DocCom 14, 18, 19, 29 Flashcards
Sharon Cane is an 8 year old girl of German descent, in your office with her parents. You borrowed an extra chair from the next office, and Sharon positioned herself near the window. As you begin the interview her parents lean forward and explain that Sharon has been having stomach aches, and that something needs to be done because she is missing school so often. They interrupt one another and escalate in volume to almost shouting. Which intervention best demonstrates “matching and leading” in relation to the parents?
A. Walk over to Sharon, stand next to the window and ask her: “How are you feeling?”
B. Lean forward, look each of the parents in the eye, and softly say “Let’s let Sharon talk first.”
C. Ask Sharon to sit next to her parents since the discussion is all about her.
D. Walk over to Sharon and gently guide her to the empty chair, asking her to sit down.
E. Lean back in your chair and softly say “Let’s give Sharon a chance to describe the problem.
B. is correct. By leaning forward (as the parents do) the clinician can “match” their behavior. Changing the tone of voice to softly is “leading.” Clearly Sharon is the focus, but her parents have an important role and should not be excluded by ignoring them (A. or D). E is a second best strategy if “matching and leading” does not work, with A,D or C less appropriate non-verbal interventions.
Tom Pawlak is a 48 year old of Polish descent, in the ER because he was “spitting up blood.” As you go into the cubicle, Mr. and Mrs. Pawlak look up anxiously and quietly say hello. Mr. Pawlak has his arms crossed over his chest and his hands are gripping his elbows. Mrs. Pawlak is sitting in a chair at the foot of the stretcher, resting her right elbow on the stretcher while her left hand is gripping her handbag in her lap. Which behaviors are recommended for establishing rapport with both Tom and Mrs. Pawlak?
A. Fold your arms and quietly introduce yourself.
B. Hold out your hand to Tom and clearly say hello.
C. Hold out your hand to Mrs. Pawlak and clearly say hello.
D. Wave hello and clearly introduce yourself.
E. Put your hands into your pockets and quietly introduce yourself.
A. is recommended. When receiving non-verbal clues that a new patient does not feel “safe” it is useful to match the patient’s behavior. In Tom’s case matching his crossed arms is appropriate, along with a friendly but toned down introduction. Initiating a touch or being too friendly upfront (as in B. C. and D.) is likely to feel inappropriate if patients are in physical or emotional pain and distressed (as with Mr. and Mrs. Pawlak, or if you are about to reveal bad news.
Maria Correa is a 86 year old widow of Cuban descent, whose pneumonia has responded well to treatment in hospital, and you think she may be able to go home soon. You need more information about her living situation at home to plan for home health care, and remember that she has already said she does not like strangers in her house. You also need to check her lungs and other physical findings to be certain that she is ready; right now she seems very relaxed and clearly feels “safe” with you. What is your recommended position/ posture when asking about her home situation, an issue that may be difficult for her?
A. Stand next to the bed and hold her hand.
B. Stand at the foot of the bed so that the patient can look straight at you.
C. Lean against the window sill to signal that you expect a lengthier conversation.
D. Move the chair at the head of the bed so that so that both of you are looking in the same direction and sit down.
E. Move the chair at the head of the bed so that so that you look at Mrs. Correa and sit down.
E. Is recommended. Sitting down so you are at eye level eliminates a power differential. Sometimes, looking in the same direction (D) is advantageous, but here it would be awkward for Mrs. Correa to maintain eye contact with you, and it would limit your opportunity to observe her non-verbal reactions. Sometimes, patients feel more comfortable if you hold their hand (A), but that is more risky when you are having a complex discussion, and could be felt as a pressure tactic.
Joshua Reynolds is a 35 year old married man of British descent, in your practice for over 3 years with puzzling stomach problems, here today to follow up on the GI series he had last week–the results are within normal limits. He gave a mixed message when you asked him about how things are at home, quickly saying “Fine,” but lowering his voice and crossing his arms. Which of the following options would be recommended for your response?
A. Say, “I’m glad things are going well at home but let me know if there are any changes.” Then move on.
B. Attribute the posture and tone to his physical discomfort because he has had a stable home life all along, and then move on.
