If there are two things that scare medical students right out of their boots, it is board exams and not having enough information. Bad news for those who like good news in this case, as the USMLE Step 1 and Step 2 have expanded questions about communication skills and ethics. Medical school curriculum does not typically spend a lot of time teaching and reviewing communication skills, so oftentimes it comes down to the individual student to fill in this hole.
Timing & COVID-19 Impact
Originally (per the official November 2019 update), the USMLE planned to increase the number of Step 1 test questions assessing communication skills on May 4th, 2020. However, per the official USMLE update on April 22nd, 2020, this change has been delayed until "at least June 1, 2020." (If you're not already doing so, we strongly recommend following the USMLE's official announcements and updates.)
How to Approach Communication Skills & Ethics Questions on the USMLE
The best way to approach ethics and communication questions on the USMLE is to realize that multiple choice questions are woefully inadequate at capturing complex clinical and ethical situations.
The world of board exams is very black and white and doesn't leave room for the grays that make up normal medical decision-making. Often test writers take advantage of that by offering answer choices that seem very reasonable but yet are not compatible with the science foundation they’re drawing from.
USMLE Ethics & Communication Skills Sample Questions
1. A 29 year old male with past medical history of systemic lupus erythematosus comes to the emergency department with altered mental status. Patient was found down in his home by a neighbor and then called 911. The workup reveals that the patient is profoundly hypotensive and is intubated for airway protection and admitted into the intensive care unit. A diagnosis of disseminated intravascular coagulopathy is made. Despite aggressive resuscitation, the patient passes away in the evening. The physician on call is calling the family to inform them about the news. After introductions, which of the following is the most appropriate statement by the physician?
A. "I am incredibly sorry to report that your family member has passed away. Rest assured, we did everything we could."
B. "What do you know so far about your family members' condition up to this point?"
C. "Your family member had a condition called disseminated intravascular coagulopathy that caused him to be very sick".
D. "How is your evening? I hope that so far it has been well".
E. "Are you familiar with your family member's history of lupus?"
This is a pretty classic communication skills USMLE question. All that's needed to answer this question is basic knowledge of how to deliver bad news using the SPIKES protocol.
Before giving concrete information, it is often best to elicit what the family member already knows. This will help to prevent any surprises, such as mismatched expectations. In addition, it provides a natural transition point to begin talking about the update you are about to give them.
Choice A is a good sentence but would be better suited to later in the conversation. The same could be said of choice C. Choice D doesn't approach the topic at hand, while choice E would be helpful after eliciting how much they know.
For questions like this, make sure to have the background knowledge and then apply it systemically like any other question. Many questions like this can have the answer teased out by the way it's constructed. Most correct answers in communication questions use soft and empathetic language such as choice A which would be valuable later in the conversation.
2. A 87 year old male with a past medical history of hypertension, chronic kidney disease, and Alzheimer's disease comes to the emergency department with his wife and son. The family members note that he has become increasingly altered over the past two or three days and now is not responding to questions appropriately. A full workup is done and reveals urosepsis. The patient is given fluid, antibiotics and is admitted to the floor where he begins to decline, requiring bedside dialysis. A family meeting is called by the treating physician. The patient has designated his son to be the healthcare power of attorney. The son does not want the patient to be intubated or kept on artificial life support. The wife would like all things to be done for her husband. They agree to an additional family meeting after the weekend. However, in the interim the patient declines and is in respiratory distress likely requiring intubation in the next hour. The covering physician calls the son who reiterates his desire to not have his father intubated. What is the next best decision in management?
A. Attempt to call the wife and get a consensus not proceeding with intubation.
B. Attempt to arrange a multi-line call with the son and wife.
C. Intubate the patient and attempt to achieve family consensus in the morning.
D. Do not intubate the patient.
E. Call the admitting physician for further clarification.
This is a classic ethical question where you have to try and draw black and white lines into a gray scenario. Students often get into trouble choosing the answer that seems right for the clinic but not on the exam. For example, choices A, B, and E are reasonable in a clinical scenario and may occur in real life. However, on the exam the decision made by the authorized decision maker is final and answer choices reflect that.
How to Study for Communication Skills & Ethics Questions on the USMLE
Now that these questions are not as scary as they sound, how do you prepare for them? For my students, the gold standard is still UWorld.
Do not fret if you get a bunch of silly questions wrong while doing these sections in the beginning. Getting these questions right requires doing them so that you've seen many different scenarios and how you are supposed to handle them. For those who still need additional training, Medical Ethics for the Boards by Conrad Fischer is an excellent resource, as is Case Files Medical Ethics and Professionalism.
However, make sure to go through all of the UWorld questions twice here before spending money on additional resources. One will often see that the second time around most of the concepts have clicked and students see a big jump in their ability to answer these questions.