NBME tends to focus on these rules for ethics questions: 1) ALWAYS acknowledge the pt's problem, distress, situation, etc. 2) NEVER ask the pt to lie 3) NEVER be a dick. The answer may sound robotic, but should never be mean. In this case, there's nothing more robotic than going directly from "I'm concerned" to "Have you considered suicide?" 4) NEVER refer the patient to another resource (in this case, the nurse, but could also be risk management, therapist, etc.) 5) COMMUNICATE with other clinicians/experts, etc. to resolve issues. Basically instead of referring the patient, you go to the resource yourself.
what I got from this question: NEVER (99% of the time) refer a patient to see anyone
This is a postpartum mood disturbance, a pretty common disorder that has to have an onset within 4 weeks of delivery to be termed as such. Postpartum blues is the most mild, with a 50-85% incidence rate (per FA 2018), usually resolves within 10 days and treatment is only supportive but need to follow-up to assess for possible postpartum depression. Postpartum depression = 10-15% rate, characterized by depressed affect, anxiety, poor concentration for greater than 2 weeks and needs to be treated w/ CBT + SSRI. I think the question is getting at screening for this and a potentially more problematic complication, postpartum psychosis.
SIGECAPS criteria: (1) feeling weepy/overwhelmed, (2) fatigue/irritability, (3) anhedonia, (4) difficulty sleeping, (5) "I feel guilty...", for a period of 6 weeks = meets the criteria for a depressive episode, and since this was in the post partum period, may be post partum depression.
Next best step is to screen for suicidal ideation/thoughts of harming the child.
"Has it come as a surprise to you how hard parenting is? Many people feel that way." I don't think this validates their feelings, and it would make someone feel badly if you said "hey everyone deals with this shit". Also this answer focused on parenting, rather than the psychiatric concern (postpartum depression).
"im concerned about how bad you've been feeling lately". I think this does acknowledge their feelings, and does show that the physician is engaged. Yes, its blunt. But at its worst, its still more complete than the other ones.
Tough question based on you're reading style.
I totally get how asking about suicide, and asking about it directly is important. But my confusion is how this answer doesn't provide any good segue. I went with "has it come as a surprise..." because i figured that would lend itself nicely to the patient opening up. When i feel it is appripriate, i would then bring up the conversation about self-harm, harming the baby, and suicide. But as its written, the patient tells you they feel shitty, and the physician very directly says "wow you feel pretty shitty". Seems very insensitive and not optimal for honest communication.
submitted by ∗yotsubato(1208)
Well thats a really crude way to screen for depression...