1. A 29 yo male is brought to the ED after his sister found him unconscious in the tub at home.

EMS was called to the scene who performed cardiopulmonary resuscitation and were able to
obtain a return of spontaneous circulation. A large amount of heroin was found by his side which
on chromatographic testing was found to contain lethal amounts of fentanyl. The patient is
transferred to the ICU for further care and is placed on mechanical ventilation. Brain imaging
shows obscurement of the gray-white matter interface. His temperature is 85F, HR is 177, and
RR on the ventilator is set to 35. A medical student on the team determines that the patient is
likely brain dead and will not recover. The most likely contravening factor to making this
determination in this patient is?
a. A respiratory rate of 35 on the ventilator
b. Obscurement of the gray-white matter interface on brain imaging
c. Tachycardia on cardiac telemetry
d. Presence of pharmacologic activity that may distort brain death testing
e. Return of spontaneous circulation during cardiopulmonary resuscitation

R/o
Drugs of abuse
Electrolyte abnormalities

When can a patient be declared to be brain dead?

Criteria for brain death

1 PaCO2 > 60 – no spontaneous respirations (basis of the apnea test)
2 T > 90 F (you cannot declare a hypothermic person brain dead)
3 No active brainstem reflexes

Copyright July 2024, Divine Intervention Pro Consulting LLC

2. A 67 yo M with a history of NYHA Class 4 heart failure on digoxin, carvedilol, isosorbide
dinitrate, enalapril, and eplerenone comes to his primary care physician for follow up and
adjustment of his pharmacologic regimen. The patient’s code status was discussed at the
previous visit and he voiced a desire to receive end of life pain control and comfort measures but
declined resuscitation and mechanical ventilatory support. He is doing well but has to use
multiple pillows at night once or twice a month to sleep comfortably. Further examination is
notable for 3+ bilateral lower extremity edema. During a test of the patient’s gait and motor
activity, he begins to complain of severe chest pain and becomes unresponsive. The patient is
connected to a cardiac monitor which reveals a wide complex, irregular, tachyarrhythmia which
devolves to asystole 20s later. His carotid pulse is not perceptible. What is the next best step in
the management of this patient?
a. Immediate transfer to a tertiary care center
b. Institution of chest compressions and bag valve mask ventilation -> chest compressions =
resuscitation = pt is DNR
c. Unsynchronized cardioversion to a normal sinus rhythm -> cardioversion = resuscitation;
pt is DNR
d. Succinylcholine administration and endotracheal intubation -> pt is DNI
e. Transfer to a morgue given the high likelihood of impending death
f. Insertion of a central line for parenteral nutrition -> never done as an acute procedure

Patient’s code status: DNR/DNI = declined resuscitation and mechanical ventilatory support

Copyright July 2024, Divine Intervention Pro Consulting LLC

3.A 19 yo freshman college athlete comes to the medical geneticist for a follow up exam after
collapsing during a basketball game. He is accompanied by his girlfriend and his coach. He has
been highly recruited for the last 4 years and expects to be a top 10 NBA draft pick. A
transesophageal echocardiogram obtained 2 hrs after his collapse reveals asymmetric septal
hypertrophy associated with the left ventricle. Further genetic testing confirms the diagnosis. The
physician plans to discuss these test results and implications for his long term future at this visit.
Arrange the following physician responses in order of what should be done first to what should
be done last.

S1-What is your current understanding of all that is going on?

S2-Unfortunately, your test results are worse than what we initially hoped for.
S3-Even though we cannot cure your HCM, we can provide medications to reduce your
symptoms and allow you to enjoy your life in a meaningful way.
S4-Before we review your test results, would you prefer that we discuss things privately or
would you rather have your girlfriend/coach here?
S5-Would it be ok if we discuss the results of the tests we conducted?
S6-Can you tell me more about what your current concerns are?

What does the NBME expect you to know here?

Model to break bad news to the pt = SPIKES model

Setting – who should be in the room = s4

Perception – “what do you know so far?” = s1
Invitation – s5
Knowledge – drop the truth/bombshell s2
Empathy – s6
Strategy/Summary – s3

S2-Unfortunately, your test results are worse than what we initially hoped for.

S6-Can you tell me more about what your current concerns are?

S3-Even though we cannot cure your HCM, we can provide medications to reduce your
symptoms and allow you to enjoy your life in a meaningful way.

Copyright July 2024, Divine Intervention Pro Consulting LLC

Pt is refusing care

4.A 35 yo female is brought to the emergency room by her sister with shortness of breath that
has progressively worsened over the last 2 hrs. Physical exam is notable for bilateral jugular
venous distension. Her BP is 65/40, HR is 195, respirations are 35/minute, and breath sounds are
bilaterally auscultable. She is alert and is able to count backwards in serial 7s while naming the
last 10 presidents. A spiral chest CT demonstrates complete occlusion of the right pulmonary
artery. A recommendation is made by the physician to institute tenecteplase therapy. The patient
adamantly refuses and states that she wants to go home. What is the most appropriate physician
response in this circumstance?
a. “Would you mind sharing thoughts behind your decision to not receive
tenecteplase?” = explore their reasoning
b. “You will very likely die without tenecteplase therapy and your family will really miss
you”
c. “Let us discuss some hospice options available to patients in your situation”
d. “Despite your objections, it is my fiduciary duty as a physician to administer
tenecteplase”
e. “Would you be willing to submit yourself to an evaluation by our hospital psychiatrist?”

Pt is refusing care
- Explore their reasoning

Copyright July 2024, Divine Intervention Pro Consulting LLC

5.A 49 yo M with a h/o Afib on metoprolol and apixaban is scheduled to undergo a partial
colectomy for Crohn’s disease. To reduce the risk of bleeding associated with this procedure,
what is the NBSIM?

Stop oral anticoag (eg, Apixaban) 5d before surgery

Bridge w heparin

What do you do in a situation where a patient’s spouse refuses to honor a DNR order associated
with the patient’s living will?

Honor the living will

For a patient with urinary incontinence, what should be done in a healthcare setting to decrease
the risk of Catheter Associated Urinary Tract Infections (CAUTIs)?

Reduce risk of Catheter Associated Urinary Tract Infections (CAUTIs)

1st line: Incontinence brief (adult diapers)
2nd line: Intermittent catheterization (scheduled cath)

Copyright July 2024, Divine Intervention Pro Consulting LLC

6.Some Key Ideas/Terms To Know (help with reading questions!)
The most common source of private insurance in the US is employer provided insurance
A hospital that gets paid more from the Center for Medicare services for delivering quality care
(counseling patients on quitting smoking, making sure people get their vaccines on time, a
reduced number of infections in ICUs, etc) reflects a pay for performance model. If a provider
is not following established guidelines, implementing this payment model can “encourage” them.
Insurance companies can pay “access fees” to certain physicians so they can receive discounts
for services rendered by these physicians. These physicians are called “preferred providers”
Let’s assume Patient A has health insurance with a deductible of $1000 and a copay of 10%. If
Patient A has a $10,000 medical bill, he will have to pay $1900 from his medical bill (deductible
= $1000 first before insurance kicks in + copay of 10% = 10% of the $9000 balance which is
$900)
An “in network” physician is one that accepts a particular kind of insurance. An “out of
network” physician does not accept that insurance.
Critical access hospitals are small hospitals often set up in rural areas to provide care for
people living > 35 miles from other hospitals.

7.A hospital in Pennsylvania has been losing money for years. According to the CEO, the
hospital gets limited reimbursement from the Center for Medicare and Medicaid services (CMS)
as a result of poor adherence to standards of care. One area identified for improvement was
achieving a door to balloon time of < 90 mins in the management of ST elevation myocardial
infarctions. In February 2023, the hospital was able to achieve this goal in 22 out of 100 patients
diagnosed with a STEMI. A medical student was tasked with studying this process as a means of
making recommendations for improvement. By the end of the medical students’ study and
intervention, the hospital was able to improve to achieving the < 90 min door to balloon time
metric in 99 out of 100 patients. The medical student achieved this by designing streamlined
processes to identify patients with an MI and also removed inefficiencies in the process of
STEMI patients getting admitted, calling appropriate consults, and having cath labs prepped.
This standardized process is now applied to all STEMI patients. The hospital’s profits and CMS
reimbursement has improved significantly since these measures were implemented.
These improvements are a good representation of lean technique/six sigma
This will show up as a USMLE question testing concepts like improving efficiencies (getting
things done faster and with less), eliminating waste, and making processes run better. It is
achieved with the DMAIC principle. Define (identify the problem), Measure (quantify the
problem), Analyze (Identify the cause, create solutions), Improve (Execute your created
solutions), and Control (maintain gains, keep doing your good deeds). Examples include
questions testing concepts like reducing hospital length of stay, shortening patient discharge
times, improving turnaround times for obtaining labs, bulk purchase of hospital equipment
to reduce cost, preventing “over-ordering” of tests, etc. Basically, can you do more with
less?

Copyright July 2024, Divine Intervention Pro Consulting LLC

A healthcare organization pays out a bonus of $10 to any individual that reports unintentional
errors. Other measures are also implemented to encourage error reporting including offering
guarantees that offenders will not be discriminated against in the workplace. What kind of QI
concept is being emphasized in this case?

Safety/Just Culture

Concept:
8.A 67 yo M smoker with a h/o unstable angina pectoris comes to the office to discuss results of
an US obtained in the process of screening for an abdominal aortic aneurysm. The ultrasound
showed an infrarenal aortic diameter of 7 cm. The patient is currently asymptomatic. The
physician recommends endovascular repair to reduce his risk of future morbidity and mortality.
His current medications include metoprolol succinate and isosorbide dinitrate. In addition to
recommendations on smoking cessation, what is the next best step in the management of this
patient?
a. Endovascular repair of the patients aneurysm
b. Coronary angiography with transluminal stent placement
c. Echocardiography to assess cardiac wall motion
d. CT chest angiography to assess pulmonary vessel patency
e. Watchful waiting till he becomes symptomatic

Pt has a serious medical condition (unstable angina)

Endovascular repair = elective surgery
Concept: Fix the serious condition first (coronary angio to fix UA first)

Copyright July 2024, Divine Intervention Pro Consulting LLC

9.What is the most common cause of an adverse event in medicine?

