Challenging Question

Possible Response

A patient who needs emergent surgery says, “I can’t afford the cost of staying in the hospital. I have no insurance. Just give me something to relieve the pain and I will leave.”

“I know that you are concerned about medical costs, but your life will be in danger if you don’t have surgery. Let our social workers help you with the cost issues.”

“Should I tell my sexual partner about my venereal disease?”

“Yes. There is a chance that you have already transmitted the disease to your partner, or he or she may be the source of your infection. The most important step is to have both of you evaluated and appropriately treated.”

An anxious patient who you suspect has been abused asks, “Why are you asking me these questions?”

“I am primarily concerned about your safety, and my goal is to make sure that you are in a safe environment and that you are not a victim of abuse.”

Challenging Question

Possible Response

A patient recently diagnosed with HIV asks, “Do I have to tell my wife?”

“I know that it’s difficult, but doing so will allow you and your wife to take the appropriate precautions to treat and prevent the transmission of the disease.”

A doorway information sheet indicates that the patient is Mr. Smith and that he presents with dizziness, but when you enter the room, you find a female patient.

Begin by saying, “Excuse me, Mrs. Smith?” When the patient responds, “No, I am Mrs. Black,” you can say, “Oh, I think the nurse must have given me the wrong chart. Hello, Mrs. Black. What is your problem?” You can then go on to discuss the patient’s presenting complaint, but remember that the vital signs listed on the doorway information sheet are those of a different patient, so you will need to take the patient’s vitals during the physical exam.

A female patient attempts to seduce her male physician by saying, “Doctor, do you have time to have dinner with me at my place?”

“I am sorry, but that would be inappropriate, since you are my patient, and it would not be permissible in the context of a doctor-patient relationship.”

Challenging Question

Possible Response

An elderly male patient says, “I think that it is normal at my age to have this problem” (impotence) or “I am just getting old.”

“Not necessarily. Age may play a role in the change you are experiencing in your sexual function, but your problem may have other causes that we should rule out, such as certain diseases (hypertension, diabetes) or medications. We also have medications that may improve your sexual function.”

“I read in a journal that the treatment for this disease is herbal compounds.”

“Herbal medicines have been suggested for many diseases. However, their safety and efficacy may not always be clear-cut. Let me know the name of the herbal medicine and I will check into its potential treatment role for this disease.”

Challenging Question

Possible Response

“I am afraid of surgery.”

“I understand your feelings. It is normal and very common to have these feelings before surgery. Is there anything specific that you are concerned about?”

A patient who has a serious problem (unstable angina, colon cancer) asks, “I want to go on a trip with my wife. Can we do the tests after I come back?”

“I know that you don’t want to put off your trip, but you may have a serious problem that may benefit from early diagnosis and management. Also, it is possible that you could suffer complications from this problem while you are on vacation if we do not effectively deal with it before you leave.”

“I did not understand your question, doctor. Could you repeat it, please?”

Repeat the question slowly. If the patient still doesn’t comprehend the question, ask if there is any specific word he failed to understand, and try to explain it or use a simpler one.

“What is a bronchoscopy?” (MRI, CT, x-ray, colonoscopy)

Explain the meaning of the term using simple words. For example, “Bronchoscopy is using a thin tube connected to a camera to look into your respiratory airways and parts of your lungs,” or “An MRI is a machine that uses a large magnet to obtain detailed pictures of your brain or body.”

“What do you mean by workup?”

“It means all the tests that we are going to do to help us make the final diagnosis.”

A patient who is late in seeking medical advice asks, “Do you think it is too late for recovery?”

“It is never too late to seek help, and I am glad you made the decision to pursue treatment options with me. We will do our best to help you, but next time I want you to feel comfortable coming to me as soon as you feel you might have a problem.”

Challenging Question

Possible Response

A patient with pleuritic chest pain asks, “Is this a heart attack? Am I going to die?”