C. Say, “If you are having troubles at home it would be good for me to know,” and then wait for him to respond.
D. Lean forward and say, “Tell me a bit more about what’s been happening at home.”
E. Cross your arms, lean forward and say, “You are telling me that home is fine but you look rather concerned. Can you tell me a bit more about what’s been happening at home?”
E is recommended. Within mixed messages, the non-verbal aspect is more likely to be accurate than the verbal one. Verbalize your observation about the mixed message and match the patient’s behavior in order to build rapport and more swiftly enhance understanding. A and B ignore the non-verbal component. Mr. Reynolds may not understand why the physician expresses doubts in C and D, and therefore may be reticent to share underlying concerns.
Ken Maloy is the husband of a 30 year old Caucasian woman who was in a car accident and died as she arrived at the hospital. As soon as her identity was established, Mr. Maloy was told that his wife had a very serious accident and that he should come to the hospital immediately. He was not informed that she died. You must give him the bad news, and have introduced yourself and quickly led him into an empty office. You asked him to take a seat, moved your chair a bit closer, slightly leaned towards him and then said, “I’m sorry I have bad news for you. I have to inform you that your wife was in a serious car accident and died just before she arrived at the hospital.” He sits back and screams. What is the recommended way to proceed?
A. Reach out, hold his hand and gently say, “I understand that this is a great shock for you.”
B. Touch his upper arm and state softly, “This must be terrible for you.”
C. Continue to slightly lean towards him and remain silent until he has a chance to fully express his initial shock.
D. Stand up, put your hand on his shoulder and say, “I’m ready to help you in any way that I can, in this terrible moment.”.
E. Continue to slightly lean towards him and ask, “Is there anyone I could call for you?”
C. is recommended. Mr. Maloy is in shock and needs time to collect himself. Leaning towards him in an attentively and waiting for him to indicate his readiness for more interaction with you is likely to be helpful. Many people feel a strong inclination to comfort him, both verbally and non-verbally, but chances are good that he will feel this as intrusive, or be entirely unable to perceive comforting of any kind, until he indicates readiness. Many people will experience these attempts as invasive.
Gary Brown is a 27 year old single man of Nigerian descent, in your office for the first time because he has been experiencing diarrhea and night sweats and generally feeling unwell for the past month. You thoroughly explore his complaints and the story of his illness, and have just begun asking more about his sexual history. Mr. Brown maintained good eye contact until you asked about sexual orientation, and then looked down and noticeably lowered his voice. He answered “I’m straight.” Which of the following options is recommended to help address the mixed message?
A. State: “Talking about sex is uncomfortable for many people, and in this situation it is important for me to fully understand your current life situation.”
B. Say, “Let’s move on to other details and I’ll return to this issue a bit later.”
C. Lean forward a bit, and remain silent to give him time to elaborate further on this sensitive topic.
D. State: “Understanding your sexual preferences and activities is a key part of making a good assessment of what might be going on here..”
E. Rest your head on your hand to mirror the patient’s non-verbal behavior and ask for more details.
A. is recommended. Legitimizing (m6) verbally the discomfort the patient is expressing non-verbally might put him more at ease about disclosing his sexual history. Mirroring (E) may not work since the patient has withdrawn significantly, is looking at the floor and may be less aware of your nonverbal cues. Shifting the topic temporarily (B), or just waiting (C) might work, but does less to assist with his discomfort as expressed in a mixed message. D is “just the facts” and does not acknowledge verbally or non-verbally the emotional content of the situation.
Mandira Das is a 33 year old married woman from India, your patient for 2 years. You just confirmed that she is 8 weeks pregnant and Mrs. Das is elated. She has suffered because of 5 early miscarriages, and never before made it to 8 weeks, so she is hopeful that this time she will have a baby. Unfortunately, given her medical history, you feel you’ve an obligation to caution her. You are sitting at your desk and she is sitting at the side of your desk, with her right hand on her left shoulder. What is the recommended approach?
A. Get up and put your arm around her shoulders stating “I’m glad you are so happy but we are not quite out of the woods yet.”
B. Move closer and hold her left hand which is resting in her lap and tell her “I’m glad you are so happy but we are not quite out of the woods yet.”
C. Smile at first and then transition to a more serious facial expression stating “I’m glad you are so happy but we are not quite out of the woods yet.”