Medical error

A car manufacturing company introduces software into a vehicle that makes it impossible to start
without the gear being in “P” mode. What kind of quality improvement concept is being
emphasized in this circumstance?

Forced function

What is the most effective technique for minimizing adverse events in healthcare?

Forced function

During patient check in for an elective hernia repair, the operating surgeon states the patient’s
name, reason for coming to the hospital, and the specific site where he would be obtaining
surgical intervention. She then asks this patient to confirm/repeat what was stated. This exchange
is a good example of?

Closed-loop communication

Copyright July 2024, Divine Intervention Pro Consulting LLC

10.A 45 yo M with a h/o stable angina comes to the urologist after a primary care referral for a
vasectomy. He has 4 children with his 35 year old wife and they have both decided to not have
kids anymore. He is able to ascend 6 flights of stairs before having chest pain or angina
symptoms. What is the most appropriate next step in the management of this patient?
a. Proceed to surgery without further workup
b. Calculate the revised cardiac risk index and use these results to determine the safety of
obtaining a vasectomy
c. Recommend against surgery as the patient has functional limitations with his angina
d. Obtain an electrocardiogram to assess myocardial function
e. Recommend that his wife use condoms whenever they have sex

What does the NBME expect you to know here?

If a pt is getting a minor procedure, they can proceed to surgery directly

If a pt is getting a major procedure

 Calculate MET
o >4 = proceed to surgery
o <4 = Pre-op w/u

Minor procedures: most biopsies, cataract surgery, minor urologic/OBGYN procedures

4 MET activities: climbing up a flight of stairs, cycling, yardwork, walking 4 mph
Major procedures: Thoracic, cardiac, GI, vascular, procedures. It will intuitively make sense as
big surgery

As an aside, what pre-op testing should be obtained on NBMEs in patients undergoing any kind
of lung resective surgery?

PFTs (FEV1 > 1L)

Copyright July 2024, Divine Intervention Pro Consulting LLC

Communication: Patient Hand-off = SBAR

11.A 46 yo M with a h/o hyperlipidemia and T2DM comes to the ED with a 2 hr history of
severe headache. He describes it as the worst headache of his life. He is evaluated by a triage
nurse who relays her findings to the physician on duty. Arrange these sentences in the
appropriate order for communicating these findings.

A-Would it be possible for us to obtain a non-contrast CT scan of his head?

B-Mr X was watching TV with his family at home when he suddenly started complaining of a
severe headache.
C-The headache has continued to worsen in intensity and he is now showing signs of nuchal
rigidity.
D-I am concerned that this patient has a subarachnoid hemorrhage

Communication: Patient Hand-off = SBAR

Situation = Mr X was watching TV with his family at home when he suddenly started
complaining of a severe headache.

Background = The headache has continued to worsen in intensity and he is now showing signs of
nuchal rigidity.

Assessment = I am concerned that this patient has a subarachnoid hemorrhage

Recommendation = Would it be possible for us to obtain a non-contrast CT scan of his head?

The physician instructs the nurse to obtain a non-contrast head CT, EKG, blood cultures, labs
(CBC, CMP, urine drug screen) and a neurosurgical consultation emergently. How can the error
associated with this process be minimized?

Closed-loop communication

Copyright July 2024, Divine Intervention Pro Consulting LLC

12.A 55 yo M with a h/o NYHA Stage 1 CHF well controlled with metoprolol checks into the
hospital for an elective cholecystectomy. He has been cleared by the pre-op clinic. What is the
next best step in medication management to prevent unfavorable surgical outcomes?

If you are on a beta-blocker and you have no AE, you can continue it with surgery

13.A 49 yo M with a history of T2DM and Stage 1 CKD is in the ICU receiving antibiotics for a
diagnosed pseudomonas infection. The admitting physician prescribed IV gemifloxacin the night
before. He notices that the patient is instead receiving IV gentamicin. The physician instructs the
nurse to immediately discontinue the gentamicin and make a substitution for the originally
prescribed antibiotic. He also recommends initiation of dialysis protocols in addition to 2L of
normal saline administration for renal protection. The physician decides to explain the issue to
the patient. What is the most appropriate physician statement in this circumstance?
a. “You are at risk for acute kidney injury as a result of your past medical history, so we
will be administering extra fluids and an antibiotic”
b. “Your original antibiotic does not appear to be controlling your infection so we are
switching to a new one and adding some fluids” -> lying
c. “An error was made in administering gentamicin instead of the prescribed gemifloxacin
but they thankfully both have similar coverage so this should not be an issue” ->
d. “I am concerned about a worsening of your infection so I will be switching to a new
antibiotic and extra fluids to protect your kidneys”
e. “An error was made in administering a different antibiotic than what was
prescribed. We are trying to correct this by switching to the originally prescribed
antibiotic while giving fluids to reduce your risk of developing acute kidney injury”
-> own up “an error was made”
f. “An error was made in administering gentamicin instead of the prescribed gemifloxacin
so we are placing a consult across to the risk management committee for
recommendations on further action”

Copyright July 2024, Divine Intervention Pro Consulting LLC

14.A new pediatric intern comes to work at 7.05 am. Rounds have already begun. He apologizes
profusely to the senior and describes how there was significant traffic on the highway. He was
supposed to arrive by 6.45 am. He was corrected by the same senior last week for similar
behavior. Which of the following represents the most appropriate response in this scenario?
a. Report the intern to the program director
b. Sit down with the intern and gently explain the importance of reporting to work on
time
c. Accept the interns apology given the challenges of starting residency
d. File a report with the promotions committee as this demonstrates a repeated pattern of
negligent behavior that may cause patient harm
e. Report the intern to the chief resident

Two-strike rule
Intern only has 2-strikes
Take punitive action by the 3rd strike

What should be done in an emergency situation?

Step in immediately

What is the chain of command that should be utilized when a fellow resident identifies
problematic behavior in another resident?

fellow resident
Chain of command
Senior resident
Chief resident
Program Director

What is the chain of command that should be utilized when an attending physician identifies
problematic behavior in another resident?

attending physician
Chain of command
Program director

How should mental illness in a resident be addressed?

Offer psychiatric resources

Copyright July 2024, Divine Intervention Pro Consulting LLC

What are the 2 measures with the best evidence for dealing with underperforming residents?

1 offer coaching
2 frequent feedback sessions

The senior resident decides to privately resolve the issue with the intern. Arrange the following
sentences in order.
A-I would like you to make coming to work on time a priority.
B-Repeated problems like this would involve me having to escalate this to the chief resident
C-You have on 2 occasions now come to work late.
D-Your actions this week are not consistent with what we discussed last week

Communication: How to Confront Someone = DESC model

Describe = You have on 2 occasions now come to work late.

Express displeasure = Your actions this week are not consistent with what we discussed last
week

State change = I would like you to make coming to work on time a priority.

Consequences = Repeated problems like this would involve me having to escalate this to the
chief resident

Copyright July 2024, Divine Intervention Pro Consulting LLC

Pregnant Minor

15.A 17 yo F is brought to the pediatrician by her mom. A pregnancy test obtained 10 weeks ago
was +ve. Her mom is requesting that the patient receive prenatal care. The patient adamantly
refuses and states that she wants to go home and tend to the fetus herself. What is the NBSIM?

Honor the wishes the patient (pregnant teen mom carrying the baby, even if she is a minor)

Conflicting Wishes: Old Living Will or Recent DPOA

16.A 43 yo M with a h/o terminal small cell lung cancer is brought to the emergency room by his
friend of 12 years who is his current durable power of attorney (DPOA). At the last visit, he
expressed wishes to his physician that all healthcare decisions, including those relating to end of
life care be made by his close friend. He is profoundly short of breath and is unable to participate
in the interview. His SaO2 is 40% and decreasing. His palpable systolic blood pressure is 50
mmHg. His DPOA requests that the patient be placed on a ventilator and all measures be
tried to resuscitate him. The patient signed a living will 7 years ago where he requested that
no resuscitative efforts be explored in the event of a terminal diagnosis. What is the NBSIM
of this patient?

Concept: follow the most recent wishes

In this case, the DPOA is the more recent
NBS? Follow DPOA -> resuscitate

Copyright July 2024, Divine Intervention Pro Consulting LLC

17.An 89 yo M comes to the physician for a follow up exam. He has been doing well but was
newly diagnosed with HTN. His physician decides to place him on low dose daily Losartan
therapy. The patient mentions that a close friend of his uses prazosin and has done really well
with it. He wonders if the physician can prescribe the same medication. The physician calmly
mentions that prazosin is not an ideal antihypertensive agent in the elderly. What is the most
likely reason behind the physician’s statement?

Prazosin = alpha-1 blocker a/w AE: orthostatic hypotension, which will inc fall risk, esp in
elderly

Other medications that carry similar dangers on NBMEs?

Benzo
TCA
Anticholinergic
Many antihistamines eg, diphenhydramine

How do we assess this complication on NBMEs?

Assess fall risk with get-up-an-go test (TUG = timed up and go)

Copyright July 2024, Divine Intervention Pro Consulting LLC

Elderly

18.Given the following scenarios, what is the most likely finding/observation in the elderly?

Dosing interval for warfarin: increase dosing interval bc you have dec cyp-450 activity w age;
warfarin is met by liver

Dose of gentamicin needed for a lung infection: decrease gent dose bc aminoglycosides are
excreted by kidney; GFR dec w age

What are the sleep pattern changes associated with old age on NBMEs?
1 insomnia
2 early morning
3 frequent night time awakening

Hearing: presbycusis = dec in high freq hearing

Memory: mild dec in memory

As an aside, what is the BRF for pressure sores on NBMEs?

