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NBME 22 Answers

nbme22/Block 4/Question#7 (reveal difficulty score)
A 27-year-old man comes to the physician for ...
Ask the patient to identify the pros and cons of smoking cessation πŸ” / πŸ“Ί / 🌳

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submitted by βˆ—cocoxaurus(58),
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submitted by euchromatin69(15),
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brise  I can't find this!? +  

submitted by βˆ—madamestep(4),

The way I think of motivational interviewing is that the goal is you want the patient to convince themself. So the goal is to get THEM to tell YOU the arguments for why they should quit.

The patient knows that smoking is bad for them. They have weighed out pros and cons in their mind and they're stuck at "I'm still going to smoke." Smoking HAS PROs: It feels great, reduces anxiety, they're used to it, and if they were to quit they'd go through awful withdrawals. But the patient also knows that there are cons. It's going to kill them.

If you start listing all the reasons why it's bad for them that they already know, they'll want to balance out the argument for why they still smoke. You're saying the cons, so they feel the need to justify the pros. BUT if you ask them what smoking is doing for them that's good, they'll feel the need to justify the cons: "Well it helps with my anxiety, but I know that's not a good enough reason to keep smoking." You can also have them argue your side by talking in the extreme in the opposite way: "So you'd NEVER see yourself quitting?" "Oh no of course I want to quit eventually!"

Here's a good list of questions to ask in each stage:

madamestep  Also people will believe the things that come out of their mouths! That's why you shouldn't tell yourself "I'm so dumb, I don't know anything" before a test. You'll actually do worse. So tell yourself you know lots of information and you'll do great before the Big Test. +  

submitted by marbledoc(0),
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someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +7  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +7  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +1  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +3  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +4  
destinedfx  ^ you're right but doctors are socially retarded at times +  

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