Question 1

An 83-year-old Caucasian male with a history of advanced colon carcinoma with metastasis to the lungs develops right-sided hemiplegia and dysarthria while at home.  His granddaughter calls you at 8:00 p.m., giving you a history compatible with a cerebrovascular event, probably an ischemic stroke.  You know this patient from before.  He is not a hospice patient, and he has always firmly expressed his decision to not be resuscitated.  He has a current, valid DNR (do not resuscitate) order.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: A stroke is a serious condition that requires admission to the hospital for evaluation, stabilization, and brain imaging studies. A DNR order implies the commitment of the physician to not attempt resuscitation if the patient's condition seriously deteriorates (e.g. cardiac or respiratory arrest), and does not imply "do not treat." (Choices C & D)Management at home or arranging for hospice is incorrect. The patient deserves to be treated for his concurrent or new conditions according to standard practice. (Choice A)Pain medication may be needed, but it is not an urgent measure to take, especially if the chief complaint of the patient does not involve pain at this point. Educational Objective: A DNR order implies "Do Not Resuscitate." It does not mean, "Do not treat." If the cancer patient is clinically competent and does not wish to be admitted to the hospital, he has the right to decide to stay home. Otherwise, he deserves to be treated for his concurrent or new conditions according to standard practice.

Question 2

A 35-year-old woman comes to the office for evaluation.  Her medical problems include migraine headaches, chronic back pain, asthma, and depression.  The patient has had extensive diagnostic workup of her back pain, including several imaging studies, that was unrevealing.  At today's visit, she is seen by another physician in the same group, as her primary physician is currently on personal leave.  The patient is mildly depressed and reports continued headaches and back pain.  During the course of the appointment, the patient discloses that her primary physician asks her to undress at every visit so he can examine her breasts.  She also mentions that they were in a consensual sexual relationship that she stopped because the physician was not willing to divorce his wife to be with her.  The treating physician contacts the patient's primary physician to discuss concerns about the patient's report.  The primary physician admits to a brief sexual relationship over a year ago when he first began treating her as a patient.  However, he denies there has ever been any inappropriate behavior in the office, stating, "She is a psych patient and is always upset; you can't trust what she is saying."  Which of the following is the best next course of action?

Accepted Answer

The best course of action is to notify the state medical board of the physician's alleged behavior. This is a serious ethical violation, and the medical board is the appropriate authority to investigate and take necessary actions.

Question 3

A 39-year-old woman has started using the encrypted email within her hospital's electronic health record system to contact her primary care physician about health concerns.  She works as an attorney and has a history of sarcoidosis, gastroesophageal reflux disease, and tension headaches.  The patient frequently sends long updates on her symptoms to her physician with medical questions referencing articles she finds on the internet, often 5-10 times a day.  Her physician, who has treated her over the past 5 years, has been spending increasing amounts of time responding to her concerns.  During this time, she has also no-showed for 2 of her scheduled in-person appointments.  When the physician is suddenly called out of the office due to a family emergency, the patient becomes frustrated by the lack of response to her emails and sends the physician several messages complaining about lack of availability.  On returning, what would be the best response for the physician to give the patient?

Accepted Answer

Explanation: According to the American Medical Association, "Patient-physician electronic mail is defined as computer-based communication between physicians and patients within a professional relationship, in which the physician has taken on an explicit measure of responsibility for the patient's care." Many health care systems have implemented encrypted email for patients to use in Health Insurance Portability and Accountability Act (HIPAA)- compliant communication with physicians. Efficient and convenient, email provides the opportunity for basic follow-up care and clarification of medical advice provided in the office setting, with ease of documentation of communication. Suggested educational resources and websites can be easily referenced in the context of an email, allowing patients to better understand pertinent health care issues. However, it is important for physicians to set clear boundaries regarding the use of email communication prior to engaging in these exchanges with patients. The parameters should include prohibiting the use of email for urgent or emergency situations, and discouraging overuse to circumvent office visits or emails containing abusive or inappropriate content. Patients should be informed that email is most useful when managing simple health care issues (eg, medication refills, basic questions about pre- or post-operative care, appointment scheduling, advice clarification). This physician should inform the patient that her email use is not appropriate and outline the parameters for their email contact. (Choice A) Discontinuing the patient's email privileges would not be the best next step. This would be more appropriate if the patient has repeatedly failed to respect set boundaries or is abusive or threatening harm. (Choice B) Mandating that all concerns be addressed in office visits would be recommended for a patient who continues to use email in lieu of office visits following a clear discussion of email parameters. (Choice C) Although some concierge practices may bill for time spent on email, currently insurance does not cover this type of service. It would be more reasonable to first discuss appropriate emailing parameters. (Choice D) Offering an explanation for why the physician was away avoids addressing the main issue, which involves the patient's lack of understanding about the appropriate use of email. Educational objective: Patient-physician email communication regarding simple, nonurgent health care issues is useful in clarifying instructions, improving rapport, and increasing patient satisfaction. Physicians should set clear parameters early on with patients regarding appropriate use of email. References: Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. (http://www.ncbi.nlm.nih.gov/pubmed/9452989)

Question 4

A quality improvement committee based at a primary care clinic wishes to improve screening and follow-up of patients with obesity. Currently, 30% of patient encounters include documentation of BMI, and 10% of patients with BMI ≥30 kg/m² are scheduled for weight management follow-up appointments. The committee sets a goal to increase BMI documentation to 40% and BMI follow-up to 30% in 3 months. It decides to test the effectiveness of a clinical decision support tool in achieving this goal. The tool is designed for clinical providers and integrated into the electronic medical record; it includes a BMI calculator and a prompt to arrange follow-up when BMI is ≥30 kg/m². An email introducing the tool and its purpose is circulated to all clinical providers. After the tool is implemented for 3 months, which of the following is the most appropriate next action according to the Plan-Do-Study-Act paradigm?