Inc in capillary pressure

Copyright July 2024, Divine Intervention Pro Consulting LLC

19.Most common complication associated with the use of TPN? Central line infx
Preferred NBME access: IJV (internal jugular vein) or subclavian vein
Not preferred NBME access: femoral vein

Who gets the “hypophosphatemic issue”? MCCOD in refeeding syndrome

P/P insulin will inc and drive phos into cells and lower serum phos -> cardiac dysfunc ->
death

20 mins after insertion, a patient complains of significant SOB; there’s unilaterally decreased
breath sounds on examination: PTX
Associated access with the complication above: subclavian vein central line

Arterial cannulation with IJV placement: ICA = internal carotid artery

MC associated organism: staph epidermidis

Should they be replaced often: no
Sudden onset arm swelling and edema in a patient with cancer: catheter-associated thrombosis
Sudden decompensation after insertion of central line with bilaterally auscultable breath sounds:
air embolism
NBS? Left lateral decubitus

Copyright July 2024, Divine Intervention Pro Consulting LLC

Patient Safety

20.A 44 yo F opens her eyes during a laparoscopic cholecystectomy for acute cholecystitis. The
surgeon notices that the anesthesiologist is asleep and asks the OR nurse to wake him up. The
rest of the case proceeds uneventfully and the patient is moved to the medicine floor from the
PACU. The surgeon expresses displeasure to the anesthesiologist after the case. What is the most
appropriate physician action in these circumstances?
a. Report the anesthesiologist to the adverse event reporting system of the hospital
b. Discuss the case at the hospital’s morbidity and mortality conference
c. Collect urine samples from the anesthesiologist for a mandatory drug test
d. Give the anesthesiologist extra time off to deal with fatigue
e. Do nothing since the surgeon has already spoken to the anesthesiologist

21.A 44 yo M calls the local clinic to request a prescription for oral oxycodone for low back
pain. His symptoms have worsened over the last 3 days. A new physician has just joined the
group practice and is on call for the weekend. The patient is going out of town within the next
few hours and does not want to miss his flight. He has been seeing a pain physician within the
same practice for the last few years who has maintained him on low dose oxycodone therapy.
This physician is on vacation and cannot be reached by phone. What is the most appropriate
physician action in these circumstances?
a. Provide a prescription over the phone and have it sent to a local pharmacy
b. Refer the patient to another physician who can prescribe the medication over the phone
c. Provide a 3 day prescription for oxycodone over the phone pending an in person visit
from the patient
d. Contact the medical board for advice prior to prescribing a controlled substance
e. Request that the patient visit the clinic for an in person evaluation prior to administering
therapy

Controlled substance – requires in person eval, esp in this case, where you have never met
this pt before

22.
Most likely healthcare outcome associated with receiving CPR: death
Most important locational predictor of positive outcomes with CPR: in-hospital CPR
DNR orders with impending surgery: suspend the DNR order

Physician-Assisted Suicide is illegal on NBME

Copyright July 2024, Divine Intervention Pro Consulting LLC

A 47 year old male with widely metastatic lung cancer is having a discussion with his physician
about goals of care. He has decided that he no longer wants to receive chemo or radiotherapy and
is ready to go home. The physician expresses understanding of the patient’s wishes and decides
to stop all therapy. The patient requests that the physician give him a large prescription of
fentanyl so he can “end it all in peace” when he gets home. What is the most appropriate
physician action in these circumstances?

What should be done on NBME exams when a fetus that was doing well suddenly dies at 38
weeks gestation?
NBS? Autopsy

Under what other circumstances should this policy be followed?

When you suspect foul play or unusual circumstances

In general, what should be done when a patient dies?

Death certificate

Copyright July 2024, Divine Intervention Pro Consulting LLC

23.Nosocomial infections and the NBMEs.
Most common mode of transmission: direct contact
Most important measure associated with decreasing the risk of nosocomial infections: wash
hands
Reducing risk of rotavirus/C. Diff infection in hospitals: wash hands w soap and water
Most important measure for decreasing the transmission of blood borne pathogens: use gloves
(physical barrier)
MC kind of nosocomial infection: cather-associated UTI
MC nosocomial infection COD: healthcare-associated PNA

A medical student is tasked with caring for a 25 yo M who presented with nuchal rigidity,
headache, and high fevers. Gram stain of an LP specimen revealed gram -ve diplococci. What
kind of precaution should be taken in caring for this patient? Droplet precautions

Other organisms:
Droplet precautions =
1 surgical mask
2 gown
3 gloves

PIN
Pertussis
Influenza
Neisseria Meningitidis

C-Diff: Contact precautions = gown + gloves

3 NBME interventions for reducing the risk of ventilator associated pneumonia?

VAP interv (best -> worst)

1 supraglottic secretion drainage
2 elevate head of bed
3 chlorhexidine mouthwash

Reducing the risk of pneumothorax with central line insertions?

Use ultrasound

For NBME purposes, how should a pressure ulcer be cultured for infection?

Copyright July 2024, Divine Intervention Pro Consulting LLC

Deep tissue specimen

For NBME purposes, what kinds of cultures are obtained when a CLABSI is suspected?

CLABSI = central line infx

1 Central line blood cx x2
2 blood cx fr another peripheral vein

Example
1 Central line blood cx x2 grows 10^20
2 blood cx fr another peripheral vein 10^2 S aureus

Cancer patients and pain management:

Ladder: non-opioids -> opioids
Add-on therapy with opioids: stool softener

A 67 yo male comes to the physician with a 3 week history of severe pruritus and yellowing of
the skin. Imaging shows a pancreatic lesion with extensive involvement of the superior
mesenteric artery and vein. What recommendation should be given to this patient with regards to
long term care?

Pancreatic lesion encasing vessel = inoperable (poor prog)

Hospice

Assuming that this patient is in severe pain and has not responded to high dose ketorolac therapy,
what pharmacotherapeutic regimen is recommended for adequate pain control?

Ketorolac = NSAID
IV opioid

Opioid progression in palliative care:

1 IV opioids -> oral opioid

Neuropathic pain in terminally ill patients/patients on chemotherapy:

TCA, SNRI, pregabalin, gabapentin

Nausea/vomiting:

Copyright July 2024, Divine Intervention Pro Consulting LLC

Ondansetron
Prochlorperazine (anti-emetic)
Metaclopramide

Organ considerations with opioids:

Liver or kidney dz -> dec dose

NBME contraindications to getting a transplant?

Incurable or terminal illness eg, CJD, ALS

A 47 yo M on vincristine pharmacotherapy for testicular cancer comes to the physician for

follow up. He was placed on pharmacotherapy after complaining of severe “needle like” pain in
his lower extremities. He is now having more urinary accidents and feels “warm all the time”.
Physical exam is notable for bilateral pupillary mydriasis. What is the most likely etiology of this
patient’s symptoms?

TCA tox -> anticholinergic (mydriasis,

A 55 yo F with a history of breast cancer comes to the physician for follow up. She was taken off
anastrozole therapy 1 year ago. For the past 2 weeks, she has been having significant back pain.
PE demonstrates marked tenderness to palpation of multiple spinous processes. What is the next
best step in diagnosis?

c/f bone mets fr breast CA

NBSID?
1 MRI
2 Bone scan

Upon confirmation of the diagnosis, what should the patient receive to manage her pain
symptoms?
Palliative radiation + bisphosphonate or denosumab

What can be given to a patient experiencing severe emesis from cisplatin chemotherapy?
Ondansetron
Moa: blocks the receptor cisplatin binds to cause nausea

Copyright July 2024, Divine Intervention Pro Consulting LLC

A 45 yo F with a history of glioblastoma multiforme is being evaluated by an internist in a
hospice. PE demonstrates profound cachexia and severe temporal wasting. The nurse states that
the patient barely makes it through 3 spoons of her daily nutrition. The patient states that “she
does not feel hungry”. What is the next best step in pharmacotherapeutic management?

Inc appetite
Megestrol (progesterone analogue)
Steroids
Dronabinol (medical marijuana to inc appetite)

2 weeks later, the patient begins to complain of worsening shortness of breath. She is gasping for
air on a physical exam. She is known to have a prior opioid addiction. What is the next best step
in the management of this patient?

DOC for SOB in terminally ill pts = Morphine

A 47 yo M with Stage 4 lung cancer is being evaluated by a pulmonologist. He was transferred

to a hospice 3 weeks ago after his malignancy was deemed to have a terminal prognosis. PE is
notable for profound stridor and decreased bilateral air movements. An obtained CXR shows
resorptive atelectasis. CT imaging demonstrates 75% occlusion of the trachea with a
serpiginous mass. What is the next best step in the management of this patient?
Tracheal stenting (form of comfort care)

Pt w pancreatic CA, pruritis, jaundice. NBS? ERCP + biliary stent (to drain bile acids causing
pruritus)

How should delirium in a terminal patient be managed?

Antipsychotic

A 75 yo M with end stage heart failure is referred for hospice care after becoming inotrope
dependent. He is currently on digoxin and statin pharmacotherapy. Upon acceptance to hospice,
what is the next best step in pharmacotherapy to reduce the risks of adverse effects?