D. State simply, “I’m glad you are so happy but we are not quite out of the woods yet.”
E. Lean backwards, cross your arms and state “I’m glad you are so happy but we are not quite out of the woods yet.”
C. is recommended. “Match” the patient with a smile about the good news and then non-verbally “lead” into a more serious aspect of the conversation with a new facial expression, in order to stay in rapport. Putting an arm around her shoulder or taking her hand (A,B) are undesirable at this time, as by crossing her chest with her arm the patient has taken assumed a protective posture.. E may be interpreted as withdrawal from the patient or her situation, and experienced as unsupportive. D is “just the facts” and does not utilize any non-verbal cues to show your concern and involvement.
Kim Park, a 25 year old woman of Korean descent, is in for an initial visit, and needs a physical for her new job as a kindergarten teacher. When you asked about heart disease in the family, her mood changed dramatically, and she told you that her father is still in intensive care, after a heart attack a week ago. Her voice is almost a whisper, her hands are crossed in her lap, and she is staring at the floor. You would like to hear more about this situation. What body posture is recommended, as you quietly tell her that you are sorry to hear bout her father’s illness?
A. Slightly lean back.
B. Stand up, reach out and touch her shoulder.
C. Move your chair closer and lean towards her.
D. Slightly lean towards her, cross your hands and rest them in your lap.
E. Slightly lean forward and place the tissue box right next to her.
D. is recommended. Leaning forward and mirroring her non-verbal gesture will likely strengthen rapport. Pushing for emotional expression by providing tissue before she is crying (E) could be felt as intrusive. For personal or cultural reasons many patients do not feel comfortable showing strong emotions, especially at an initial “routine” visit.
Kathleen Baker is a 15-year-old high school student of German extraction. She comes in with her mother for a preventive health appointment. During the interview you ask Kathleen if she is sexually active. She looks toward her mother and denies sexual activity. What is the recommended option for obtaining accurate information about her sexual history?
A. Explain the importance of this question for the patient’s health.
B. Ask about sexual activity again when Kathleen’s mother is not in the room.
C. Ask what Kathleen is feeling at this point in the interview.
D. Explain the meaning of the phrase “sexually active” and ask again.
E. Make a note to ask about sexual activity again when Kathleen is older.
B. is recommended. Asking a teen about sexual activity in front of parents is a poor strategy. To overcome the mistake, legitimize the patient’s response (“this question is often difficult for teens to talk about”) and continue the interview. Revisit the issue of sexual activity and assure confidentiality when Kathleen’s mother is absent, perhaps during the physical exam. Waiting until she is older (E) is not appropriate since very many 15-year olds are already sexually active
- James Brown is 73, an African American retired police officer in for follow-up of a prostate nodule. He is recently remarried–his first wife of 43 years died from breast cancer 3 years ago. Now, his PSA test is elevated, and you suggest a biopsy. In talking with him about treatment options he says that he is “unalterably” opposed to a prostate biopsy or treatment. What statement or question is most highly recommended for furthering Mr. Brown’s care?
A. “I hear what you are saying; I’m wondering if you have concerns about how a biopsy or treatment might affect your sexual functioning or sexual health?”
B. “I hear what you are saying; I’m worried about the seriousness of your situation, because untreated prostate cancer can spread to your spine, lung, brain or bowel; become terribly painful, or cause your kidneys to shut down, among other problems.”
C. “I hear what you are saying; what do you already know about prostate cancer and what it can do to you, what treatment might achieve, and what the side-effects of treatment might be?”
D. “I hear what you are saying; would it be helpful to have your wife join us for further discussion, because there is a lot we have not yet discussed?”
E. “I hear what you are saying; I’d like to arrange for you to speak with a colleague whom I trust, and who has much more experience with the details than I do.”
A. is recommended. “Unalterable” resistance often signals a strong emotional component and his recent marriage strengthens the possibility that he may fear losing sexual functions. In the future it may be useful to invite his wife as well (D) but the first step would be to explore the patient’s own concerns. Health problems in areas that relate to sexual attractiveness/desirability or functioning (e.g., prostate, breast) should trigger an early exploration of patient’s concerns and feelings, whether they signal the need (as Mr. Brown did) or not.