Accepted Answer

Explanation: 11ec2b69_c1f0_8b3a_8f63_dbb2b05a9a6d_MD0005_00 The Plan-Do-Study-Act (PDSA) paradigm is a continuous and incremental method of improving a process. It involves iterative implementation, assessment, and refinement of a quality improvement (QI) intervention to achieve a desired change (eg, improvement in obesity screening). The PDSA cycle includes 4 steps: Plan: Identify a specific, realistic goal (including timeframe), factors affecting process quality, and a testable intervention. This QI project defined a goal for obesity documentation (to 40%) and follow-up (to 30%), and an intervention (clinical decision support tool) addressing convenience and efficiency. Do: Implement the plan and continually collect data that will be used to measure change and effectiveness (eg, information from electronic records). Study (or Check): After the defined timeframe, analyze data to determine whether the intervention achieved the defined goals. After this QI project is implemented for 3 months, the next best step is to review charts to assess for changes in BMI documentation and follow-up because this information directly measures the defined outcome. Act: After data analysis, determine modifications needed for the next cycle based on lessons learned in the Study stage. The entire PDSA cycle can be repeated as needed, with each cycle further refining the intervention and process until the desired goal is reached. (Choices A and B) Staff feedback can be collected during the Study stage to inform lessons learned and needed modifications. Similarly, data on cost-effectiveness can help determine feasibility and value (ie, optimizing quality while minimizing costs). However, neither action directly assesses project goals (ie, percentage of providers documenting and following up on BMI). Therefore, chart review should be done first to quantitatively determine overall performance. (Choices C and E) Determining provider barriers to BMI documentation and identifying best practices of providers with highest documentation and follow-up are examples of actions in the Plan stage (because they could have inform the tool's content and design). They are less appropriate at this stage because the tool has already been implemented. Educational objective: The Plan-Do-Study-Act paradigm guides improvement of a process through continuous and incremental implementation, assessment, and refinement of a quality improvement intervention. References: Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. (http://www.ncbi.nlm.nih.gov/pubmed/28629348)

Question 5

A quality improvement committee based at a primary care clinic wishes to improve screening and follow-up of patients with obesity. Currently, 30% of patient encounters include documentation of BMI, and 10% of patients with BMI ≥30 kg/m² are scheduled for weight management follow-up appointments. The committee sets a goal to increase BMI documentation to 40% and BMI follow-up to 30% in 3 months. It decides to test the effectiveness of a clinical decision support tool in achieving this goal. The tool is designed for clinical providers and integrated into the electronic medical record; it includes a BMI calculator and a prompt to arrange follow-up when BMI is ≥30 kg/m². An email introducing the tool and its purpose is circulated to all clinical providers. Three months after implementation of the tool, the committee analyzes patient charts to determine changes in obesity screening and follow-up. They find that obesity documentation now occurs in 32% of patients and that follow-up is arranged for 12% of patients with BMI ≥30 kg/m². The clinic's providers report that, while the tool functions properly, they often overlook it because patient vital sign measurement, including weight, and arrangement of follow-up appointments are typically part of medical assistant workflow. Which of the following is the most appropriate subsequent action?

Accepted Answer

Explanation: This quality improvement intervention sought to improve BMI documentation (to 40%) and follow-up (to 30%) by implementing a clinical decision support tool. However, chart analysis, representing the "Study" step of the Plan-Do-Study-Act (PDSA) paradigm, indicates the process failed to reach targets (eg, increase of only 2%) after 3 months. Provider feedback suggests that the tool may have performed poorly because it focused on clinicians rather than medical assistants, who collect BMI data points (eg, weight and height intake) and schedule follow-ups in this clinic. The next PDSA step, "Act," involves responding to lessons learned in the "Study" step to refine the intervention. In this case, the best action is to respond to provider observations by training and involving medical assistants in use of the tool. The tool should then be retested (ie, initiating a new cycle starting from "Plan") to assess whether the modified intervention improves the intervention's ability to reach specified goals. (Choices A and D) PDSA emphasizes an incremental approach that builds upon previous experiences to improve (rather than immediately discard) an intervention. Therefore, it is premature to discard this tool now or revise goals, as only one cycle has been completed, some improvement (ie, of 2%) was achieved, and no modified versions have been retested. Moreover, the current goals are already specific (eg, defined percentage increase over specified time frame). The tool should first be retested with modifications that address lessons learned (eg, lack of assistant involvement). (Choice B) Increasing clinician alerts is unlikely to improve the intervention because it does not address assistant workflow and may increase risk of alert fatigue. (Choice C) Retesting the tool without modifications that address lessons learned is unlikely to generate further improvements. Educational objective: As part of the Plan-Do-Study-Act paradigm of a quality improvement intervention, following implementation and assessment, the intervention should be refined based on lessons learned and subsequently retested. References: Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. (http://www.ncbi.nlm.nih.gov/pubmed/28629348)

Question 6

A pharmaceutical company sales representative comes into the office to provide information on a new discount program for the company's antidepressant medication.  One of the office staff members performs a search of the practice electronic record system; she finds 2 patients on the schedule for the following week who are taking the drug and provides the names and addresses to the sales representative so that he can send information about the program.  Later that day, when the clinician is notified of what happened, she immediately instructs the sales representative to not contact the patients and delete their information from his laptop computer.  Which of the following is the most appropriate next step in addressing this situation?