Stop statin
Digoxin, positive inotrope, helps w sx
Pt is terminal, so wont benefit from long term benefit of statin

24.A pharmaceutical company intends to conduct a randomized control trial on the effectiveness
of an mRNA based COVID-19 vaccine in males and females aged 5-10 years. A similar vaccine

Copyright July 2024, Divine Intervention Pro Consulting LLC

has been approved in clinical trials involving 12-20 year olds with an excellent safety profile.
This same vaccine has also been administered in adults and the elderly with minimal side effects.
Postmarket surveillance studies are currently being conducted. Prior to beginning this study, the
researchers should obtain consent from?
a. The siblings of the study participants
b. The parents of the study participants
c. CEO of the healthcare organizations participating in the study
d. Randomized control trials should not be carried out in children

25.A 55 yo Senegalese immigrant comes to the ED with his 23 yo son with a 3 day history of
severe abdominal pain and 6-8 bloody bowel movements a day. The patient does not speak
English but motions to his son to help him interpret during his conversation with the physician.
What is the next best step in the management of this patient on NBME exams?

Get a certified medical interpreter/translator

26.A 25 yo female comes to the physician for her last follow up appointment 3 months after an
open reduction and internal fixation for a left tibial fracture. She has been able to ambulate after
undergoing physical therapy and is now able to tolerate a 6 mile trail walk every morning. The
physician runs marathons and during the therapeutic encounter emphasizes the importance of
continued physical activity as a means of improving the patient’s functional capacity. The patient
sends the physician a friend request on social media 2 days later. What is the most important
physician response in this scenario?
a. Accept the friend request as social media interactions do not constitute unethical
physician-patient interactions
b. Consult the ethics committee for appropriate guidance since the physician is also
interested in physical activity
c. Refer the patient to another physician as interactions of this nature are inappropriate
d. Accept the friend request as this is the patient’s last therapeutic encounter with the
physician
e. Decline the friend request

27.How can the risk of venous thromboembolic disease be decreased in hospitalized patients?

Copyright July 2024, Divine Intervention Pro Consulting LLC

LMWH (enox)
Intermittent pneumatic compression device

NBS?
28.What is the next best step in management given the following case scenarios?

7 yo F with a frothy green foul smelling discharge from the vagina.

Dx Trichomoniasis (STI) in a child = sexual abuse -> Call CPS

74 yo F brought to the physician for her annual physical. Multiple bruises are visualized during
the PE. When asked about these lesions by the physician, the patient states, “I’m fine”.
Dx Elder abuse -> Call APS (adult protective services)

What kind of question should be used to initiate a discussion on NBMEs in relation to intimate
partner abuse? In what setting should this be done?
C/f IPV -> Ask “Do you feel safe at home?”

What if the partner refuses your suggestions, what are you supposed to do?
Create a safety plan

Should you call CPS/APS?

No

29.A 64 yo M is brought to the ED with a 2 hr h/o profound, progressively worsening

hematemesis. He has a h/o laryngeal cancer and per an advanced directive signed 4 years ago
(when the initial diagnosis was made) wants no lifesaving measures employed in the case of an
emergency situation. At a follow up appointment 2 weeks ago, the patient expressed to his nurse
a desire to pursue all measures to sustain his life if things were to go awry. What is the NBSIM?

Resuscitate (honor the pt’s most recent wishes, disregard the old advanced directive)

Copyright July 2024, Divine Intervention Pro Consulting LLC

Jehovah’s Witness
30.A 49 yo M is brought to the ED by ambulance after involvement in a significant MVA. His
palpable SBP is 60 mmHg and emergent imaging obtained reveals a large hyperdensity in his
pelvis with multiple fractures. He has a signed Jehovah’s Witness card on his neck stating that he
does not want a blood transfusion. Similar wishes have also been expressed in a living will
within the patient’s medical record. What is the NBSIM?
a. Try to contact family to obtain consent for a blood transfusion
b. Emergent exploratory laparotomy and pelvic stabilization
c. Packed RBC transfusion with emergent surgical consultation
d. Withhold all life sustaining measures according to the patient’s wishes
e. Consult the hospitals’ risk management committee

Ex-lap
Do everything you can except give blood

Pt w TB refuses Tx NBS? Tx anyways bc pub health issue

31.A 25 yo M IVDU comes to the ED with a 2 week h/o productive cough, worsening SOB,
fevers, and night sweats. He has lost 5 pounds within this time period. A rapid HIV screen is +ve
but the patient is COVID-19 negative. An obtained CXR shows cavitary infiltrates. His WBC is
19k. An obtained sputum sample shows acid fast organisms consistent with Mycobacterium
Tuberculosis infection. The patient wants to go home and refuses all therapy from the physician.
The physician explains the deleterious long term effects of refusing appropriate therapy with the
patient demonstrating full understanding. What is the NBSIM?
a. Respect his autonomy and allow him to leave against medical advice
b. Endotracheal intubation and rifampin, isoniazid, pyrazinamide, ethambutol, and
pyridoxal phosphate therapy
c. Outpatient rifampin, isoniazid, pyrazinamide, ethambutol, and pyridoxal phosphate
therapy with close follow up
d. Engage with hospital security to place the patient in a negative pressure room and
begin rifampin, isoniazid, pyrazinamide, ethambutol, and pyridoxal phosphate
therapy
e. Consult the healthcare systems’ risk management committee

32.The NBMEs and estranged family members rule

Close friend of pt

33.When should a medication reconciliation be done on NBME exams?

During any transition of care
34.A 65 yo M comes to the physician for his annual wellness exam. He has a history of benign
prostatic hyperplasia well controlled with daily terazosin and dutasteride therapy. His medical

Copyright July 2024, Divine Intervention Pro Consulting LLC

history is otherwise unremarkable. He has no complaints other than mild chest pain when he has
sex with his wife. An EKG obtained shows no abnormalities. A decision is made to begin the
patient on isosorbide dinitrate for his symptoms. The physician is given a warning alert as he
tries to electronically send this prescription to the pharmacy. What quality improvement measure
is being emphasized in this situation?

Terazosin + Nitrate are CI bc of AE ortho hOtn

Warning alert = Human factors engineering

Why are electronic prescriptions preferred?

Dec risk of handwriting errors

35.A 45 yo M presented to the ER 2 days ago with worsening fevers and right sided pain.
Urinalysis and a helical CT obtained confirmed a diagnosis of pyelonephritis that was
subsequently treated with ceftriaxone. He is now afebrile, pain free, and ready for discharge. The
physician arranges follow up with his outpatient primary care doctor along with outpatient
antibiotic therapy. What is the most appropriate physician action prior to discharge?
a. Recommend a 1 week course of double strength trimethoprim sulfamethoxazole
b. Recommend a 1 week course of daily 800 mg trimethoprim sulfamethoxazole taken by
mouth
c. Recommend a 1 week course of daily 800 mg trimethoprim sulfamethoxazole taken
intravenously
d. Recommend a 1 week course of once daily 800 mg trimethoprim sulfamethoxazole
taken by mouth

Duration
Freq
Dose
Drug
Route of administration

Copyright July 2024, Divine Intervention Pro Consulting LLC

36.A physician deems a 33 yo M incapable of making health care decisions for himself after 1-
on-1 evaluation in addition to consultations with the hospital psychiatrist and neurologist. The
patient does not agree with the results of this assessment. What is the NBSIM?
Court-order

Can you administer a urine drug test to an individual (even a child) without telling them what the
urine test is for?
No – cannot test w/out informed consent violates autonomy

A 35 yo M is being evaluated by a physician on the floor for worsening fevers, flank pain, and
lower abdominal discomfort. The patient was initially admitted 3 days ago with a diagnosis of
acute pyelonephritis and was placed on IV ceftriaxone therapy. His WBC has increased from
18,000 on admission to 33,000. The physician notices that the patient is receiving IV
vancomycin. In addition to investigating the cause of this medical error, what is the NBSIM?
a. Admit to the patient that a mistake was made as a result of negligence on the part of the
treating nurse.
b. Replace the administered vancomycin with ceftriaxone therapy -> incorrect bc a mistake
was made, and you have to own up first
c. Admit to the patient that a medication administration error was made
d. Implement a system of checks and balances to make sure errors of this nature never occur
again
e. Provide free medical care to the patient as a result of the discovered error

In situations where the physician has a conscientious objection to a medical intervention that the
patient requests, what should be done on NBME exams?
Refer to another physician

Pt is refusing care
A 32 yo F at 27 weeks gestation comes to the emergency room with a 2 day h/o decreased fetal
movement. FHR is 350 bpm. A transvaginal ultrasound reveals an amniotic fluid index of 60 cm
with extensive fetal edema. The physician recommends the emergent institution of percutaneous
umbilical blood sampling to aid in the diagnosis and treatment of fetal anemia. The patient
refuses this recommendation. What is the NBSIM?

1 explore reasoning
2 if they still refuse care, honor the patient’s wishes

Can a physician refuse treatment to a neonate with a futile prognosis born at 20 weeks gestation?

Copyright July 2024, Divine Intervention Pro Consulting LLC

Yes

Considerations??

Fetus <23w, low chance of survival

37.A 59 yo M is brought to the ED after being found down in his hotel while on a business
meeting. He is apneic and has to be placed on a ventilator. EKG is consistent with pulseless
electrical arrest. After multiple attempts, return of spontaneous circulation is achieved. MRI of
the brain is consistent with global anoxic injury. The patient’s primary care physician is called
and he mentions that a document was signed 3 years ago where the patient stated that he was not
interested in life sustaining measures and would like to “go peacefully”.
What is the NBSIM?
D/c resuscitation

What is the document called?

Living Will/Advanced Directive

What is a classic alternative on NBMEs to this document?

Durable Power of Attorney (DPOA)

Assuming a patient does not have this document or the alternative (and no one knows his
preferences for care), what is the NBSIM?

Spouse
Adult children
Parents
Adult siblings

38.What are classic NBME scenarios where patient confidentiality should not be honored?

Unsafe automobile driver, report to the DMV

Suicidal/homicidal
Reportable dz to Dept of Health
1 HIV
2 Hep B/C
3 Trich
4 Gonorrhea 5 Chlamydia 6 Syphilis 7 TB
39.Given the following case scenarios involving pharmaceutical companies, what is the
most appropriate NBSIM?

