WBR0743

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Serge Korjian)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Ethics
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 47-year-old man presents to the physician's office for his annual check-up. His past medical history is significant for hypertension, dyslipidemia, and a myocardial infarction 2 years ago. At the time, the patient underwent cardiac catheterization and was prescribed metoprolol, aspirin, and clopidogrel. Before the end of the visit, the patient confesses that he has not been taking his medications for the past 6 months, and he does not feel like he truly needs them. Which of the following questions is the most appropriate to address the patient's non-adherence to his medications?]]
Answer A	AnswerA::"Are you having difficulty paying for three medications at the same time?"
Answer A Explanation	AnswerAExp::The patient did not describe any financial issues with his non-adherence. There is no reason to jumps to conclusions that may sometimes reflect personal judgment.
Answer B	AnswerB::"Can you please explain to me what bothers you with your medications?"
Answer B Explanation	AnswerBExp::Identifying the patient's reason for non-adherence is key to addressing his concerns and finding ways to get him back on track with his medications.
Answer C	AnswerC::"Taking your medications is important for secondary prevention of your coronary artery disease."
Answer C Explanation	AnswerCExp::Without a real understanding of the cause of the patient's non-adherence, such comments may not be helpful and often irrelevant for the patient.
Answer D	AnswerD::"We can probably discontinue metoprolol so you don't have to take 2 medications at once."
Answer D Explanation	AnswerDExp::The patient never expressed concern regarding the number of medications he had to take. Stopping evidence-based therapies that reduce morbidity and mortality is never an appropriate initial approach.
Answer E	AnswerE::"Do you think you are doing the right decision by stopping the medications?"
Answer E Explanation	AnswerEExp::Physicians must refrain from expressing personal judgment by asking judgmental questions or by making judgmental comments. This approach may often affect the physician-patient relationship and cause a lack of trust.
Right Answer	RightAnswer::B
Explanation	[[Explanation::While facing situations of non-adherence, physicians must be very careful about their approach. Discussing the non-adherence in a non-judgmental tone prevents offending the patient or breaking his/her trust, which further worsens non-adherence. Accordingly, the physician must attempt to understand the patient's concerns in order to address them objectively and effectively. It is important to ask about the reasons and barriers that may be preventing the patients adherence to medications. It is important not to ask directed or closed-ended questions that tend to be judgmental by jumping to personal conclusions about the situation. Educational Objective: Identifying the patient's concerns and reasons for discontinuing medications is the best initial approach in cases of non-adherence. References: Delamater A. Improving Patient Adherence. Clinical Diabetes. 2006;24(2):71. First Aid 2014 page 61]]
Approved	Approved::Yes
Keyword	WBRKeyword::Medication adherence, WBRKeyword::Non-adherence, WBRKeyword::Ethics, WBRKeyword::Patient communication, WBRKeyword::Communication
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