Accepted Answer

Explanation: 11ec2b69_c1ee_b678_8f63_311a475af6dd_MD0005_00 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards that providers and other health care entities (eg, insurance plans) must follow to protect patient confidentiality (ie, protected health information [PHI]). PHI refers to any personally identifiable information regarding the patient's health, services provided to the patient, and payments made for services. Providers are required to protect PHI against unauthorized disclosure and take steps to ensure compliance by their workforce (eg, office staff). These steps should include restricting physical access of unauthorized persons within health care facilities, device security measures (eg, password protection), and employee training. In general, PHI can only be transferred to persons outside the facility on direct authorization by the patient. Exceptions can be made for purposes of treatment (eg, sending records to a treating specialist), payment (eg, insurance audits), health care operations, or legal/regulatory requirements (eg, law enforcement). A breach of privacy refers to disclosure of PHI to an unauthorized person or for an improper purpose. In this case, patient information was given to an unauthorized person for a purpose (ie, marketing) that does not fall under any of the relevant exceptions. In cases of breach, the patient must be notified in writing (Choices B and C); first-class mail is preferred, but email is acceptable if the patient has agreed to electronic notifications. The notification should include a description of the breach, what information was disclosed, and what actions are being taken to mitigate the breach and prevent future disclosure. (Choice A) Although notification must be made within 60 days, it should be made as soon as possible without any unreasonable delays. Inquiring whether the patient received any contact from the unauthorized person who received PHI is unnecessary. (Choice D) The unauthorized person receiving PHI should be explicitly instructed not to allow further disclosure, but directing noncovered entities (ie, organizations not subject to HIPAA) to institute disciplinary action is not required. In addition, this does not ensure the patient is made aware of the breach of information. Educational objective: A breach of privacy refers to disclosure of patient information to an unauthorized person or for an improper purpose. In cases of breach, patients must be notified in writing, including a description of the breach, what information was disclosed, and what actions are being taken to mitigate the breach and prevent future disclosure.

Question 7

A mother brings her 4-year-old son to the clinic for evaluation of 2 days of abdominal pain.  She moved to the United States from Vietnam 3 years ago with her husband and children and cannot speak or understand English.  She is fluent in Vietnamese.  Her husband is fluent in English but is currently out of town on business.  The boy is accompanied by his 7-year-old sister, who is fluent in Vietnamese and learning English in elementary school.  The treating physician is unable to speak or understand Vietnamese, and there is no Vietnamese interpreter available in the clinic.  They are joined by a family friend, who is fluent in both languages.  The boy has stable vital signs and does not appear to be in distress.  Which of the following is the most appropriate choice to communicate with this patient?

Accepted Answer

Explanation: Recent census data estimate that up to 20% of United States residents speak languages other than English at home. Many of these patients have limited English proficiency (LEP) and have difficulty communicating with medical personnel. Communication problems can lead to misunderstanding of diagnoses, medication reconciliation, and follow-up care. As a result, LEP patients can have more adverse events than English-speaking patients. Medical interpreters are trained to take a medical history and would be the preferred method of obtaining this patient's history. However, many health care facilities may not have adequate staffing to cover all major languages. Telephone interpretative services are a reliable back-up option. These services involve the doctor using a speakerphone to contact a trained medical interpreter, who can assist in obtaining an adequate medical history from the patient. (Choice A) Although the boy appears stable, sending him home without further evaluation is inappropriate as he may have a serious condition. (Choice B) Children should not be used as interpreters except in emergency situations when there are no other options. In addition, this child may not be able to use the necessary English to obtain the medical history. (Choice C) Family members and friends can be inaccurate and unreliable with medical details unless they are specifically trained on the expectations of interpretation. (Choice E) Examining the boy to determine the problem without first obtaining a medical history can lead to a misdiagnosis. If he has stable vital signs and does not appear to be in distress, it is best to find an interpreter and obtain an accurate history. Educational objective: Patients with limited English proficiency can have communication problems leading to misunderstanding of diagnoses, medication reconciliation, and follow-up care. Medical interpreters are preferred for obtaining an accurate medical history in these cases. Telephone interpretative services are a reliable back-up option. Using these services, a trained medical interpreter on a speakerphone can serve as the contact between the patient and the health care professional. References: Working with interpreters: practical advice for use of an interpreter in healthcare. (http://www.ncbi.nlm.nih.gov/pubmed/23448332) Navigating language barriers under difficult circumstances. (http://www.ncbi.nlm.nih.gov/pubmed/18711157)

Question 8

A 63-year-old man admitted for urolithiasis complicated by a urinary tract infection is treated with intravenous antibiotics.  The patient is a Russian-speaking immigrant who lives with his son.  During the night, the nurse sees that one of his intravenous catheters is infiltrated and cannot be used.  The nurse is unable to secure a second peripheral intravenous line and notes that the patient is becoming progressively hypotensive with a blood pressure of 105/50 mm Hg and pulse of 89/min.  He calls the medical resident covering the patient for assistance.  The resident has little experience placing peripheral intravenous lines but has placed several internal jugular lines, including 5 independently, during his intensive care rotations.  The resident asks the patient in English for consent of immediate central line placement.  During the attempt to insert the internal jugular line, the patient develops a large pneumothorax.  In the root cause analysis of this adverse event, which of the following could be the most important patient-related factor?

Accepted Answer

Explanation: 11ec2b69_c1ef_79c9_8f63_2f82b020f93d_MD0005_00 Root cause analysis (RCA) is an important quality improvement tool to identify the multiple influencing factors behind undesirable outcomes, with the goal of recommending corrective measures. RCA provides a framework to analyze and categorize various contributory elements by general groups, such as patient, staff, task, equipment, and work environment; this allows for more complete understanding and prioritization of potential solutions. Examples of patient-related factors include clinical condition; cultural or religious beliefs; language; state of emotional distress; and various interpersonal relationships with family members, loved ones, and the medical team. Although many factors (eg, lack of translation services, lack of resident training in peripheral access management, nursing workloads) likely contributed to the adverse event in this case, the most likely patient-related contributing factor is the language barrier between the treating physician and patient. This barrier can diminish discussion of the risks, operator experience, benefits, and alternate approaches. It may have led to the clinical decision for an intervention with which the resident was more comfortable (central line) instead of an intervention more appropriate for the patient's clinical situation (more peripheral access). (Choice A) The absence of an attending physician to supervise a trainee during a nighttime procedure is an education and training factor that may have contributed to an unsafe practice on the part of the trainee. (Choice B) The availability of appropriate equipment to reduce the risks of a procedure is an equipment factor. (Choice D) The patient's support system can affect clinical decision making and the choices that patients make regarding their care. However, this patient's living situation and support network likely had less relevance than the language barrier in the decision to place a central venous catheter overnight. (Choice E) The medicolegal environment is a broader institutional factor and not patient specific. Educational objective: Root cause analysis is an important quality improvement tool to understand adverse events and identify the reasons behind undesirable outcomes, with the goal of recommending corrective measures. Systematically categorizing various factors allows for more complete understanding and prioritization of potential solutions. References: Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22421911) Medical errors and clinical risk management: state of the art. (http://www.ncbi.nlm.nih.gov/pubmed/16749601) Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. (http://www.ncbi.nlm.nih.gov/pubmed/21949441)