Copyright July 2024, Divine Intervention Pro Consulting LLC

Concept: Accept gift/money pertaining to research/education

A physician is about to give a lecture on thrombolytic agents. He has for the last 3 years been in
charge of a clinical trial for a new thrombolytic agent, X for which he has received $3m in
research funds.
Financial disclosure at the beginning

A 35 yo internist recently received a Physician of the year award in a small town in Kentucky. A
company that specializes in the production of oral hypoglycemic agents offers him a cash award
of $500,000.
Decline

A 35 yo internist recently received a Physician of the year award in a small town in Kentucky. A
company that specializes in the production of oral hypoglycemic agents offers him a cash award
of $500.
Accept

A 35 yo internist recently received a Physician of the year award in a small town in Kentucky. A
company that specializes in the production of oral hypoglycemic agents offers to underwrite the
cost of all his continuing education licensure requirements for the next 5 years.
Accept

40.During a flight from New York to Hawaii, a 49 yo M slumps to the ground on his way back
from the restroom. He is unresponsive. The flight attendant asks for help overhead and a
gastroenterologist comes to evaluate the patient. Despite multiple attempts at CPR and
defibrillation, the patient remains apneic and ROSC is not achieved. He is declared dead by EMS
after the plane undergoes an emergency landing. The patient’s family feels that the physician
should have done more to help their loved one and decides to have him sued.
What is the most appropriate physician response in this scenario?
Express empathy

What does the NBME expect you to know about the legal ramifications of this case?
Good Samaritan Law
41.Given the following clinical scenarios, what is the most appropriate NBSIM?

Copyright July 2024, Divine Intervention Pro Consulting LLC

A 49 yo M is brought to the hospital for an outpatient hernia repair. During the course of the
procedure, the physician notices a fungating mass around the terminal ileum that likely
represents malignancy.
Close the patient, wake them up, get consent before excising the mass

A 14 yo M is brought to the ER with a 3 hr h/o severe headache and a T of 103. On PE, he has
nuchal rigidity. The physician recommends an immediate lumbar puncture and the institution of
antibiotic therapy. The patient’s parents state that according to their tradition, a 7 day wait time is
required for rites and absolutions to be performed before any “scientific measures” are allowed.
LP + abx (ignore the parents)
This is an emergent condition in a pediatric patient, tx in an emergency

A 47 yo M is brought to the ER with generalized tonic-clonic seizures. He is a known alcoholic.

A decision is made to begin lorazepam therapy. The patient yells at the physician and with
slurred speech states “don’t come near me, I don’t want that evil stuff in my body”.
Give the benzo
In an emergent situation in an altered pt, do what is medically indicated (ignore the pt’s wishes)

A 47 yo M is brought to the hospital by MedEvac after collapsing on a boat. His friends state that
he had a severe headache a few mins before he collapsed. A non-contrast head CT obtained
reveals a lentiform density around the right parietal lobe. The neurosurgeon recommends an
emergency craniotomy. Multiple attempts at reaching the patient’s wife prove to be futile.
NBS? Perform the craniotomy

What is the general rule regarding patients < 18 on an NBME exam?

Need parental consent

When is parental consent not necessary on NBMEs?

Mental health
Reproductive health
* You cannot get any surgical procedure (abortion) w/out parental consent

42.Most common perpetrator of child abuse

Primary caregiver
43.Ocular finding associated with child abuse
Retinal hemorrhage

Copyright July 2024, Divine Intervention Pro Consulting LLC

44.Most common method of suicide in the US
Firearms

45.BRF for suicide

Hx of prior suicide attempt

46.Unusual LP findings on NBMEs in suicidal individuals

CSF:
1 Low levels of NE/5HT
2 High levels of cortisol

47/48.What must be done before cutting patient ties on an NBME exam?

1 notify in writing
2 provide referral

49.A 29 yo surgery resident is asked to prescribe methadone by his sister who has been in drug
rehab for the last 5 years. She has no record of relapse. She missed her clinic appointment and
needs to go on an impromptu trip.
No, methadone is a controlled substance
Don’t prescribe meds to family members

50.A 15 yo F comes to the physician for her annual checkup. While her parents are out of the
room, she asks the physician for an ethinyl estradiol prescription. She doesn't want her parents to
know about this.
Prescribe the OCP + counsel (don’t need parental consent)

51.Vaccine that should be administered before a newborn leaves the hospital.

Hep B vaccine

52.A parent asks her 6 year old child’s pediatrician if he can receive the COVID-19 vaccine.
Yes anyone > 6 mo

53.A 30 yo F comes to the pediatrician’s office for her newborn’s 2 month visit. The physician
recommends the administration of the rotavirus, DTaP, HiB, PCV13, and inactivated polio
vaccine. She refuses these vaccines and wants to leave.
Yes, can refuse

Copyright July 2024, Divine Intervention Pro Consulting LLC

54.A psychiatrist is driving to the hospital for his shift when he notices a car accident on the side
of the road. There is one individual in the car. The victim is able to converse, is alert and
oriented, and appears completely stable. There is no fire or visible life threat from the accident.
The psychiatrist decides to take the patient to the emergency room in his car and places the
accident victim in his back seat. On arrival at the ED, the patient is noted to have complete
paralysis of the upper and lower extremities. Radiographic imaging reveals C-spine injury.
Yes the psychiatrist is legally liable bc he deviated fr the standard of care
This was not an emergency situation, pt was stable

55.35 yo F at 30 weeks gestation comes to the ED with a 3 hr h/o profuse vaginal bleeding.
Transabdominal ultrasonography with doppler shows bleeding from fetal vessels overlying the
cervical os. FHR tracings show recurrent late decelerations with a FHR of 70. A crash cesarean
section is recommended. The mom, who is hemodynamically stable, alert, and oriented to
person, place, and time states that she wants a vaginal delivery. The physician emphasizes the
high risk of fetal demise without the procedure. The patient verbalizes a complete understanding
of the physician’s objections and still wants a vaginal delivery.
Vaginal delivery - Honor the patient’s wishes

56.A 34 yo F is brought to the ED. She is the only survivor of a plane crash that killed all
passengers on board. Her vital signs are within normal limits. She has no perceptible brainstem
reflexes. According to the patient’s medical record, the last date of her last menstrual period was
17 weeks ago. Transabdominal ultrasonography reveals a healthy fetus. There are no fetal heart
rate abnormalities.
Pt is braindead, pt is 17w old not yet at term
Keep mom alive + deliver baby when appropriate

57.A 33 yo F at 39 weeks gestation comes to the ER after noticing blood emanating from her
vagina. Her pregnancy has been complicated by polyhydramnios that was diagnosed in the 3rd
trimester. She delivers a fetus who is unresponsive and is emergently intubated. Further
diagnostic evaluation reveals an undivided cerebral hemisphere. There is no evidence of brain
activity on an EEG. The patient has a 10 month old with severe heart failure and is on a
transplant waitlist. The mother requests that her son receive the heart of her brain dead child.
Allow transplant -

58.A 37 yo F with a h/o multiple sclerosis comes to the ED 2 hrs after she stopped seeing
anything from her right eye. She states that she had eye pain that started 2 days ago that did not
respond to ibuprofen therapy. The patient received the diagnosis of multiple sclerosis 10 years
ago and had regularly scheduled 3 month visits with her neurologist. She has called the

Copyright July 2024, Divine Intervention Pro Consulting LLC

neurologist’s office for the past 8 months and has been unable to schedule appointments and
have her natalizumab refilled. Upon further investigation, the ED physician discovers that her
neurologist retired 10 months ago.
Yes the neurologist is legally liable – this is patient abondonment
You did not notify them in writing and refer them to another dr (transition of care)

59.A 19 yo M comes to the ED with a 2 week h/o SOB, fevers, and moderate chest pain. His
ESR/CRP are markedly elevated. A systolic murmur that increases with inspiration is heard at
the LLSB. The patient is admitted to the hospital for further evaluation. Blood cultures obtained
the next morning reveal gram +ve cocci in clusters. A decision is made to begin IV vancomycin
therapy. The patient refuses and wants to leave. He is advised on the risks of leaving the hospital
and is told to sign an “Against Medical Advice” Form. He walks out of the hospital and does not
sign the form.
No legal trouble, document pt refusal

60.A 25 yo F comes to the physician for her first prenatal visit. She comes to the visit with her
husband who she married 6 months ago. Her last menstrual period was 9 weeks ago. A blood
sample shows that the lady is Rh-. Her antibody status is positive. Her husband is known to be
Rh+. The patient states that she has never been pregnant before but has had 4 abortions in the
past. She requests that the physician not disclose this information to her husband and wants the
physician to mention that she had a blood transfusion in the past for anemia.
Don’t disclose, BUT DON’T LIE

61.A nurse mistakenly gives a patient 1000U of aspart instead of the ordered 75U. 55 mins after
the dose was given she notices her mistake and immediately begins an infusion of D5W. What is
the NBSIM?
Admit error

What kind of error was committed by the nurse in this circumstance?

Active error
The pyxis machine at a hospital has an antibiotic rack that includes cefotetan, cefazolin, and
cefuroxime placed side by side. What is 1 potential issue associated with this setup?
Latent error – mistake waiting to happen

How can errors of this nature be reduced in the EMR?

Tallman lettering

For errors of this “general nature”, do we fix the healthcare worker or the healthcare system?

