, advance directives, and surrogates.

[#197] An incapacitated patient has a living will, and the family asks to withdraw the ventilator. What is the most appropriate action?

Extubate; no CPR (#197 End-of-life care, advance directives, and surrogates)

[#197] With no advance directive, the spouse and adult children disagree about a feeding tube. What is the most appropriate next step?

Encourage family consensus based on patient's wishes (#197 End-of-life care, advance directives, and surrogates)

[#197] A patient has no family, but a neighbor who knew the patient's wishes is present. What is the most appropriate next step?

Ask the neighbor (#197 End-of-life care, advance directives, and surrogates)

[#197] A dying patient is in severe pain, and an opioid may depress respiration. What is the most appropriate management?

Give enough to control pain (#197 End-of-life care, advance directives, and surrogates)

[#197] A patient in uncontrolled pain asks for medication to end his life. What is the most appropriate response?

Reevaluate after pain is controlled (#197 End-of-life care, advance directives, and surrogates)

[#197] A competent patient with terminal cancer declines chemotherapy. What is the most appropriate statement by the physician?

'I respect your choice; I'll keep you comfortable' (#197 End-of-life care, advance directives, and surrogates)

[#197] A physician declines a patient's request for a lethal prescription. Which ethical principle is the physician acting on?

Nonmaleficence (#197 End-of-life care, advance directives, and surrogates)

[#197] The patient's wishes are clearly documented. Which is more likely: Follow the documented wishes or Ethics committee or court order?

Follow the documented wishes. ethics committee or court order → unnecessary when the patient's wishes are clearly documented

[#197] Family members disagree about care for an incapacitated patient. Which is more likely: Follow one relative's preference or Family consensus (substituted judgment)?

Family consensus (substituted judgment). following one relative's preference → encourage family consensus based on the patient's wishes (substituted judgment)

[#197] A dying patient has severe pain. Which is more likely: Enough opioid to control pain or Start low to avoid harm?

Enough opioid to control pain. starting low for fear of addiction / respiratory depression → give enough to control pain (double effect)

[#212] Family #212: which members belong to the “Prevention and screening” family?

Members: primary prevention · secondary prevention (screening) · hand hygiene · public AEDs · community intervention.

[#212] A program targets healthy women aged 30-40. Which level of prevention does this represent?

primary prevention (#212 Prevention and screening)

[#212] A widow is starting to date again after a long marriage. Which level of prevention is most appropriate?

primary prevention (#212 Prevention and screening)

[#212] An intervention acts before disease exists, such as exercise or condoms. Which is more likely: Primary prevention or Secondary prevention (screening)?

Primary prevention. screening (mammography, HIV testing) offered as primary prevention → screening detects existing disease = secondary; primary acts before disease exists (exercise, condoms)

[#212] A program tests the hearing of all newborns. Which level of prevention does this represent?

secondary prevention (screening) (#212 Prevention and screening)

[#212] A recent immigrant from a high-hepatitis B region has had no prior care. Which level of prevention is most appropriate?

secondary prevention (screening) (#212 Prevention and screening)

[#212] A ward has an outbreak of nosocomial resistant Klebsiella. Which intervention is most effective at controlling this?

hand hygiene (#212 Prevention and screening)

[#212] Contact spread of a nosocomial organism must be broken. Which is more likely: Negative-pressure rooms or Hand cleansing between patients?

Hand cleansing between patients. negative-pressure rooms for nosocomial spread → those are for airborne agents (TB, measles, varicella); contact spread is broken by hand cleansing before/after each patient

[#212] A donor wants fewer sudden cardiac deaths, with results in 1-2 years. Which intervention best meets this goal?

public AEDs (#212 Prevention and screening)

[#212] A program must reduce sudden cardiac deaths in the short term. Which is more likely: Public AEDs or Antismoking or statin programs?

Public AEDs. antismoking or statin programs for sudden cardiac death → they take years; public AEDs (early defibrillation) give short-term results

[#212] A city taxes sugary drinks to reduce obesity. Which type of intervention is this?

community intervention (#212 Prevention and screening)

[#235] Family #235: which members belong to the “Abuse and neglect (domestic, child, elder)” family?

Members: intimate partner violence · elder abuse/neglect · child sexual abuse.

[#235] A patient has bruises at different stages and circumferential neck bruising. Which form of abuse is most likely?

intimate partner violence (#235 Abuse and neglect (domestic, child, elder))

[#235] A husband insists on joining his wife in the treatment area. Which form of abuse is most likely?

intimate partner violence (#235 Abuse and neglect (domestic, child, elder))

[#235] A patient in a tense marriage has vaginal abrasions and ecchymoses. Which form of abuse is most likely?

intimate partner violence (#235 Abuse and neglect (domestic, child, elder))

[#235] The physician asks directly and nonjudgmentally in private, separating the partner without accusation. Which is more likely: Private direct questioning or Confronting the suspected abuser?

Private direct questioning. leading questions or confronting the suspected abuser → ask directly and nonjudgmentally in private; separate the partner without accusation

[#235] A competent adult's safety is assessed and she is informed about shelters. Which is more likely: Safety assessment, shelter information or Marital therapy or urging leaving?

Safety assessment, shelter information. marital therapy or telling her to leave → competent adult IPV: assess safety, inform about shelters

[#235] A very thin elderly woman living with family has ecchymoses of varying ages. Which form of abuse is most likely?

elder abuse/neglect (#235 Abuse and neglect (domestic, child, elder))

[#235] The victim is a child or an elder. Which is more likely: Handle like adult IPV or Mandatory report to protective services?

Mandatory report to protective services. handling elder or child abuse like adult IPV → children and elders: mandatory report to protective/social services

[#235] A child has age-inappropriate sexual behavior and declining school performance. Which form of abuse is most likely?

child sexual abuse (#235 Abuse and neglect (domestic, child, elder))

[#235] A patient has unexplained injuries but denies abuse. Which condition is this?

235 Abuse and neglect (domestic, child, elder)

[#378] Family #378: which members belong to the “Ethical principles and interpreters” family?

Members: Autonomy · Nonmaleficence · Professional interpreter.

[#378] A patient insists on a risky, low-yield invasive test. Which ethical principle applies?

Autonomy (#378 Ethical principles and interpreters)

[#378] A patient chooses a risky test that could cause harm. Which is more likely: Utilitarian frameworks or Autonomy vs nonmaleficence?

Autonomy vs nonmaleficence. utilitarian frameworks → risky patient choice = autonomy vs nonmaleficence

[#378] A patient's choice conflicts with potential harm. Which ethical principle applies?

Nonmaleficence (#378 Ethical principles and interpreters)

[#378] A non-English-speaking patient has a child available to translate. Who should interpret for this patient?

Professional interpreter (#378 Ethical principles and interpreters)

[#378] A non-English-speaking patient needs translation for a visit. Which is more likely: Family member or staff or Professional medical interpreter?

Professional medical interpreter. family members (especially children), staff → use a professional medical interpreter

[#396] Family #396: which members belong to the “Health insurance plans (HMO, PPO)” family?

Members: Health maintenance organization · Preferred provider organization · Point of service plan.

[#396] A plan has low copays, a PCP gatekeeper and a restricted network. Which type of insurance plan is this?

Health maintenance organization (#396 Health insurance plans (HMO, PPO))

[#396] The plan has low copays with a gatekeeper. Which is more likely: HMO or PPO or POS?

HMO. PPO, POS → these have higher cost sharing; low copay + gatekeeper = HMO