Question 9

A 75-year-old man is hospitalized with a severe pneumococcal pneumonia.  After 48 hours of hospitalization, he begins to recover.  On the 3rd day of hospitalization, he suddenly develops chest pain while being prepared for discharge.  An emergency CT reveals a pulmonary embolus.  After reviewing the patient's chart, it becomes apparent that although he had no contraindications, he was not placed on anticoagulant thromboprophylaxis.  The patient's wife arrives and asks if this complication could have been prevented.  Which of the following is the best response to her question?

Accepted Answer

Explanation: Errors are an unfortunate reality of patient care, especially as the practice of medicine grows more complex. Physicians are ethically obligated to disclose medical errors to patients and family. A forthright apology and explanation of the medical facts contribute to building trust and strengthening the physician-patient relationship. Research has shown that when medical errors are made, patients and their families primarily care about receiving an explanation and an apology from the responsible physician(s) early in the process. Prompt disclosure actually decreases malpractice risk, as litigation is more often pursued when the patient and family feel deceived or avoided. Therefore, this patient and his wife should be informed that prophylaxis decreases the risk of thrombosis and that it was mistakenly not given. (Choices A, C, and E) Although there is no way to prevent all potential complications of pneumonia and thrombosis can occur with or without prophylactic treatment, these statements do not acknowledge that the patient's thrombotic event may be the result of a medical mistake. Research has shown that the risk of venous thromboembolism is reduced in patients who receive prophylaxis. (Choice B) This statement is inaccurate as prophylaxis decreases the risk but cannot prevent thrombosis. Educational objective: Physicians are obligated to inform patients and family of medical errors. Timely disclosure accompanied by an empathic apology and explanation will help to preserve the physician-patient relationship. References: Teaching medical error disclosure to residents using patient-centered simulation training. (http://www.ncbi.nlm.nih.gov/pubmed/24280843) Disclosing medical errors: the view from the USA. (http://www.ncbi.nlm.nih.gov/pubmed/24461211)

Question 10

A 33-year-old woman comes to your office because she thinks that she is pregnant.  A urine pregnancy test in the office is positive.  She states that she would like you to be the physician responsible for her prenatal care.  You begin taking a thorough history, which reveals that the patient currently has several sexual partners and is not sure who actually fathered the child.  You explain to her that HIV testing is a routine part of prenatal screening and that given her sexual history, she is at an increased risk of contracting the virus.  She becomes slightly offended and refuses to be tested for HIV.  What is the best response to this patient?

Accepted Answer

Explanation: The American Medical Association has recommended that physicians should support routine HIV testing when indicated to protect patients and to avoid injury to third parties. As a result of substantial medical and social advances, physicians are no longer required to obtain written consent for HIV testing unless required by law. However, physicians should document the conversation about HIV testing in the chart. This patient is certainly at high risk for HIV infection. While it is recommended that all pregnant women be screened for HIV, this patient does retain the right to refuse this test. (Choice B) The Center for Disease Control does have guidelines regarding the reporting of HIV/AIDS, but there are no regulations that require testing pregnant women for HIV against their will. (Choice C)This patient has a right to refuse HIV testing, and refusing to treat this patient without offering a suitable alternative would constitute patient abandonment. (Choice D) There are no laws requiring that pregnant women be tested for HIV. (Choice E)Child Protective Services should not be notified because this patient has a right to refuse the HIV test. Educational objective: Universal HIV screening for pregnant women is recommended, but women do retain the right to refuse testing.

Question 11

A 24-year-old woman comes to the office accompanied by her caseworker.  This is the first time that she has been seen in the office, and she appears mildly anxious.  However, she quickly relaxes once the female physician enters the room.  The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend.  Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant.  The patient says, "I would like to go on birth control.  I want a baby one day but not until I am married."  The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan.  The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child.  The patient becomes tearful and says, "My mom doesn't know what's best for me.  I know I can be a good mom."  Which of the following is the most appropriate next step in assisting the patient with these decisions?

Accepted Answer

Explanation: There are several ethical issues raised in this situation regarding the patient's moderate intellectual disability and ability to make her own health care decisions. The priority at this time is to determine whether she has a designated guardian, as the guardian must be included in the decision-making process. It is appropriate and respectful to ask the adult patient about guardianship status first. If the patient does not know or appears confused, it is appropriate to ask the parent or caseworker. Parents are assumed to be the guardian of a patient who is a child; otherwise, a guardian may have been appointed in the event of parental death, child abuse, neglect, or other circumstances. When children reach age 18, their parents may pursue guardianship in order to continue to make decisions for those with an intellectual disability, especially if an adult child's disability is severe enough to impair global decision-making capacity or ability to communicate. However, if the parent does not pursue guardianship, the patient becomes his or her own guardian. It should be noted that guardianship laws vary by state. (Choice A) Assessing the patient's understanding of contraceptive choices is essential. However, it must be first determined if a guardian has been appointed; if so, then the discussion should be conducted with the guardian present. (Choice B) Although assessing the patient's understanding of the responsibilities of parenthood is important, the priority is to determine whether the patient is in charge of making her own health care decisions. (Choice D) Recommending tubal ligation to this patient would be coercive. It disrespects her presumed autonomy and dismisses her stated desire to have a child one day. (Choice E) This would be true only if the patient were under the age of 18 or if the mother were known to be the patient's appointed guardian. Educational objective: It is important to determine guardianship status for adult patients with intellectual disability. Guardianship should be clarified early in the medical relationship to facilitate decision making.