Christine Porter is 28, a married hair stylist of Anglo American decent who is in today complaining of vaginal discharge. She has been married for 5 years, says she is monogamous and thinks her husband is as well. They have sex frequently because for the last year she has been trying to get pregnant. After the physical and review of a vaginal smear, gonococcal infection is apparent, and immediate treatment of both partners is indicated. What is the recommended statement or question to begin to establish a treatment plan?
A. “It is clear that you have gonorrhea. This is an easily treated sexually transmitted infection. You or your husband has been unfaithful, otherwise you would not have gonorrhea.”
B. “It is clear that you have gonorrhea. This is an easily treated sexually transmitted infection. Your husband needs to go to his doctor to be checked out as well. If you have had sexual contact with anyone else that person (or persons) needs to get evaluated too.”
C. “It is clear that you have gonorrhea but I’m not sure what else is going on here. I can treat this easily, but your husband will need to go to his doctor (or come in here) so that he can give a specimen for cultures too. Then we can talk some more.”
D. “It is clear that you have gonorrhea. We will treat it and I advise you to use condoms in the future to prevent sexually transmitted infection.”
E. “It is clear that you have gonorrhea. We will treat it with antibiotics which should clear it up. I can give you more information, and there are some good Websites about sexually transmitted infections. I’ll give you the URLs.”
B. is recommended. The patient needs straightforward information. Passing judgment on lifestyles (A.) or avoiding sensitive issues (C,E.) is not useful. Sometimes people engage in activities that put them at risk for STI’s but they do not equate them with sexual intercourse (e.g., oral sex). The term “monogamous” may have a different meaning for the patient, and thus it is important to go beyond just asking about intercourse. Many states mandate reporting of sexually transmitted infections to the health department and initiate contact tracing. Thus, your patient is likely to be asked about sexual partners, and you should notify the patient of such regulations if appropriate.
Nicole Bovary is 30, of French descent. You are a male physician whose spouse recently filed for divorce, complaining that you are married to your work. Ms. Bovary is a very attractive new patient in for a routine check up; however, you have met her before because she is a legal assistant in the same office as your divorce lawyer. Early in the visit, she expresses regret about your upcoming divorce and reveals that she is also in the midst of a divorce. You were surprised to see her, and you definitely feel some attraction to her. As you converse about next steps after her unremarkable history and physical, she asks if you would like to go for coffee after work. What is the recommended strategy for responding to Ms. Bovary’s suggestion?
A. “What a lovely idea. I’d be pleased to have coffee, and we can continue our discussion outside the office setting.”
B. “What a lovely idea. I’d be pleased to have coffee, and we can continue our discussion. I’ll help you find another physician to care for your medical needs.”
C. “What a lovely idea. I’m afraid I must decline right now; and I’ll initiate conversation with a senior colleague with more experience in this kind of situation.”
D. “What a lovely idea. I’m afraid I must decline right now–let’s set up another check for next year, and of course contact us for any medical issues in the meantime.”
E. “What a lovely idea. I’m afraid I must decline right now. This seems a little inappropriate and I wonder if you would be willing to speak with your employers, or even a counselor, about limits in professional relationships?”
C. is recommended. Professional roles and boundaries are confused. Despite your feelings of attraction, your obligation is to maintain appropriate professional boundaries. The recommended response is to politely acknowledge but clearly decline Ms. Bovary’s invitation, and to obtain thoughtful input from trusted colleagues before the patient’s next appointment. (see M 41 for additional discussion of this key professional issue.)
Frank Caldoni is a 58 year old, married tax attorney of Italian extraction. A week ago he was hospitalized following a heart attack. Once he stabilized he confided in you that the heart attack occurred while he was visiting a prostitute and not a client, and that his wife of 30 years had no idea about his repeated extramarital sexual experiences. You then had a few days off, and are seeing him for the first time again today, when he is about to be discharged. You are a bit taken by surprise when Mr. Caldoni pulls you over in the hallway, and asks you in a whispering tone “do you think my system is still going to work?” You suspect that he is referring to his sexual functioning. What is the recommended way to respond?
A. Touch Mr. Caldoni on the arm and say, “Let’s step into your room, where we can have some privacy and I’ll try to respond to your concerns.”