Copyright July 2024, Divine Intervention Pro Consulting LLC

Fix the sys

As an aside, when is it appropriate for a physician to have a sexual relationship with a patient?
Never

62.A rural ER with only 1 physician and nurse are confronted with 3 patients who all present at
the same time. Patient A is a 37 yo F who has over the past 12 hrs had worsening shortness of
breath and chest pain. Her BP is 115/75 and EKG shows sinus tachycardia. Patient B is a 22 yo
varsity athlete who has had chest pain for the past 3 days and has bilaterally auscultable breath
sounds. His BP is 110/73, HR is 65 bpm, and RR is 17. Patient C is a 55 yo M with chest pain
radiating to his jaw with territorial ST elevations visualized on an EKG. What is the most
appropriate physician action in these circumstances?
C - MI
A – PE
B-

In taking care of 1 patient first over the other, is an ethical principle being violated?
Triage does not violate ethics

NBME implications for healthcare systems overrun with a pandemic (e.g. COVID-19)?
Stop elective surgeries to devote resources to people who need it most

Copyright July 2024, Divine Intervention Pro Consulting LLC

Quality Improvement

63.What is the most likely quality improvement concept being emphasized with the following
case scenarios?

A hospital is about to establish a new ICU. They design a project to examine dosing of opioids in
the ICU and set up a taskforce to determine all the steps in this process along with a detailed
analysis of potential pitfalls along the way.
Proactive planning before error has happened = failure modes and effects analysis
Task force or multidisciplinary team
Hazard analysis

A 49 yo M dies in a hospital ICU from intracranial hemorrhage. He had initially been getting a
heparin infusion for a submassive pulmonary embolism. The hospital sets up a taskforce to
thoroughly analyze his hospital course and identify factors along the way that may have led to
his death. Plotting?
Root Cause Analysis = why did this happen?
Retrospective – after the error has happened
Plot on fishbone diagram (Ishikawa)

Copyright July 2024, Divine Intervention Pro Consulting LLC

Quality Measure

64.What kind of quality measure is being emphasized in the following measured situations in an
ICU?

Are readmission rates among heart failure patients increasing after measures are implemented to
reduce their hospital length of stay?
Indirect – balanced measure

Outcome = readmission rates

Intervention to reduce hospital LOS

# of adverse drug events after a tallman lettering system is implemented in an ICU.

Direct – outcome measure
ADE = outcome
Tallman lettering = intervention

# of patients having follow up appointments scheduled by the discharging nurse after admission
for a CHF exacerbation.
No intervention – process measures

Multiple, overlapping safety systems to reduce error:

Swiss cheese model

2:00
NBME “buzzwords” for quality/safety practices that improve standardization in healthcare
systems?
Checklist
Protocol/Algorithm
Pre-Procedure Timeout
2:02
A procedure kit for placing central lines in a major university hospital is found to have 3 extra
lidocaine vials, 4 extra syringes, and a thermometer. The hospital notices that most of these
“extra” items get thrown away and decides to have the manufacturer create a custom central line
kit that contains exactly what is needed. What quality/safety principle is being employed by the
hospital in this circumstance?
Simplification

65.A 47 yo M is brought to the ED with multiple fractures and severe injuries. He is the only
survivor of a significant motor vehicle accident. On arrival, he is profoundly hypotensive and his

Copyright July 2024, Divine Intervention Pro Consulting LLC

PaO2 is 60. 5 mins after arrival, his PaO2 is now 50 and continues to decrease. The patient has
an advanced directive that indicates a willingness to obtain resuscitation but specifically refuses
endotracheal intubation. What is the most appropriate NBSIM?
Code status: DNI
Resuscitate but don’t intubate (can even do bag valve mask)

66.A 37 yo F brings her 10 year old daughter to the ER. Over the last 4 hrs, her daughter has
developed progressively worsening SOB and fevers. PE is notable for audible stridor and
tripoding. The physician mentions that he is concerned about epiglottitis and recommends
immediate intubation. The patient’s mom states that she does not feel comfortable with
intubation and would like her daughter to be transferred to another hospital.
Intubate in the OR
This is a medical emergency in a pediatric pt – ignore the mom

67.A 17 yo F is brought to the pediatrician for her annual exam. A urine sample is being obtained
by the physician to screen for STIs. The patient’s mom requests that the physician privately test
some of the urine for marijuana.
Decline
You cannot test a pt without their consent

68.A 31 yo F is brought to the ED by ambulance after colliding with another vehicle on the
highway. Her 2 year old daughter was in the car during the incident. Her blood alcohol level is
found to be 10x the legal limit. What is the most appropriate NBSIM by the physician?
Call CPS

69.A 44 yo M has been in a persistent vegetative state for the past 3 weeks. This determination
has been agreed upon by 4 neurologists involved in the patient’s care. He was brought to the ER
4 weeks ago by friends after he passed out at a party. A drug screen on admission showed
extensive amounts of opioids, marijuana, and other illegal substances in his urine. The internist
in charge of the patient’s care decides to discontinue normal saline and TPN administration. The
family of the patient refuses the physician’s recommendations despite detailed explanations of
the futility of continued medical care.
Court order

70.A 67 yo M with a h/o terminal Stage 4 small cell lung cancer calls his oncologist’s office. He
has had severe headaches over the last 5 days and significant neck swelling. He is unable to
speak to anyone and leaves a message. His oncologist is out of town and does not receive these
messages until a 2 week period has elapsed. The physician calls the patient’s family and finds
out that he passed away 5 days ago. The family plans to sue the physician.

Copyright July 2024, Divine Intervention Pro Consulting LLC

Yes onc is liable bc this is Patient abandonment

71.A 15 yo M comes to the physician to request surgical contraception. He started dating a girl 6
weeks ago and is concerned about getting her pregnant. His girlfriend requested that he have a
vasectomy before having sex with him.
No, counsel + decline
You cannot do an elective surgical procedure without patient consent

72.A 3 yo M is diagnosed with acute lymphoblastic lymphoma. He presented 2 weeks ago with a
1 week history of fevers, weight loss, night sweats, and diffuse cervical lymphadenopathy. His
parents state that they want to try a 3 month course of alternative medicine therapy before
considering the physician’s recommendations.
Tx the ALL

73.A 43 yo M is brought to the physician from work after a ladder fell on his ankle. Imaging
reveals a Grade 1 ankle sprain requiring 3 weeks of rest and physical therapy for complete
resolution. He requests that the physician extend the time of rest and physical therapy to 3
months so he can spend more time with his family.
No this is fraud

74.A 39 yo F with a h/o IVDU is in hospice. She was admitted 3 weeks ago after treatment
failure for end stage hepatocellular carcinoma. She is on a timed 3 hr regimen of round the clock
morphine. She is in tears and states that the morphine is not controlling her pain. She requests a
dose increase to help with her pain symptoms.
Inc dose
Extended sustained release opioids

75.A 14 yo M is scheduled to participate in a research study on the efficacy of a COVID-19

vaccine in 10-20 year olds after his parents provided informed consent. When the child arrives,
he refuses to receive the vaccine and does not want to participate in the study. What is the next
best step in this situation?
Don’t give the vaccine – bc this is a research study and not an emergency tx, child not assenting
is valid

76.A 23 yo M medical student has been on an OBGYN rotation for the past 5 weeks. He wants
to go into OBGYN. He asks his supervisor if he can introduce himself as a “student doctor” so

Copyright July 2024, Divine Intervention Pro Consulting LLC

he can get fewer patient refusals. What is the most appropriate supervisor response in this
situation?
Decline
Misrepresentation

77.A new 3rd year medical student is on his anesthesia rotation. He is working with a senior
resident on a 49 yo F undergoing a routine endometrial ablation for abnormal uterine bleeding.
The patient is under mild sedation. The medical student asks the resident if he could practice
placing a central line on the patient since she was sedated and “won’t feel any pain”.
Decline

78.A 65 yo F with a h/o Alzheimer’s dementia is brought to the ED by her daughter with a 12 hr
h/o significant abdominal pain and vomiting. Angiography is consistent with occlusion of the
superior mesenteric artery. The physician recommends embolectomy and exploratory laparotomy
to evaluate for ischemic bowel. The patient demonstrates a detailed understanding of her
condition and the risks and benefits of the planned interventions. The daughter is worried that her
mom cannot give informed consent. What is the most appropriate NBSIM?
Yes pt w dementia can give consent (ie has capacity as long as they are able to communicate
Indications
Risks
Benefits
Alternatives

Dementia does not automatically preclude consent

79.A 13 yo M comes to the ED with his friend who has a h/o biliary atresia. PE is notable for
extensive yellowing of his skin. His PT/INR is elevated. According to the physician, his life
expectancy is limited and a liver transplant is necessary. The 13 yo offers to be a donor for his
friend. The parents of the 13 yo politely disagree to having their son be an organ donor. The 13
yo insists that “the organs are his and he can do with them as he pleases' '. What is the most
appropriate NBSIM?
Listen to parents
If under 18, Cannot donate organs w/out parental consent

80.A 46 yo M agrees to donate a portion of his liver to a friend. His friend offered him $750 to
help cover his medical expenses in donating his liver. The physician taking care of the ill patient
finds this out. What is the most appropriate physician action in these circumstances?
Allow the transplant
Allowed to receive compensation for covering medical expenses

Copyright July 2024, Divine Intervention Pro Consulting LLC

81.A 78 yo F at a nursing home is brought to the ED with a 3 day h/o lower abdominal pain and
foul smelling vaginal discharge. Gram stain of a vaginal sample shows gram negative diplococci.
What is the NBSIM of this patient?
GNDiplococci = neisseria gonorrhea – c/f elderly sexual abuse – call APS

82.A 39 yo obstetrician is on call with the labor and delivery service. She is HIV+ and has an
undetectable viral load on HAART. A 31 yo F at 36 weeks gestation is admitted to the labor
floor for a C-section. Her pregnancy has been complicated by gestational diabetes with resultant
fetal macrosomia. What is the most appropriate NBSIM?
Yes

83.Can a physician refuse care to a HIV+ patient?