“On the basis of your history and my clinical exam and findings, my suspicion for a heart attack is low. It is more likely that inflammation of the membranes surrounding your lungs is causing your pain, and this is usually not a life-threatening condition. However, we still need to do some tests to confirm the diagnosis and rule out heart problems.”

“Do you think I have colon cancer?” “Do you think I have a brain tumor?” “Do I have endometrial cancer?”

If the patient’s chief complaint is consistent with his question, tell him, “That is one of the possibilities, but there are other explanations for your symptoms that we should rule out before making a diagnosis.” However, if the chief complaint is inconsistent with his concern, say, “It is unlikely for a patient with your complaint to have this type of cancer, but if you are really worried about it, I will try to rule it out by conducting some tests.”

“My friend told me that you are a very fine doctor. That’s why I came to you to refill my prescription.”

“I am happy that you came to see me, but since this is your first visit, I can’t give you a refill without first reviewing your history to better understand your need for this medication. I will also need to do a physical exam and perhaps order some tests.”

“Will my insurance cover the expenses of this test?”

“I’m not sure, but I can refer you to a social worker who does have that information. If necessary, I can write a note to your insurance company indicating the importance of this test.”

A person who wants to return to work at a job that can negatively affect his health asks, “Can I go back to work?”

“Unfortunately, work may actually worsen your condition. Therefore, I would prefer that you stay at home for now. I can write a letter to your employer explaining your situation.”

“Do you think that this tumor I have could become malignant?”

“We really won’t know until we remove the tumor and get a pathology report on it. We will keep you informed as soon as we get any information.”

Challenging Question

Possible Response

“Since I stopped smoking, I have gained weight. I want to go back to smoking in order to lose weight.”

“There are healthier ways to lose weight than smoking, such as exercise and diet. Smoking will increase your risk of cancer, heart problems, and lung disease.”

A patient with a shoulder injury says, “I am afraid of losing my job if my shoulder doesn’t get better.”

“We will do our best to help you recover from your shoulder injury. With your permission, I will communicate the situation to your employer.”

“Will I ever feel better, doctor?”

The answer depends on the prognosis of the disease and can vary from “Yes, most people with this disease are completely cured” to “A complete cure may be difficult to achieve at this advanced stage, but we have a lot to offer in terms of controlling the symptoms and improving your quality of life.”

A person who has a broken arm asks, “Doctor, do you think I will be able to move my arm again like before?”

“It is hard to tell right now, but these fractures usually heal well, and with physical therapy you should regain the normal range of motion of your arm.”

“I think that life is full of misery. Why do we have to live?”

“Life can certainly be challenging. Is there something in particular that is bothering you? Have you thought of ending your life?” You can then continue screening for depression.

A young man with multiple sexual partners and a recent-onset skin rash says, “I am afraid that I might have AIDS.”

“Having multiple sexual partners does put you at risk for STDs, including HIV infection, but this rash may be due to many other causes. I agree that we should do an HIV test on you in addition to a few other tests.”

A patient who needs hospitalization says, “My child is at home alone. I have to leave now.”

“I understand your concern about your child, but right now staying in the hospital is in your best interests. With your permission, one of our social workers can make some phone calls to arrange for child care.”

Challenging Question

Possible Response

“Do you have anything that will make me feel better? Please, doctor, I am in pain.”

“I know that you are in pain, but I need to know what is causing your pain in order to give you the appropriate treatment. After I am done with my evaluation, we can decide on the best way to help manage your pain.”

A patient you believe is pretending (malingering) says, “Please, doctor, I need a week off from work. The pain in my back is terrible.”

“I know that you are uncomfortable, but after examining you, I don’t find disability significant enough to keep you out of work. I plan to prescribe pain medication and exercises, but a large part of your recovery will involve continuing your normal daily activities.”

“Stop asking me all these stupid questions and just give me something for this pain.”

“I know that you’re in pain, but I need to determine the cause of the pain if I am to give you the right treatment. After I am done with my evaluation, we will give you the appropriate treatment.”