B. Touch Mr. Caldoni on the arm and say, “This is a common situation, and after rehabilitation, people rarely have any problems having sex again.”
C. Touch Mr. Caldoni on the arm and say, “Look, just stick to your wife, because heart attacks occur more frequently during extra-marital affairs.”
D. Touch Mr. Caldoni on the arm and say, “This is a common situation, and the right thing to do next is to speak with your own primary care physician, who knows you well, as you begin your rehabilitation.”
E. Put your arm around Mr. Caldoni’s shoulders and say, “Let’s step into your room, so I can give you a bit more detail about the dangers of heart attacks during extramarital affairs.” (When in the room, add, “I think it would help to consider marriage counseling.”)
A is recommended. By moving the conversation to a non-public setting you will be able to provide confidentiality and put the patient at greater ease to discuss his true concerns. The patient feels comfortable enough with you to discuss his personal situation. Although your assumption is likely correct that Mr. Caldoni is worried about sexual functioning, it is necessary to clarify a cryptic statement like the one he made. The reassurance in B is too glib, C is a bit patronizing, D shows your own discomfort with this kind of concern. Putting your arm around him before you fully understand his concern (E) is ill-advised and, like B, C, and D, E also fails to express the value of fully understanding him.
Ken Quantas, a 35 year old single teacher of Cuban extraction, came in today because of a persistent cough and weight loss. After completing your history and exam, your differential diagnosis includes HIV-related illness. Which statement is recommended for exploring the HIV hypothesis?
A. “I know that you are feeling poorly. I’ll prescribe some effective antibiotics and check you again next week. If you don’t feel better then we’ll also need to talk about the possibility of HIV and I’ll need to know more about your sexual activity.”
B. “I know this is embarrassing, but I need to know if you have risk factors for HIV.”
C. “I am concerned that you might have HIV infection. Have you considered that this could be the reason for your persistent cough and unexpected weight loss?”
D. “I ask all of my patients about their sexual history. In your case, with persistent cough and unexpected weight loss, HIV infection is one possibility and that means we should discuss your sexual activity at this time.”
E. “I am concerned that you could have HIV. Let’s talk about the consent form for HIV testing.”
D. is recommended. D legitimizes the request for a sexual history (“I ask all of my patients”), and indicates the possible relationship between the symptoms and a diagnosis of HIV. Labeling something as “embarrassing” (B) can make it more difficult for the patient to talk about. To forgo a risk factor inquiry and go straight to the HIV testing consent form (E) could be confusing to the patient. On the other hand, announcing your concern, but not following up right now (A) raises anxiety levels, and many patients would find another physician asap, and / or put on pressure to report “improvement” at the next visit in order to avoid further inquiries.
Sandra Margolis is 50; a clothing store manager of Jewish extraction who had a double mastectomy and opted not to have breast reconstruction because her insurance would not have covered it. As her primary care physician, you are checking in on how she is adapting, a few weeks after she completed her treatments with the oncologist. She offers that she generally feels well, has gone back to work and is getting ready for a long planned vacation to Florida. You know that concerns about body image and sexual functioning are universal after this surgery. What is the recommended statement / question that would gently invite her to explore these issues?
A. “After a mastectomy many women have difficulties adjusting to their body changes. Do you plan to put on a bathing suit when you are on vacation? Do you still have intercourse with your husband?”
B. “After a mastectomy many women have difficulties adjusting to their body changes. Are you planning to go on the beach in Florida? How has your husband adjusted to your surgery?”
C. “After a mastectomy many women have difficulties adjusting to their body changes. How is your sex life? Has your husband already adjusted to the fact that you don’t have breasts anymore? It can be very difficult for some men to get used to it.”
D. “After a mastectomy many women have difficulties adjusting to their body changes. How do you feel about the loss of your breasts now? How does your husband feel about it?”
E. “After a mastectomy many women have difficulties adjusting to their body changes. Do you feel strong enough to resume your sex life with your husband? How is he adjusting to the situation? There are Websites with information that can help women in your situation.”
D. is recommended. Although each answer initiates the topic by normalizing the challenges common to women who undergo mastectomy, open-ended inquiry as in D is more likely to facilitate the exploration of feelings, and allow you to be helpful.