No

84.A 13 yo F is brought to the ED by her mom with a 12 hr h/o profound hemoptysis. Her
palpable systolic blood pressure is 50 mmHg. Her measured Hb is 5 and a blood transfusion is
recommended. The mother, who is a member of Jehovah’s Witnesses, adamantly refuses the
transfusion. What is the most appropriate NBSIM of this patient?
Transfuse

85.A hospital ICU has received 4 citations over the past year from the Center for Medicare
Services. There have been 35 patient safety incidents over this time period identified by
investigators that have overall led to 12 patient deaths. The hospital determines that many of
these incidents could be traced to nosocomial infectious spread by physicians, medical students,
and other allied health professionals that work in this ICU. Which of the following interventions
would most likely decrease the risk of spreading infection by direct contact within this ICU?
a. Offer training on hand hygiene practices to all staff every 5 years
b. Institute remuneration reductions for hospital staff that fail to comply with handwashing
regulations
c. Send regular emails to hospital employees on the importance of routine hand washing in
reducing the number of nosocomial infections
d. Provide hand hygiene electronic reminders in front of patient rooms and increase
the number of hand hygiene stations available to staff in the ICU
e. Provide moisturizing solutions to decrease hand dryness amongst ICU staff

As an aside, what is the most effective mode of hand hygiene?

Use of an alcohol based sanitizer = most effective mode of hand hygiene

Copyright July 2024, Divine Intervention Pro Consulting LLC

A surgeon just completed an emergent cholecystectomy complicated by the extensive loss of
blood. The physician and many of the circulating nurses have blood stains on their gowns and
hands. What is the most appropriate next step in preventing the spread of nosocomial infection?
a. Hand washing with soap and water – bc blood

b. Use of an alcohol based sanitizer

86.A morbidity and mortality conference is conducted at a rural healthcare facility in Virginia to
review recent events in the hospital’s emergency room associated with multiple patient deaths.
The primary event under review was the death of 25 out of 30 patients who were brought in by
ambulance after a shooting at an elementary school located half a mile away from the hospital.
Most of the patient’s brought in by ambulance sustained a variety of wounds with 2 patients
sustaining gunshot wounds to the head, 15 patients sustaining minor abdominal/lower extremity
wounds, and 13 patients sustaining significant wounds leading to splenic, hepatic, and
retroperitoneal injury. The ED is staffed at any given time by 8 nurses, 2 physicians, and a
“technician” that helps with various clinical tasks as needed. Upon review, it is noted that only
25% of the patients with significant trauma received timely medical intervention. What is the
most likely intervention that will reduce similar occurrences within this healthcare system in the
future?
a. Offering regular staff training and triage drills in the management of mass casualty
events
b. Increasing the number of staff available at the emergency room to attend to patients
c. Increase the number of rooms available for patient triage and assessment in the
emergency department
d. Host regular morbidity and mortality conferences to revisit this event and it’s attendant
lessons for healthcare professionals
e. Implement measures to reduce transport time from disaster zones to the hospital’s
emergency room

Poor triage
Training = most effective intervention

Copyright July 2024, Divine Intervention Pro Consulting LLC

87.What kind of precautions should be adhered to in caring for patients with TB, COVID,
measles, and varicella? Airborne precautions
1 respirator (N95)
2 gown
3 gloves
4 eye protection

Hospital location: negative pressure room (

P/P negative pressure means air will flow inside (high to low)
Rather than have the bad air w dz leave the room
Filtration for these patients: HEPA filter = High Efficiency Particulate Attenuation Filter
Want to filter the air leaving the room (to reduce transmission)

Filtration for a 2 week old child awaiting stem cell transplantation for severe combined
immunodeficiency:
HEPA filter for air coming in
PT w SCID, place in positive pressure room (higher pressure inside the room so bad
things outside don’t come in and potentially cause dz)
Bc you want

88.In the management of COPD patients, which of the following measures of respiratory support
is associated with a decreased risk of infectious complications?

CPAP/BiPAP vs endotracheal intubation?

CPAP/BiPAP have lower risk of infx bc NIPPV = non-invasive

Nasal vs oral intubation?

Oral intubation has the lower risk of infx (this is why oral intub is more common)
We don’t nasal intubate bc of the high risk of infx

What are some specific measures that can be taken in a healthcare setting to increase the
probability of returning to baseline function after undergoing endotracheal intubation?
ICS = Incentive Spirometry
Early mobilization

89.An obstetrician is performing a crash cesarean section on a 29 yo F with recently diagnosed

vasa previa after fetal decompensation. The obstetrician notices some blood under her gloves. A
linear laceration is seen on the 3rd digit of her left hand.

Copyright July 2024, Divine Intervention Pro Consulting LLC

What is the most appropriate initial step in management? Wash hands w soap + water

After initial management, what specific microbes should this patient be tested for?
HIV + Hep B, C

The following labs are obtained from the patient;

HCV RNA: Negative
HbSAg: Positive
Anti-HbC (IgG): Positive
HIV antigens and RNA: Negative

The following labs are obtained from the obstetrician;

HCV RNA: Negative
Anti-HCV antibodies: Negative
HbSAg: Negative
Anti-HbC: Negative
Anti-HbS: Negative
HIV antigens and RNA: Negative

Given the results obtained from the patient and obstetrician, what is the most appropriate next
best step in the management of the obstetrician?
Hep B vaccine (active immunity) + Hep B immune globulin (passive immunity)

90.What is the most common cause of readmission after hospital surgery? Surgical site infx

91.Mr. X presents to an ED with chest pain and SOB. He was accompanied by his girlfriend. He
requests to see a physician but in triage becomes belligerent. Security escorts the patient out of
the ED. An hour later, the patient presents again complaining of worsening chest pain. His
girlfriend reports that he also had a seizure. She is requesting help in lifting her partner to a bed
in the emergency room but the ED security refuses and asks them to leave. The patient’s
girlfriend drives 20 mins to take Mr. X to another hospital. He is declared dead on arrival. What
does the NBME expect you to know here?
EMC: Emergency Medical Condition
MSE: Medical Screen Exam (regardless of your ability to pay)
Dumping: No
Concept: EMTALA = Emergency Medical Treatment and Active Labor Act

92.An 87 year old neurologist has been observed to misdiagnose 13 patients over the last 11
months with Parkinson’s disease. He has over the last 3 months also required more help from his
medical assistant for basic tasks he previously handled on his own.

Copyright July 2024, Divine Intervention Pro Consulting LLC

Next steps in management on NBMEs;
First line: report to supervisor or chief of med staff

2nd line: state medical board

Medicare
93.Given the following case scenarios, how would these patients be best able to pay for
healthcare?

68 yo M who spent 2 weeks in the ICU for the treatment of a severe lobar pneumonia.
Part A = Inpatient care (AI )

Same male as above being discharged and needing to pay for outpatient ciprofloxacin therapy.
Part D = Drugs (DD)

Same male as above visiting his PCP for outpatient follow up.
Part B = Outpatient (BO)

Who typically qualifies for medicare? >65+

What are some other patient populations that would qualify for the kind of insurance in the case
scenario described above?
1 ALS
2 ESRD
3 Social Security Disability

94.A few scenarios

How should a hospital investigate the death of a 19 yo M who received defibrillation for
hemodynamically unstable VTach?
Root Cause Analysis
(error here is that HDUS VT is tx w synchronized cardioversion)

When a patient makes sexually suggestive comments to the physician/is seductive, what should
be done on NBMEs?
Chaperone

A medical student is on his surgery rotation. His patient, Mr. X, has been having worsening
fevers and abdominal pain 3 days after a colectomy for ulcerative colitis. The medical student
observed that the sterile field was broken by one of the residents during the surgery and feels that

Copyright July 2024, Divine Intervention Pro Consulting LLC

this is a direct cause of the infection. What is the most appropriate action by the student in these
circumstances?
Report

What should be offered to a 45 yo M with Glioblastoma Multiforme who is now completely bed
bound, cannot read or write, and is completely dependent on others for his activities of daily
living?
Hospice

How can goals of care be established in a palliative medicine setting?

Family meeting

What antibiotic is used as infection prophylaxis before most surgeries?

Cefazolin 30-60 min before the procedure

If an individual has been intubated for > 5 days, what should be considered to prevent long term
airway complications?
Tracheostomy tube

Reducing the risk of falling in elderly patients on inpatient admission?

Close to nurse
Bed alarm

Most important history item to be obtained in a person > 50 visiting a gastroenterologist?

Blood in stool

What should be done when a healthcare worker encounters an unlabeled syringe?

Discard and report as adverse event bc this is a patient safety issue

The predominant mode of physician compensation in the US is fee for service. We are slowly
transitioning to value based payments which reimburse based on the “quality” of the healthcare
services you render.

Copyright July 2024, Divine Intervention Pro Consulting LLC

Other Useful Tips/Questions
95.When a patient expresses frustration (e.g delay before a physician sees them, etc), validate
their feelings first. Don’t offer your excuses.

96.When you want a patient to initiate a positive life change (e.g start exercising, eating a
healthy diet, etc), consider using motivational interviewing. The right answer on the NBMEs
usually revolves around asking about “factors” that may be impeding the patient’s ability to
make the change. Don’t threaten (you will die), demean (couch potato), or ask about when they
want to make the change when you have not addressed the impeding factors.

97.For an individual that has lost a loved one;

Yearning for the loved one, being sad/irritable, having sleep issues, illusions/hallucinations of
the dead, crying when you see something associated with that person, a mild decrease in appetite,
etc are normal. These people are usually still able to care for themselves and engage/interact
with others.

Wanting to die or commit suicide, being psychotic, seeing the dead person and believing it’s real,
not being able to care for oneself, not wanting to interact with others, etc is NOT normal

98.Delirium in a palliative patient is managed with antipsychotics. Anxiety is managed with a

benzo. Only pick a sitter as an answer for delirium if it’s given as an answer choice.

99.A terminal patient that is having respiratory distress and issues with “secretion clearance”
should receive a drug like atropine or glycopyrrolate (antimuscarinics).

