Step 2 CSのchallenging questions〜その①

USMLE Step 2 CSでは、challenging questionsといって、患者役がわざとこちらを困らせるような質問をしたり態度をとったりすることによって、こちらの対応力を評価することがあります。私のような英語が苦手な日本人にとっては、臨機応変に対応することが難しいこともある分野だと思います。様々なchallenging quesionsに対する「答え」をまとめた、シリーズ①です。参考にしてください。

Challenging questionsの基本

基本的には、challenging questionsに対しては、1. 患者の意見や感情に共感（empathy）し、2. その行為を正当化（validation）し、3. 質問に答え、そして4. 次に進む（move） 、という流れになります。

1. Empathy

I understand your feelings/concern/situation.

2. Validation

Many of my patients with similar problems (in this situation) have felt the way you did.

3. (Answer or) Safety

On the basis of the information I’ve gathered from you so far, I think XXX.

4. Move

But to answer your question (deal with your concern) confidently, I need to take more histories/ perform physical exam/ let me finish taking history.

I’ll figure out what is wrong. /  I’ll do everything I canto help you get through/overcome this. / We will do the best for you.

There is no reason to be unnecessarily concerned at this time / There is no reason to feel embarrassed about it. The most important thing is that you are here now. Let’s work on this together.

 

特に、この”3″に関してはそれぞれのchallenging questionsに対して個々の答えが必要になることもあります。以下の解答例（対応例）を参考にしてください。

 

病歴聴取中のchallenging questions

カルテとは別の名前を名乗った場合

I think the nurse must have given me the wrong chart. Hello, Mr.XX.

 

入室時より怒っている患者

I can see you are angry. I know that it is hard for you to wait for me in the room. I’m here for you now and I’ll focus on you and your concern.

 

急に怒り出し、「Do you suspect me?」と言い始めた時

No, but I have to know it to be able to treat you correctly.

 

入室時より咳が止まらない/ティッシュで鼻をかんでいる患者

Are you all right? Can I see it? I’m going to do anything that makes you better.

 

「I can’t breathe」と苦しそうにしている患者

Is there other position that makes you feel better? Let me help. Your oxygen in your blood is not enough. Let me give you oxygen. I’ll do and finish taking history and doing physical exam as quickly as possible.

 

「Give me oxygen！」と叫んでいるCOPD患者

You had COPD. Giving (unnecessary) oxygen may stop your breathing. Let me give you necessary and sufficient oxygen.

 

泣いている患者

Can I ask you the reason you’re crying? Can I continue to ask you?

I’m sure you tried your best.

It’s not your fault. It’s a medical problem.

 

何度も質問を繰り返す患者

Can I ask you the reason you repeat my questions? Please do not repeat my questions just to save your time because it’s very important for me.

 

「I cannot understand you. Call another doctor.」と言う患者

You know that I am a foreign doctor and my accent is a little bit strange. I’ll try to do my best to make myself understandable and do the best for you.

O.K. It’s your right, but I’d like to tell you that I’m a well-qualified doctor and I can help you to overcome your problem. Could you give me a chance?

If you still feel this way (the same way) at the end of our meeting, I can arrange for you to see a different doctor.

 

病歴聴取から身体診察に移る際、手を洗っている時に話しかけてくる患者

Please wait a minute. I’d like to give you my full attention.

 

「トイレに行きたい」と言う患者

Of course, you can. Do you need any help?

 

質問に答えない or ただ歩き回るだけの患者

I’m your doctor and anything you tell me will be confidential.

I can only imagine how any patient in your situation might feel, butif you don’t speak with me, I will not be able to help you. Please have a seat /answer my questionsand help me determine what is going on.

 

Domestic violenceが疑われるが、何もないと嘘をつく or 答えない患者

First try: You look anxious/nervous. Is there something you would like to share with me/bothering you?

Second try: You look anxious.I’m concerned about your safety. (Your health/safety is very important/our priority.I want to make sure that you are in safe environment.) Anything you tell me will be confidential. Please feel free to answer my question.