“So what’s the plan, doctor?”

“After we get the results of your tests, we will meet again. At that time, I will try to answer any questions you might have.”

“Do you think I will need surgery?”

“I will try to manage your problem medically, but if that doesn’t work, you may need surgery. We can see how things go and then try to make that decision together in the future.”

A female patient has only one sexual partner, and she is diagnosed with an STD. She asks you, “Could he possibly be cheating on me?”

“You most likely contracted this infection from your partner. It would be best to talk to your partner about this to clear things up. He needs to be tested and treated, or else you risk becoming reinfected.”

A patient is shouting angrily, “Where have you been, doctor? I have been waiting here for the whole day.”

“I am sorry you had to wait so long. We had some unexpected delays this morning. But I’m here now, and I will focus on you and your concerns and spend as much time with you as you need.”

Challenging Question

Possible Response

A bleeding patient reacts angrily when you mention that she may need a blood transfusion and states that she refuses to be given any blood.

First determine the reason for the patient’s reaction, and then respond accordingly. For example:

■ “I have a religious objection to receiving blood.” You say, “I respect your opinion and will make sure you do not receive a blood transfusion until we have explained its benefits and have obtained your permission.”

■ “My brother died following a blood transfusion, and I’m afraid the same thing will happen to me.” You respond, “I am sorry for your loss, but I want you to know that it is rare for patients to die as a result of a blood transfusion. I will take all necessary precautions before giving you any blood.”

■ “I have had a blood transfusion before, and I had a serious reaction.” You say, “Thank you for telling me this. I will determine the reason you had this reaction and will treat it before giving you any blood.”

A patient is wandering around the room ignoring you and is not answering your questions or listening to you.

“I can only imagine how any patient in your situation might feel, but if you don’t speak with me, I will not be able to help you. So please have a seat and help me determine what is going on.”

A patient repeats your questions before answering them.

The patient may have a problem understanding or hearing you. Ask the patient why he is repeating your questions. If the problem relates to comprehension and you are not a native English speaker, ask him to stop you whenever he has difficulty understanding what you are saying. If the problem relates to his hearing, draw closer to him.

Challenging Question

Possible Response

A patient asks you a question while you are washing your hands.

Tell him that you would like to give him your full attention. Make sure you establish eye contact when you respond to him.

During the encounter, a patient asks if he can take a bathroom break.

Do not force him to stay in the examination room, and offer him your assistance.

A patient wants to be examined by another doctor.

Find out why. You can say, “It is certainly your right to choose another provider, but I want to reassure you that I am a well-qualified doctor and can help you if you will allow me to address your concerns. If we still need another opinion, I would be happy to help you select another doctor who might be a better fit for you.”

A patient with auditory hallucinations asks if you think he is crazy.

“There is no such diagnosis in medicine. I think you may have a physiological problem or a disorder in your mood, and there is a good chance that we can address it.”

A patient asks you if his previous doctor made a mistake in his treatment.

If the patient indicates that the previous doctor’s findings or treatment differs from yours, you can say, “Although your previous doctor may have had a different treatment plan, we have to do our best to make a decision on the basis of what we have discovered today. I’m sorry if this may be frustrating for you, but we want to give you the treatment that we think will be most effective and safe for you.”

A patient wants to know how to deal with a son who is gay.

Ask the patient if she or her son has any guilt or confused feelings about his sexual orientation. If so, encourage her or her son to seek guidance from a mental health professional.

Challenging Question

Possible Response

An educated 58-year-old woman asks, “I read in a scientific journal that hormonal replacement therapy causes breast cancer. What do you think of that, doctor?”

“Studies do in fact show a slight increase in the risk of developing breast cancer after more than four years of combination estrogen and progesterone use for hormonal replacement therapy. The current recommendations are to use hormonal replacement therapy solely for the relief of hot flashes, and only for a limited period of time.”

“Did I have a stroke?”

