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NBME 24 Answers

nbme24/Block 4/Question#24

A 13-year-old girl who has a 6-year history of type ...

Discuss further the impact of the patient's illness on the family

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submitted by nwinkelmann(187),

I just thought of a way to (hopefully) avoid getting these types of answers wrong. First, when I read them I always look for the least "asshole" answer. Then, if you're still stuck, try to put the statement into a quote that you would say to a patient as a physician, remembering that open-ended, non-judgmental questions are ideal.

The answer for this could be phrased as a question/statement by the doctor, to the family, as "Tell me more about how this impacting your family and daily life." Had it been phrased like that, I DEFINITELY wouldn't have gotten it wrong. I would have never even had the opportunity to make an assumption about the family's fighting being due to diet concerns and thus needing a nutritionist referal (which is what I chose).

usmile1  I think the reason dietician was incorrect is because she has had diabetes for 6 years and her diabetes was well controlled that entire time. Then for the past two months her glucose control has been poor. This is pointing towards the issue NOT being that they don't know how to manage the diabetes so referring to a dietician wouldn't be useful. +1  
tiredofstudying  99.99/100 times the answer will never include referral. The only reason I do not say 100/100 is because there may be an answer one day that is to refer, but through all of UW, Rx, and NBME it has never been to refer, so do with that info what you will +  




Ugh... got tripped up with "Refer both patient and her parents to a dietician"

Over thinking...I thought the source of their arguments were at meal times especially...so maybe they can find a good solution with a dietician.

OCCAMs RAZOR THIS SHIT. keep it simple stupid. The answer fits the best after re reading it.

nwinkelmann  SAME.... ugh! +  
johnson  Also - you're almost NEVER referring/passing on a patient with the USMLE. +6  
bmd12  They are at meal times, which is why she's having difficulty following the prescribed diet bc her parents are arguing during that time so its difficult for her to correctly execute it when theyre constantly bickering, and bc she's only 13 so she cant effectively manage her diet without the help of her parents. And since the diet has been working with the patient prior to all the bickering, you can assume the diet is not the root cause. +  




To get such vague questions right:

  1. Consider saying all the statements in the snarkiest tone possible under your breath (translate to mother tongue if IMG for bonus effect).

"Stop Bickering" - while saying, don't you get a hint of paternalism, like the doctor treating the parents as teenagers themselves. They are fully grown-up themselves; they know they shouldn't bicker!

  1. Don't choose the refer option on Step 1 (99% of the time correct).... unless no other option at all fits your case first UWorld has questions going to court as the right answer even! But in all of them, it was evident that no other option could come close to being polite/nice/ethical/legally correct.

  2. Options that say - encourage/endorse/discuss/ask - are always preferred. Communication = Key Questions





Shouldn't we first address the issue by correcting her glucose levels by readjusting insulin and then see what are the problems?





The diet is prescribed, so no need to refer to dietician anymore. It is a case of the patient non-compliance of diet. But why can't advise the parents to stop bickering?