Question 12

A 34-year-old man comes to the office to establish care and receive an opioid prescription.  His medical concerns include a history of disc atrophy with likely thecal sac entrapment at C2, C3, and C4 that is associated with severe shooting pain with neck extension.  He also has a large skin graft on his left upper thigh from a water heater burn.  The patient, a general contractor, recently moved to the area and has not yet established a relationship with a new primary care physician.  He reports "my previous physician put me on high-dose oxycodone that enabled me to continue working."  Physical examination reveals numbness and weakness of both arms, which the patient reports has been getting worse for some time.  The physician recommends surgical consultation to discuss surgical options.  The patient is reluctant to consider surgery and requests a refill of his opioid pain medication.  He explains, "Without the medication, I am unable to work.  My family is relying on me.  I only have a 1-week supply left."  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: Managing patients who request opioid medication is frequently challenging because it may be difficult to differentiate inadequate pain management from drug-seeking behavior. Prescription opioid misuse and dependence have escalated rapidly, requiring increasing oversight and monitoring. Prior to prescribing opioids, the best approach is to confirm the patient's medical history and prescription use by contacting the patient's previous physician. State-based prescription drug monitoring programs should also be checked to identify undisclosed prescriptions, clarify prescription patterns, and determine whether the patient has obtained prescriptions from multiple prescribers. By identifying potential opioid misuse, physicians can make more informed decisions regarding opioid prescriptions. Risk factors for opioid misuse include a personal or family history of substance use and psychiatric disorders. Features concerning for drug-seeking behavior include requesting high doses or a specific medication by name, running out of medication before the refill is due, reporting lost or stolen medication, and pain out of proportion to the physical examination. (Choice A) Although a pain contract may be useful in documenting shared decision-making and a monitoring plan, the first step is to confirm the patient's history with outside sources. The efficacy of pain contracts has not been established. (Choice B) Referring the patient to a pain management specialist may be helpful, but it does not address his acute condition because he has a possible legitimate need for the opioid pain medication. Abrupt discontinuation may precipitate a severe uncomfortable withdrawal syndrome and risk of suicide. (Choice C) Although the risks of prescription opioids should be reviewed, this patient reports needing high doses and is unlikely to be receptive to a nonopioid analgesic. In addition, abruptly stopping an opioid medication could lead to withdrawal symptoms. Patients who are on long-term, high-dose opioid therapy need a careful balance of deescalation of dosing while preventing withdrawal symptoms. (Choice E) It would be inappropriate to prescribe high-dose opioid medication without verifying the prescription. Educational objective: Physicians should assess patients for prescription drug misuse prior to initiating opioid therapy. This includes verifying medication history by contacting the patient's previous physician and by using prescription drug monitoring programs. References: Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health. (http://www.ncbi.nlm.nih.gov/pubmed/28152391) CDC guideline for prescribing opioids for chronic pain-United States, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/26977696) Breaking the pain contract: a better controlled-substance agreement for patients on chronic opioid therapy. (http://www.ncbi.nlm.nih.gov/pubmed/27824537)

Question 13

A 24-year-old woman comes to the office accompanied by her caseworker.  This is the first time that she has been seen in the office, and she appears mildly anxious.  However, she quickly relaxes once the female physician enters the room.  The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend.  Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant.  The patient says, "I would like to go on birth control.  I want a baby one day but not until I am married."  The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan.  The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child.  The patient becomes tearful and says, "My mom doesn't know what's best for me.  I know I can be a good mom." The patient reports that she does not have a guardian, and the caseworker confirms that the patient is responsible for her own decision making.  The caseworker provides additional information regarding the patient's level of functioning.  She states that the patient lives in a group home and has a female roommate.  The patient plans to move in with her boyfriend, who has been diagnosed with borderline intellectual functioning.  The patient says, "My boyfriend is very nice and helps me a lot.  When we live together we can do the shopping ourselves.  He has his own job and works in the supermarket 3 days a week.  His sister is very nice, too, and she visits him every week.  She said that there is an injection I can have so that I don't get pregnant until we are married."  The physician educates the patient regarding contraception in simple terms and reviews the various birth control options, including depot progesterone injections.  The patient responds, "I don't know.  Whatever you recommend, doctor."  Which of the following would be the most appropriate response to this patient?

Accepted Answer

Explanation: 11ec2b69_c1ea_97c7_8f63_e7638fba1f59_MD0005_00 At age 18, a person with intellectual disability is presumed to be a competent adult with the ability to make health care decisions, including those related to reproductive health. However, given this patient's known cognitive impairment, her ability to make her own medical care decisions is in question. Therefore, the first step is for the physician to evaluate the patient's capacity to make an informed decision about using contraception at this time. There are four important criteria for assessing a patient's capacity: The patient's understanding of the options, appreciation of the possible consequences of a decision, ability to weigh the risks and benefits of a decision, and ability to communicate a decision based on these considerations. In this case, the patient's understanding of the options and consequences is unclear. The physician should ask the patient to repeat back what was discussed in order to assess if she has an understanding of the information presented. If her capacity is in question, the next step would be to consider filing for a guardianship application with the courts. (Choice A) The physician should first assess this patient's capacity to make this decision. (Choices B and E) The patient should be given educational materials and time to confer with others about her decision. However, this will not help the physician in determining if the patient has the capacity to make her own decision. (Choice D) A physician should not administer treatment to a patient who lacks the capacity to make decisions, even if the patient consents to the treatment. Educational objective: Adult patients with intellectual disability are allowed to make health care decisions for themselves, unless it is determined that they lack decision-making capacity and guardianship has been established. Physicians play a role in the assessment of capacity. References: Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective (http://www.ncbi.nlm.nih.gov/pubmed/24455249)

Question 14

A healthy 28-year-old man comes to the office for a routine health maintenance examination.  The patient is seen by his primary care provider, who has known him since childhood.  The provider also cares for the patient's 26-year-old wife, who is currently pregnant.  The wife is also followed regularly by a high-risk obstetrician for serial ultrasounds due to complications of Rh(D) alloimmunization.  She is Rh(D)-negative; her husband is Rh(D)- positive.  Her records indicate that she had been pregnant previously with another partner and had an elective termination of pregnancy.  During the visit, the patient discusses how excited he and his wife are to become new parents.  He mentions that he has done some research about Rh sensitization and has read about cases similar to his wife's.  He asks how his wife could have this problem considering this is the couple's first child.  Which of the following is the most appropriate response?

