You have just finished giving instructions and a prescription to a 28-year-old male from China who speaks some English, but not well. You gave the instructions with the aid of an interpreter, but are concerned that the patient might not fully understand them.
Which one of the following is the best course of action?
Correct Answer D:
In order to be sure that cross-cultural patients understand your instructions, it is most helpful to ask them to repeat the instructions to you in their own words. A website would probably not normally be specific or culturally sensitive to the patient’s condition. The physician should speak in a normal tone to the patient and not to the interpreter. Family members may be used as convenient translators, but to maintain confidentiality it is best to use a trained medical interpreter.
A 67-year-old male who recently had a screening colonoscopy presents for follow-up. During the procedure, a mass was discovered in the sigmoid colon and a biopsy revealed a poorly differentiated adenocarcinoma. When you tell the patient you have the test results and can provide information about the prognosis, he says, “To be honest, I can tell that the news is not good, and I would rather not talk about it right now.”
Which one of the following would be the most appropriate next step?
Correct Answer C:
When giving bad news to a patient, it is important to assess how much information the patient wants to know and tailor the discussion accordingly (SOR C). If the patient states that he does not want to know about the prognosis, the most appropriate response is to ask if he would like to talk again at another time. The physician may be regarded as rude, cruel, or uncaring if he persists in providing information that the patient is not ready to hear. In addition, the patient is more at risk for feelings of hopelessness, depression, or anxiety if he is not psychologically ready to hear a bad prognosis. Once the patient verbalizes a readiness to discuss the prognosis, specific information can be provided, focusing on both the positive and negative aspects of the situation.
It is not appropriate to discuss the case with the patient’s wife, unless he specifically requests she be a proxy to receive the information. Referrals to either a support group or an oncologist should be deferred until the information has been discussed with the patient.
Studies indicate that patients most frequently want physicians to ask about their spiritual beliefs in which one of the following situations?
Correct Answer A:
Patients often welcome spiritual discussion, depending on the situation. The percentage that welcome this discussion increases with the severity of illness, and is greatest among those who are very seriously ill with a potentially fatal disease. Spiritual inquiry during medical care should focus on understanding, compassion, and hope, and should be directed toward individuals who suffer from serious illness.
An 84-year-old woman is brought to the office by her daughter, who is your patient. The mother has just moved in with the family because she can no longer care for herself due to progressive, long-standing dementia. On physical examination the mother does not respond to your words or to the physical examination. You notice that she smells of urine. On examination of the pelvis there is a diffuse erythematous rash extending over the perineum and the medial thighs bilaterally. You suspect the rash relates to urinary incontinence.
Which of the following is the most appropriate statement to the daughter at this point?
This choice demonstrates that the physician is in the position of offering guidance for care of this elderly woman. Answers a) and d) indicate that the physician is disapproving of the daughter’s care, and in admonishing her, demonstrates a lack of empathy. Answers b) and e) are inappropriate suggestions, but answer c) indicates a safe, practical, and noninvasive approach to treatment of this patient.
You have been a physician of a 32-year-old female who suggests that you should come on a date with her at a local restaurant.
Which of the following is the most appropriate response?
Medical ethics require physicians to avoid boundary violations that undermine the physician-patient relationship. Examples are sexual/physical relationships, economic involvement, overtly political requests, or similar conduct that the patient would not otherwise engage in if it were not for the trust he/she has for the physician. Physicians should avoid dating current or former patients because romantic relationships between a physician and a former patient may be unduly influenced by the previous patient-physician relationship. On this question the most appropriate answer the physician should give the patient is that the most appropriate course of action is to keep the relationship physician patient only.
→ "I would come if you promised to tell no one" (choice A) is incorrect. Around 4% of physicians date their patients while 20% of physicians report of knowing a colleague romantically involved with a patient. Whether this is known by colleagues or anyone else or not, it is not in alignment with standard medical ethics and physicians should avoid it.
→ "The physician-patient relationship has to end first" (choice B) is incorrect. While some authorities believe that depending on the physician’s specialty and the time elapsed since the physician-patient relationship ended (6 months recommended) this relationship might be okay, the American Medical Association stipulates that a former patient may still be influenced by the previous relationship and may not be able to function in an equal, consenting adult manner.
→ "It is wrong for you to suggest this, I can no longer be your doctor" (choice C) is not the best way to handle this situation as the patient might be unaware of the medical ethics the physician is obligated to abide by. The physician should decline the invitation while reaffirming the commitment to be the patient’s physician. The physician-patient relationship should be ended only if the physician feels that the professional relationship or neutrality is no longer possible.
→ "Going on a date with you would jeopardize my career" (choice E) is not the best way to decline the patient’s invitation as it may leave the patient feeling that it is all about your career. When declining, the physician should clearly communicate to the patient that it is best for their physician-patient relationship not to have a personal relationship so that he/she can better devote his/her attention to the patient’s health.
Key point:
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