They key in these questions is to understand what they are actually asking you. Don't feel bad, this is actually an area where a lot of people lose points despite their feelings of confidence in the material. We get similar questions in our school classes but where the school-written questions are typically pretty easy (we used to joke that you could cover up all the answer choices except for the first word of each and get the question right 90% of the time that way), the ones on step 1-3 are a little trickier.
To me, it helps to understand how these questions are written. Perhaps a good exercise is to try writing one yourself. I've long toyed with the idea of doing some sort of question-writing workshop because I think doing so changes how you study and how you think about test questions in a very powerful way.
So where do you start?
Lets start with an ethical concept: the limits of patient autonomy
Now lets make up a brief scenario:
56 year old man is brought into the ED following a high speed MVC. His primary survey revealed no immediately life threatening injuries. His secondary survey showed he is alert and oriented, no smell of alcohol, no focal neuro deficits. There is a deep laceration to his forehead, abrasions across his chest and abdomen in a seatbelt pattern. His vitals are stable. FAST scan negative. Further imaging is currently pending. You go in to examine the patient and repair his laceration when he begins yelling at you using multiple racial and ethnic slurs as well as a long string of profanity demanding to see a more "racially pure" physician. What is the most appropriate response?
a) leave the room and refuse to treat the patient until he could behave more approrpiately
b) attempt to find another provider that would be acceptable to the patient who could repair the laceration and complete his trauma workup
c) explain that you are the physician taking care of him and that it is up to him if he wants to leave and refuse care, but that if he stays he will need to behave more appropriately
d) place the patient in 4 point restraints and call security to come provide assistance
This is the kind of question you're probably picking the wrong answer to. Here I've described a patient who has carried his behavior well past an acceptable level in order to test your understand of ethics and how to handle this kind of situation (that you will face, I can assure you). So when I do ethical questions, I always list the four pillars: autonomy, justice, best interest, no harm. Next I test the answer choices against these pillars. Choice D does harm to the patient, is not in his best interest, does not respect his autonomy, and serves no purpose of justice, so clearly it is incorrect; it's probably a bit extreme for USMLE, they would probably have written a distractor more along the lines of 'call security for assistance and tell the patient you will have to restrain him if he can't behave.' Choice A is similarly wrong in that while you are respecting his autonomy, you are also abandoning him and not acting in his best interest and may be subjecting him to harm. Choice B is the best wrong answer because it allows autonomy to the point of disruptive and possible dangerous behavior, may be putting another colleague at risk, is not just in that it potential ties up additional resources and time, and is also not in the best interest of the patient. In this case, choice C would be the correct answer. It respects his autonomy to a point, gives him the choice of leaving and finding another physician if he wants to fire you and your hospital, is just in that it demands appropriate behavior from him and from you, and has you acting in his best interest to continue as his physician and treat him provided he can behave appropriately.
Try writing a couple questions of your own and see if that helps you see them a little differently.