100.When should a patient stop smoking before surgery? 6-8w

101.What could be done to reduce the risk of postoperative pulmonary complications? ICS inc
spiro

102.A 55 year old male with well controlled diabetes mellitus is scheduled to undergo an open
colectomy for severe diverticulosis. He is on oral pharmacotherapy and a most recent A1c was
7.1%. What should be done preoperatively to decrease his risk of complications?
Stop oral meds (metformin) -> switch to insulin (goal BG <180)

103.Many stress about the revised cardiac risk index (RCRI), but here’s what you should know.
If a person is having a high risk procedure (intra abdominal surgery, vascular, thoracic, etc) and
they have a lot of cardiac risk factors like a history of ischemic heart disease, CHF, chest pain

Copyright July 2024, Divine Intervention Pro Consulting LLC

with physical activity, etc, they need some sort of cardiac testing dictated by the vignette usually
in the form of some kind of stress test.

104.For palliative pain control, do not use meperidine (seizures) OR tramadol (too many drug
interactions especially serotonin syndrome)

105.According to the USMLEs, an emancipated minor is one who is in the military, married,
or not living with their parents.

106.An old person that has multiple hospitalizations and is unable to take medications properly
on the USMLEs needs legal guardianship.

Premature Closure
107.A 25 year old male comes to the emergency department with a 12 hour history of significant
abdominal pain radiating to the back. Medical history is significant for alcohol use disorder. His
vital signs are temperature 101F, pulse 120/min, respirations 25/min, and blood pressure 110/65
mmHg. The patient is diagnosed clinically with acute pancreatitis and usual therapy is
administered. Initial labs were not obtained by the ED physician. When asked by the rotating
medical student, he mentions “this looks like a classic case of acute pancreatitis. I mean, he’s
also an alcoholic. Getting labs when we know what he has is not cost conscious medicine”. 2
days after admission, the patient’s clinical status continues to worsen. The internist decides to
obtain laboratory studies which disclose a WBC of 17000/mm3, blood glucose 1200 mg/dl,
HCO3- 7 mEq/L, and Na 123. What specific error was committed by the ED physician in this
circumstance?
Premature Closure

108.A 47 year old male comes to the office for follow-up 2 months after being admitted to the
ICU for the management of status epilepticus. He has since had 2 other episodes of short term (<
2 minutes) seizure activity. He reports no seizures within the last 3 weeks. Current medications
include Levetiracetam. His license was suspended by the Department of Motor Vehicles pending
clearance from his physician. What is the most appropriate next best step in the management of
this patient?

6 mo seizure free before resuming driving

Availability/Recency Bias
109.A 21 year old man comes to the emergency room with a 3 day history of chest pain. He
works as a bodybuilder and the pain is reproducible with chest palpation. He has no medical

Copyright July 2024, Divine Intervention Pro Consulting LLC

history and takes a daily multivitamin. On arrival at the emergency room, the admitting
physician obtains an EKG and serum troponins. The EKG was unremarkable and serum
troponins were within normal limits. Given the severity of the patient’s symptoms, the physician
recommends coronary angiography which shows < 20% occlusion of all his coronary arteries.
By the next day, the patient’s Cr is 2.5 and he is diagnosed with acute tubular necrosis. The
admitting physician saw a 25 year old male 2 weeks ago who was initially diagnosed with
musculoskeletal chest pain but died 2 days later after a missed diagnosis of a myocardial
infarction. What specific error was committed by the ED physician in this situation?

Availability bias = recency bias

Anchoring Bias
110.A 57 year old man comes to the emergency room with a 10 hour history of severe,
progressively worsening chest pain. Medical history is significant for heart failure with multiple
exacerbations. He also has insulin resistance. Current medications include metoprolol, enalapril,
spironolactone, and empagliflozin. Minimal crackles are heard on chest auscultation and there is
trace peripheral edema. The admitting physician has seen this patient many times and has treated
3 of his previous exacerbations. The patient is diagnosed with a CHF exacerbation and placed on
furosemide therapy. 12 hrs after pharmacotherapy was initiated, the patient continues to
complain of similar symptoms. He states that his “chest pain has not improved and things are
getting worse”. The physician obtains a CXR which discloses a normal cardiac silhouette. A new
examination today fails to disclose pulmonary crackles. Furosemide therapy is continued. 4 days
after admission, the patient dies unexpectedly in his sleep. An autopsy conducted by the hospital
reveals a large embolus in the left pulmonary artery. Which of the following interventions would
most likely have reduced this patient’s risk of error related mortality?
a. Involvement of multiple physicians in the patient’s care
b. Medication reconciliation with admission
c. Considering pretest probabilities for alternative diagnoses of chest pain
d. Monthly team huddles to discuss identified errors in patient care
e. Creation of a standardized checklist for all chest pain admissions

Anchoring bias – you stick w your initial dx, even though you see new evidence that refutes the
working dx
Vs
Premature closure – you didn’t do any testing

Copyright July 2024, Divine Intervention Pro Consulting LLC

111.According to our friends at the NBME, the presence of what factor most significantly
undermines a forced function?

Workaround

112.How can the following events be prevented on the USMLE exams?

a. Performing a right hip replacement in a 67 year old male with severe left hip
osteoarthritis:
Wrong site surgery
Prevent w timeout and marking

b. A neurosurgeon operating on the wrong level of the spine:

Wrong site surgery
Prevent w timeout and marking

c. Mr. Chase Adler undergoing a cardiac catheterization when Mr. Wells Adler was
supposed to receive that cardiac catheterization:
Wrong patient surgery
Prevent w timeout

d. Performing an ERCP in a patient that did not require one:

Wrong procedure
Prevent w timeout

e. Persistent fever 2 days after surgery despite antibiotic therapy. Exploratory laparotomy
discloses the presence of a scalpel in the patient’s abdominal cavity:

What are these events called on the USMLEs?

Never events – these are events that should have never happened bc they are easily preventable

113.What is the classically tested intervention associated with reducing hospital readmission
rates in patients with CHF exacerbations?
Scheduling outpt f/u to dec readmission

114.What kind of preventive medicine strategy is being employed by a city that builds more
sidewalks as a means of promoting increased physical activity in the community?

Copyright July 2024, Divine Intervention Pro Consulting LLC

Primordial prevention – like precursor to primary prevention
Reduce the risk of developing risk factors

Primordial prevention vs primary prevention

What kind of preventive medicine strategy is being employed with the following interventions?
a. Getting the TDAP vaccine: Primary Prevention
b. Recommendation for seat belt use in kids: Primary Prevention
c. A 24 year old female getting a pap smear: Secondary
d. Recommending smoking cessation to a 24 year old male with a 4 pack year smoking
history: Primary Prevention (so he doesn’t dev lung dz)
e. Checking A1c every 3 months in a known diabetic: Tertiary Prevention (bc you already
have the dz here)

Tertiary – prevent worsening of dz, improve survival

Copyright July 2024, Divine Intervention Pro Consulting LLC

115.Given the following sample statements/circumstances, what is the best description of
the patient’s stage of change?

“I want to stop smoking within the next 3 months. I’ve been thinking about it for a while now”
Thinking = contemplation

“I have not smoked a single cigarette within the last 6 months. I do get cravings from time to
time. Can you teach me some mental tools I can use to handle these cravings when they arise?
Maintenance =

In response to a physician asking about smoking cessation: “Can we discuss this some other
time? I am just not ready right now”
Precontemplation = im not ready rn

“I plan to quit within the next few weeks. For the past 7 days, I have cut out 1 cigarette from the
25 cigarettes I usually smoke. I am now at 18 cigarettes/day”
Preparation = small steps like cutting out 1 cig are small pos changes

“I have not smoked within the last 3 days. The nicotine patch and bupropion have been quite
helpful”
Action

Copyright July 2024, Divine Intervention Pro Consulting LLC

116.Mortality Measures (for measures that address the “burden of a disease”). Note that you
would not need to calculate these on your exam!

Disability Adjusted Life Years (DALYs) = Mortality + Morbidity

Mortality is basically defined as assessing the difference between when a person dies because of
a disease vs when they should have died if they were fully healthy. If having a disease kills you
at 50 when you could have lived to 85 if you were healthy and did not have that disease, your
mortality has increased.

Morbidity measures “chronic issues” you have while alive because you’re dealing with a
particular disease

We love DALYs because they comprehensively assess disease burden (morbidity and mortality).
If you have to choose amongst a bunch of mortality measures on your exam, pick DALY.

You may be asked to pick an intervention for a disease affecting large segments of the
population. They’ll give you a list of different interventions and the DALY reductions they
offer, you should obviously pick the intervention that reduces DALY by the largest amount.
For example, if the DALY associated with T2DM is 15 and you obtain a list of interventions
like;
A: Averts 8 DALYs
B: Averts 2 DALYs
C: Averts 5 DALYs

Pick intervention A because it averts the most # of DALYs

QALY (Quality Adjusted Life Years) is pretty much the same as DALY but it looks at things
from the opposite perspective. You want to obviously IMPROVE the quality of a person’s life.
The intervention that increases your QALY the most should be what you select for a given
disease. Like DALY, QALY assesses both morbidity and mortality.

There’s more technicalities to this stuff (like the cost/QALY) but that is generally beyond the
scope of the USMLEs. QALYs are used extensively in Cost Effectiveness Analysis (CEA)
within most health circles.

Other mortality measures like Years of Potential Life Lost (YPLL), Crude Mortality Rate, etc are
not as useful because they largely assess just mortality. You should generally not pick these
answers on your exam!

Copyright July 2024, Divine Intervention Pro Consulting LLC

117.Publication bias is a classic kind of bias associated with meta-analyses. Studies not
showing significant results may not have been published and this can skew the kinds of studies
you consider in your meta analysis.

Copyright July 2024, Divine Intervention Pro Consulting LLC