Accepted Answer

Explanation: The HIPAA (Health Insurance Portability and Accountability Act) law states that a provider may share a patient's health information with family members if the patient is present (or otherwise available prior to the disclosure), has the capacity to make health care decisions, and agrees (or does not object) to the information being given. In this case, there is no indication that the wife has been asked about her wishes regarding sharing information with the husband. Given the sensitive nature of the information regarding her past pregnancy and termination, it is particularly important not to make any assumptions about her wishes. Because the wife is not present to agree or object, the most appropriate course of action is to explain that no information can be shared without her permission. (Choice A) It would not be appropriate to advise the husband to make an appointment to discuss the issue with his wife, unless the provider previously obtained the wife's permission to do so. (Choices C and E) Rh(D) sensitization can occur in a first pregnancy in the rare instance of previous maternal exposure to Rh(D)-positive blood (eg, blood transfusion, needle stick). However, a provider should not knowingly mislead regarding the etiology of a family member's health condition or avoid the problem by referring the family member to another physician to address the topic. (Choice D) This statement, although accurate, implies that the wife had a past pregnancy and violates her right to privacy. If the husband's health or safety is not jeopardized by his wife's condition, the provider should not disclose any confidential information about her to him. Educational objective: The HIPAA (Health Insurance Portability and Accountability Act) law states that a physician may share a patient's health information with family members if the patient is present (or otherwise available prior to the disclosure), has the capacity to make health care decisions, and agrees (or does not object) to the information being given. This should be honored unless a situation jeopardizes a family member's health or safety. References: Respecting patient confidentiality. (http://www.ncbi.nlm.nih.gov/pubmed/25627535)

Question 15

A 64-year-old woman comes to an academic teaching hospital due to abdominal pain and nausea.  Physical examination shows low-grade fever and right lower quadrant abdominal tenderness.  CT scan of the abdomen is consistent with acute appendicitis and a laparoscopic appendectomy is planned.  The surgeon discusses the risks and benefits of the procedure and alternate treatment options.  The patient agrees to undergo the surgery.  The surgeon plans to delegate certain noncritical components of the surgery to the senior resident.  Which of the following is the most appropriate approach regarding the resident's involvement in the care of this patient?

Accepted Answer

Explanation: 11ec2b69_c1e9_8655_8f63_51f6e8b59d31_MD0005_00 Informed consent is the process in which a physician provides the information necessary for a patient to make an educated health care decision. In academic institutions, where trainees are involved in patient care to varying degrees, this should include a discussion about the trainees engaged in the patient's care and their expected roles. In this case, when obtaining consent for laparoscopic appendectomy, the attending surgeon should disclose to the patient that the senior resident may be involved in her surgical procedure, clarify the resident's anticipated role (eg, performing certain aspects of the surgery), and explain the attending surgeon's level of supervision. Such disclosure should be made even if the resident is already known to the patient because the patient may not otherwise anticipate the resident's participation, during which she will be unconscious and unable to give consent (Choice B). Lack of disclosure prior to the procedure may prompt a later finding that true informed consent was not obtained. Patients ultimately have the right to refuse trainee involvement in their care. Most, however, will accept trainee involvement, especially if they can participate in the conversation about what parts of their care are allocated to trainees. Visiting the patient with trainees prior to the procedure, demonstrating a collegial relationship with trainees in front of the patient, and emphasizing trainee supervision may further increase patients' acceptance of trainee participation. (Choices A, D, and E) Under ideal circumstances, trainee participation in this patient's operation would occur under the attending surgeon's direct supervision and add no additional risk to the procedure, and the surgeon would take full responsibility for the outcome of the operation. However, even in these circumstances, the patient has a right to know who will be performing her procedure (ie, both the attending surgeon and the senior resident) and to decide whether she is willing to consent to their involvement. Educational objective: In academic institutions, where trainees are involved in patient care to varying degrees, informed consent (eg, for surgery) should include a discussion about all the individuals involved in the patient's care and their expected roles. References: Training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates. (http://www.ncbi.nlm.nih.gov/pubmed/21930977) Patients' perspectives on the extent of resident participation in the operating room for total hip or knee arthroplasty. (http://www.ncbi.nlm.nih.gov/pubmed/33680228)