Although you might not want to talk about this right now, I want you to know that if there is any chance that you are being abused, you should be safe.Whenever you need help, I’m here for you. We can provide a shelter for you.

 

身体検査を拒む患者

Can I ask you the reason? That is so important physical examination. I’m unable to give the final diagnosis without this.

 

関係のない話を喋り続ける患者

Today I want to focus on your XX. During your follow-up, we can discuss all your other concerns.

 

「問題ない」「年のせい」と意に介さない患者

Age might play a role in your symptom (You might not have any diseases), however there are some medical conditions that I need to rule out. Let me do …..

 

「死にたい」「私の人生なんて、、、」と悲壮な患者

I understand your feelings. Life can be sometimes challenging. Is there something in particular that is bothering you?

 

自分が知らない薬の名前などを言ってきた場合

I don’t have the information you’re looking for. Let me ask my supervisor and come back to you with the answer.

 

HIVに関する質問をする患者

Why are you concerned about HIV? Would you like to run the HIV test?

 

薬や痛み止め、早急な治療を求めてくる患者

I understand you are in pain/uncomfortable.

Before I give you medication (treat you) (I talk to your employer), first I need to know exactly what is causing your problem. I’ll take your history and perform physical examination quickly. After that, I’ll give you an appropriate medication/treatment / I can write a letter to your employer explaining your situation.(as soon as we reach the final diagnosis).

I’m afraid I can’t do that right now. (For now, let us work together to make your health better.)

 

Sexual dysfunctionを訴える患者

I’m sorry to hear that.

I know what’s going on with you. Better control of your DM. We can give you medication to enhance your performance.

 

薬の処方を求めてくる患者

Chronic disease: I cannot do it without examination. Need to know your condition. We need to see periodically patients with chronic medical disorders. Might need to change the medication or the dose. I’ll examine you and then I will give you a new prescription.

New disease: Every medicine has side effect andcan be more harmful than helpful. I want to be sure you need the medication. Let me do ……

 

「Am I fat?」と聞いてくる患者

I cannot tell right now. I have to measure your height and weight, and then I can calculate your BMI and discuss this with you.

 

「Am I crazy?」と聞いてくる患者

There is no such diagnosis in medicine. I think you have an organic problem (that may be) in your brain or in your mood, and hopefully we can fix it.

 

病院受診が遅すぎたのかと聞いてくる患者

It is never too late to seek help. The most important thing is that you are here now. I’ll do my best for you. But the next time, I want you to feel free to come to me as soon as you think you have a problem.

 

「なぜPre-employment examが要るのか」と聞く雇用前の検診患者

Employers routinely request medical examinations to ensure that potential employees arefit for the job and to check if they have any transmitted disease. I’ll perform physical examination and do some tests. Hopefully, everything is fine.

 

「Jaundice hurts my baby?」と聞く患者

Depend on the disease and severity. Mild jaundice rarely cause damage to his brain. Severe jaundice can cause. I recommend you bring ….

Physiologic jaundice usually peaks on day 4-5 after birth and then gradually disappears within 1-2 weeks.

 

しきりに時計を見る患者

I can see that you are constantly checking the time.I understand you are concerned about it. I’ll take history and physical exam as quick as possible.

 

途中で具体的な診断名（ex. HIV）を尋ねてくる患者

Why are you concerned about XX? Why are you asking about XX?

Your symptoms might be related to XX. (I hope not, but it is a possibility.) Before I can confidently answer your question, I need to know exactly what is causing your problem. Let me get some blood sample and take some images. (HIV: Only testing will confirm it. I need to do more accurate tests.)

If it turns out to be something serious, I will be there to help you and come up with a good plan to treat you.

Your symptoms are unusual for XX. No need to be unnecessarily concerned./ We need to exclude the disease.

 

まとめ

Challenging questionsを無視したら減点されます。本番で困らないよう、しっかりと対応できるよう備えてください。シリーズ②もありますので、ご期待ください。