“We don’t know yet. Your symptoms could be explained by a small stroke, but we need to wait for the results of your MRI.”

“Do I have lung cancer?”

“We do not know at this point. It is a possibility, but we still need to do additional tests.”

An African American man with sickle cell anemia presents with back and chest pain and says, “Please, doctor, I need some Demerol now or I will die from pain.”

“I know that you are in pain, but I need to ask you a few questions first to better understand your pain. Then we will get you some medications to help ease your discomfort.”

A patient with symptoms of a common cold says, “I think I need antibiotics, doctor.”

“It appears that you have a common cold, which is caused by a virus. Antibiotics do not treat viruses, and they have adverse effects that could make you feel worse. We should focus on treating your symptoms.”

“My mother had breast cancer. What is the possibility that I will have breast cancer too?”

“You are at increased risk, but it doesn’t mean that you will get it. There are other risk factors that need to be considered, and regular screening tests will be very important.”

A 55-year-old man says, “I had a colonoscopy six years ago, and they removed a polyp. Do you think that I have to repeat the colonoscopy?”

“Yes, it should be repeated. We need to screen for more polyps, and in this way we hope to prevent the development of colon cancer.”

A patient with headache or confusion asks, “Do you think I have Alzheimer’s disease?”

“I don’t know. Alzheimer’s disease is one of several possible causes that we will investigate.”

Challenging Question

Possible Response

“Can I get pregnant even though my tubes are tied?”

“There is no single contraceptive method that is 100% effective. The risk of pregnancy after tubal ligation is less than 1%, but on rare occasions it does occur. There is a high probability that if such a pregnancy occurs, it will be an ectopic pregnancy.”

A woman who is in her first trimester of pregnancy with vaginal bleeding asks, “Do you think I am losing my pregnancy?”

“Bleeding early in pregnancy increases your risk of losing the pregnancy, but at the same time, most women who have bleeding carry the pregnancy to term without any problems.”

“My brother has colon cancer. What are the chances that I will develop colon cancer as well?”

“Some types of colon cancer are hereditary, and you may be at increased risk, but it doesn’t mean that you will get colon cancer for sure. I need to get more information about your personal and family history to determine your level of risk.”

A patient with palpitations says, “My mother had a thyroid problem; do you think it is my thyroid?”

“That is a possibility. We always check a thyroid blood test, but we will also consider many other possible causes of palpitations.”

“Obesity runs in my family. Do you think that is why I am overweight?”

“Genes play an important role in obesity, but lifestyle, diet, and daily habits are also major factors influencing weight. These factors can be used in a way that can help you lose weight.”

A young man with dysuria asks, “Do you think I have an STD?”

“That is one of the possibilities. We will do some cultures to find out for sure, and we will also check a urine sample, since your symptoms may be due to a urinary tract infection.”

“I am drinking a lot of water, doctor. What do you think the reason is?”

“This may simply be due to dehydration, or it may be a sign of a disease such as diabetes. We need to do some tests to determine the cause.”

A patient with COPD asks, “Will I get better if I stop smoking?”

“Most patients with your condition who stop smoking will experience a gradual improvement in their symptoms, in addition to a significantly decreased risk of lung cancer in the future.”

Challenging Question

Possible Response

A patient with possible appendicitis asks for a cup of water to drink.

“I am sorry, but I can’t give you anything to eat or drink right now. You may need emergent surgery, and anesthesia is much safer if your stomach is completely empty.”

A patient with infectious mononucleosis asks, “Can I go back to school, doctor?”

“Now that you have recovered from the acute stage of the disease, you can go back to school, but I want you to stay away from any strenuous exercise or contact sports, as you may rupture your spleen.”

A very thin patient with weight loss asks, “Doctor, do you think I am too fat?”

Even if the patient appears to be thin, do not state as much. Instead, respond by saying, “I cannot tell right now. First I need to determine your height and weight and calculate your body mass index, and then we can let the numbers tell us if you are at a healthy weight.”