Question 16

A 33-year-old woman comes to the office due to dyspareunia.  The pain started about a year ago after the birth of her second child.  When the patient saw her obstetrician for follow-up 4 months ago, he reassured her that everything was normal and her pain would improve shortly.  She has no other medical issues and her vital signs are within normal limits.  Pelvic examination reveals an abnormal episiotomy scar with contracture around the perineum secondary to scarring.  This is the fifth patient in the past 12 months the physician has seen with the same examination findings; all 5 are patients of the same obstetrician.  Previously, after seeing the second of those patients, the physician had contacted the obstetrician to discuss his rationale for the procedure, and the obstetrician had responded, "It is an acceptable and safe procedure that generally has excellent results.  Both of those patients' symptoms should get better soon.  I appreciate your concern, but I am a specialist and I know what I am doing."  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: Physicians have an ethical responsibility to report impaired, incompetent, or unethical colleagues to appropriate authorities. Unusual practices that deviate from the standard of care and threaten patient welfare should be reported to the appropriate state regulatory body, typically a division of the state's medical board, for further investigation. Physicians have a duty to report if patients inform them about misconduct or if they directly observe the act of misconduct itself. In this case, the physician should notify the state medical board as there is reason to be concerned that this obstetrician's practices threaten patient health and welfare. If the medical board's investigation confirms misconduct, disciplinary actions may include monitoring requirements, reprimands, probation, restrictions on practice, and license suspension. (Choice A) The physician's previous attempt to discuss his concerns about the procedure was met with denial. Further discussion is unlikely to be effective and is an insufficient response when there is reason to believe that patient welfare is at risk. (Choices C and E) Explaining to the patient that she had an avoidable complication or referring her to another gynecologist is insufficient. The physician is ethically obligated to report this obstetrician as there is reasonable evidence to suspect misconduct (ie, similar physical findings in multiple patients). (Choice D) It is inappropriate to burden the patient with the responsibility of preventing this obstetrician from performing a potentially harmful procedure. Educational objective: Physicians are ethically obligated to report colleagues who subject patients to potentially harmful treatments. State medical boards are authorized to conduct investigations of possible misconduct and institute disciplinary actions if indicated.

Question 17

A 70-year-old man comes to the hospital with acute-onset chest pain.  He has stabbing pain and pressure that radiates down his arm and started an hour ago during a bicycle ride.  The patient's medical history is significant for generalized anxiety disorder, mild dementia, hyperlipidemia, and metabolic syndrome.  Initial electrocardiogram indicates no abnormalities.  He is admitted to the hospital for observation, with serial troponins and telemetry monitoring.  On hospital day 2, the patient's physician mistakenly orders a dose of valproate for him that was intended for another patient with a seizure disorder.  The patient's nurse does not double check the order and administers the medication with the patient's other medications.  Later that day, the patient tells the physician of feeling sedated and "mental fogginess" but attributes this to being awakened frequently the night before for vital signs.  The patient's daughter feels certain that a good night's sleep will improve her father's symptoms.  On realizing the error, the physician's next step should be which of the following?

Accepted Answer

Explanation: Physicians are often reluctant to disclose that a medication error has occurred, particularly when no significant harm has come to the patient. Reasons for this include fear of losing patient trust, legal action, and discipline from the medical board. However, prompt, full disclosure of medical errors has been found to have a neutral to positive effect on patient response to the error as well as the doctor-patient relationship. When an error is discovered, disclosure should be provided in person, in a timely manner that includes an apology for what occurred. Patients should be reassured of efforts to prevent further errors from occurring. (Choice A) Agreeing that the patient's over-sedation is secondary to lack of sleep would be dishonest and misleading. (Choice B) Consulting with hospital risk management would not be appropriate at this time, as it is clear that an error has occurred and no legal action is currently being threatened. The patient and his daughter will likely appreciate a prompt, honest explanation, which may mitigate desire for possible legal action. (Choice D) Transferring care to another physician would be premature as the patient has not expressed an interest in doing so, and this undermines trust in the physician's ability to continue caring for the patient. (Choice E) Waiting to speak with the pharmacy and nursing staff would be appropriate if it is unclear what has occurred or if there is a question about whether the mistake led to an adverse outcome. However, in this case it is clear that the medication error led to the patient's current complaints and the best next step is to provide full disclosure of the event. Educational objective: Medication errors present a significant risk to patient safety. Appropriate management includes prompt disclosure accompanied by an apology and discussion of preventive measures. References: Medication errors: an overview for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/24981217) Patients' and physicians' attitudes regarding the disclosure of medical errors. (http://www.ncbi.nlm.nih.gov/pubmed/12597752) Skills of internal medicine residents in disclosing medical errors: a study using standardized patients. (http://www.ncbi.nlm.nih.gov/pubmed/19940591)

Question 18

An emergency physician recently began working at a local community hospital.  The emergency department is very busy and is part of a larger training program for emergency medicine residents.  At times the physician works with residents but is not their direct supervisor.  During the third week on the job, the physician meets the emergency medicine chief resident, who comes in infrequently to cover for other residents but is busy primarily with a nonclinical research project.  He has an excellent reputation in the program and is near the end of his final year.  At the end of the shift the physician sees the chief resident in the locker room; although the physician cannot be sure, it appears that the chief resident is snorting a substance behind his locker door.  The following week the physician sees him snorting a white powder in the bathroom.  The physician confronts the chief resident and asks if he is using drugs.  He initially denies drug use but then says, "Please don't tell anyone about this.  They'll kick me out, and I've worked so hard to get here.  I'll do anything you say - stop, get help, sign up for treatment."  The physician is ethically obligated to do which of the following?

Accepted Answer

Explanation: Physicians have an ethical obligation to patients, their colleagues, and the medical profession to take action when another physician appears to be impaired due to a substance use disorder. Their first responsibility is to protect an impaired physician's patients from harm. According to the American Medical Association, "Physicians have an ethical obligation to intervene in a timely manner to ensure that impaired colleagues cease practicing and receive appropriate assistance from a physical health program, and to report impaired colleagues in keeping with ethics guidance and applicable law." Reporting is mandatory and is generally made to the state's physician health program (PHP) (which oversees the management of impaired physicians) or the state licensing board. Physicians should inform supervisors and directors of training programs. Reporting to the PHP or board will likely still be required. Physicians are also ethically obligated to intervene to stop a physician who is treating patients while impaired. Physicians are often reluctant to report impaired colleagues, fearing that they will destroy their colleagues' careers and reputations. However, not reporting continues to put patients at risk and increases the long-term adverse sequelae of substance use for the impaired physician and his or her family. It is important to note that the vast majority of physicians referred to PHPs (including those attending involuntarily) have positive outcomes. (Choice A) The significant risk of harm to the resident's patients overrides his right to privacy. (Choices B and E) It is not the role of the physician to ensure that the resident receives treatment. Coercive treatment (eg, ensuring treatment adherence under the threat of loss of medical license) and other interventions may be necessary, but these actions should be taken by the PHP or licensing board. (Choice C) This resident's ongoing substance use places patients at risk. The physician should not wait to report the issue. Educational objective: Physicians are ethically and legally obligated to report impaired colleagues to physician health programs or state licensing boards in keeping with applicable state laws. The primary ethical obligation is maintaining patient safety. References: Physician health and wellness. (http://www.ncbi.nlm.nih.gov/pubmed/16490794) Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners. (http://www.ncbi.nlm.nih.gov/pubmed/25442757)

Question 19

A 39-year-old woman with a family history of cancer undergoes genetic screening.  She tests positive for one of the genes known to cause hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome.  The patient is concerned about her diagnosis but is consoled after a detailed discussion with her physician regarding cancer screening.  At a follow-up visit, she mentions that she is being considered for a promotion at the large investment firm where she works.  The patient fears that she will be passed over for promotion or her medical insurance will be terminated due to her test results.  The physician explains that medical information cannot be released without her permission, but she remains worried.  Which of the following is the most appropriate response to the patient's concerns?

Accepted Answer

Explanation: Lynch syndrome is the most common inherited cancer susceptibility syndrome and greatly increases this patient's risk of colorectal, uterine, and other cancers. Her concerns about discrimination are reasonable and common among patients who are offered genetic screening. After cost, fear of insurance discrimination is the second most common reason for refusing genetic testing. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits discrimination by health insurers and employers on the basis of genetic information. The law defines genetic information as an individual's own genetic tests, the genetic tests of family members, or knowledge that a family member has a genetic disorder. Employers and health insurers are prohibited from requesting genetic information or requiring a person to be tested. If employers already have such genetic information on file or if the employee volunteers to release the information, it is illegal for employers or health insurers to discriminate on the basis of this information. This patient should be educated about the GINA to alleviate her concerns. (Choices B and E) Although it would be helpful to reiterate that both the patient's medical history and genetic testing results are confidential and cannot be released without her permission, educating her about protection from discrimination will more directly address her concerns. (Choice C) The GINA prohibits health insurers and employers from requesting genetic information. (Choice D) The patient's fears of genetic discrimination are legitimate. It is more appropriate to educate her about legal protections against genetic discrimination, regardless of her position of the details of her promotions. Educational objective: The Genetic Information Nondiscrimination Act of 2008 prevents employers from requiring or requesting genetic testing results of their employees. If an employer already has genetic testing information, the law prevents the employer from using the information to discriminate against the employee. References: Two cheers for GINA? (http://www.ncbi.nlm.nih.gov/pubmed/19348693) The Genetic Information Nondiscrimination Act (GINA): public policy and medical practice in the age of personalized medicine. (http://www.ncbi.nlm.nih.gov/pubmed/22314637)

Question 20

A 65-year-old man is hospitalized due to 3 days of shortness of breath that progressively worsened to the point that he was unable to walk up the flight of stairs to his apartment.  He is diagnosed with an exacerbation of chronic obstructive pulmonary disease.  A chest x-ray reveals a large hilar mass, and a subsequent CT scan confirms the presence of a 4-cm mass in the right hilum, suggestive of lung cancer.  Medical history also includes hypertension, depression, and osteoarthritis of the right knee.  The patient's sister, who lives nearby and visits him weekly, tells the physician, "My brother has not been taking care of his health.  He smokes and eats a lot of junk food.  He refuses to exercise and does not take his medications every day.  It is no wonder he got sick."  The patient responds, "I know I should eat better, but it is hard to break old habits.  What is the point of living longer if I can't enjoy anything?"  He reports that he usually takes his medication every day but sometimes forgets.  When asked for permission to perform a bronchoscopy and biopsy, he says, "Please don't tell me what they find because if it's cancer I don't want to know."  Which of the following is the most appropriate response to this patient's request?"

Accepted Answer

Explanation: Just as patients have the right to refuse medical care and interventions, they also have the right to refuse knowledge of their diagnoses or other facts about their medical conditions (principle of autonomy). Requests not to know may be based on culture or religion, or may result from a patient's fear of a morbid diagnosis. The initial approach to the patient who declines to be informed should be a nonjudgmental, open-ended discussion about the patient's concerns and reasons for refusing. For example, the physician may be able to allay a patient's fears by providing more information about possible diagnoses or outcomes, or to encourage the patient to discuss the situation with family or friends before making a final decision. It is also important for the patient to be made aware of the possible risks of refusing knowledge of a condition. If, after further discussion, this patient is adamant that he does not want to know his diagnosis, the decision must be respected by the physician. (Choice A) This response assumes that depression is the reason for the patient's decision, based on his psychiatric history rather than his competent input, and is likely to seem condescending. An open-ended discussion about the patient's concerns should occur before determining whether psychiatric referral is necessary. (Choice B) This response is paternalistic and does not respect the patient's right not to know. It conveys that only the physician (not the patient) knows what is in the patient's best interest. (Choice D) If patients are not competent to make decisions or prefer that someone else make medical decisions for them, a surrogate decision maker can be identified. However, there is no evidence that this patient is not competent to make decisions. The first step is to understand his concerns before suggesting that a surrogate be found. (Choice E) In general, physicians are obligated to share all health information with patients so they are fully informed before making health care decisions. However, in this case, a competent patient is specifically requesting that he not be told his diagnosis, and the physician must respect that decision. Educational objective: Patients have the right to refuse knowledge of their own medical information and diagnoses. In such cases, the first step is to explore their concerns and reasons in a nonjudgmental fashion before they make their decision. References: The history of autonomy in medicine from antiquity to principlism. (http://www.ncbi.nlm.nih.gov/pubmed/28601921)

Exam 2: Foundations of Independent Practice