⚠ Disclaimer: This is an unofficial publication not affiliated with nor endorsed by the FSMB, NBME®, or USMLE® program. For official information please visit usmle.org or other relevant resources.
Pavel Zhelnov, MD
@drzhelnov
Dear Colleagues,
The NBME Item-Writing Guide (6th Edition – Version November 2020) lists the following sample lead-ins based on Communication and Interpersonal Skills tasks/competencies:
- Which of the following is the most appropriate opening remark to this patient?
- Which of the following is the most appropriate response by the provider?
- Which of the following statements by the provider is most appropriate to…?
As per the Item-Writing Guide, lead-in questions in good NBME-style items can be answered without looking at the options, so it is prudent to keep this in mind while dealing with sample items below.
The official instructions from the USMLE® Step 1 Sample Items (PDF) (accessed on August 24, 2021) are as follows:
Strategies for Answering Single One-Best-Answer Test Questions
The following are strategies for answering one-best-answer items:
- Read each patient vignette and question carefully. It is important to understand what is being asked.
- Try to generate an answer and then look for it in the response option list.
- Alternatively, read each response option carefully, eliminating those that are clearly incorrect.
- Of the remaining options, select the one that is most correct.
- If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers.
The official USMLE® Step 1 Content Description (PDF) (accessed on July 29, 2021) gives us one sample Communication Item. Additionally, in the official Step 1 Sample Items (PDF) (accessed on August 24, 2021) I could identify eight more. They were not explicitly labeled as Communication Items, so these are my own personal guesses from their content. In total, this makes nine sample Communication Items taken from official sources, which I reproduce below.
The correct answers are shown as in the original document. I encourage you to review the official document to make sure they are indeed correct. The collapsible options/answer blocks were not in the original design, but I added these to facilitate separate reading of item parts.
The items are reproduced in no particular order. Also, please consider the following notice from the Step 1 Sample Items (PDF) (accessed on August 24, 2021) document:
Although the sample questions exemplify content on the Step 1 examination overall, they may not reflect the content coverage on individual examinations. In the actual examination, questions will be presented in random order; they will not be grouped according to specific content. The questions will be presented one at a time in a format designed for easy on-screen reading, including use of the USMLE Laboratory Values table (included here on pages 5–7) and some pictorials. Photographs, charts, and x-rays in this booklet are not of the same quality as the pictorials used in the actual examination. In addition, you will be able to adjust the brightness and contrast of pictorials on the computer screen.
Note that the STEP 1 ONLY specification for Communication Items is not any official designation but instead was construed by myself from the official Step 1 Content Description (PDF) as well as the Step 2 CK Content Description (PDF) (accessed on July 29, 2021), so please take this accordingly. Also, Step 3 was not considered.
I do not own any sample USMLE content, just reproduce it for self-learning purposes and in good faith:
Copyright © 2021 by the Federation of State Medical Boards of the United States, Inc. (FSMB), and National Board of Medical Examiners® (NBME®). All rights reserved. The United States Medical Licensing Examination (USMLE®) is a joint program of the FSMB and NBME.
View this page on GitHub to create a custom copy (also to track versions). Feedback is always welcome via GitHub or Twitter. Enjoy!
Sample Communication Item #1
A 22-year-old man comes to the clinic to discuss the results of an HIV immunoassay done 1 week ago. At that time, he was also diagnosed with syphilis, and intramuscular penicillin was administered. He has no other history of serious illness and no known drug allergies. He takes no other medications. He had never previously undergone HIV testing. He has had sexual intercourse with six sexual partners in his lifetime; they have used condoms inconsistently. Vital signs are within normal limits. Physical examination shows a resolving, painless chancre over the penis. He is informed that the HIV immunoassay results are positive. Which of the following is the most appropriate statement by the physician to the patient at this time?
(A) “At this time, we recommend antiretroviral therapy for all HIV-infected patients. This needs to be taken consistently for the rest of your life. Are you ready to start therapy today?”
(B) “I noticed that you had never been tested for HIV before last week, although you were at high risk for infection. Why is that?”
(C) “Pre-exposure prophylaxis is very effective in preventing HIV infection. Had you ever considered using it?”
(D) “What are your thoughts and feelings about this HIV test result?”
(E) “You must be shaken by this diagnosis, but understand that we have effective treatment for this that can enable you to lead a normal life.”
(D) “What are your thoughts and feelings about this HIV test result?”
Sample Communication Item #2
After being severely beaten and sustaining a gunshot wound to the abdomen, a 42-year-old woman undergoes resection of a perforated small bowel. During the operation, plastic reconstruction of facial fractures, and open reduction and internal fixation of the left femur are also done. Thirty-six hours postoperatively, she is awake but not completely alert. She is receiving intravenous morphine via a patient-controlled pump. She says that she needs the morphine to treat her pain, but she is worried that she is becoming addicted. She has no history of substance use disorder. She drinks one to two glasses of wine weekly. Which of the following initial actions by the physician is most appropriate?
(A) Reassure the patient that her chance of becoming addicted to narcotics is minuscule
(B) Maintain the morphine, but periodically administer intravenous naloxone
(C) Switch the patient to oral acetaminophen as soon as she can take medication orally
(D) Switch the patient to intramuscular lorazepam
(E) Switch the patient to intravenous phenobarbital
(A) Reassure the patient that her chance of becoming addicted to narcotics is minuscule
Sample Communication Item #3
A 62-year-old man is admitted to the hospital for evaluation of abdominal pain. During the interview, he responds to the questions with a single word and sometimes with sarcastic answers. He does not engage in eye contact, and he frowns as he tells the physician that this is the third time he has been asked these questions. Which of the following is the most appropriate response by the physician?
(A) “Can you tell me more about your abdominal pain?”
(B) “I understand that you do not feel well,but I need to get a history here.”
(C) “I’ll come back once you’ve calmed down, and we can talk more then.”
(D) “Listen, if you choose not to cooperate, I’m not going to be able to help you.”
(E) “You sound upset. Tell me a little more about that.”
(E) “You sound upset. Tell me a little more about that.”
Sample Communication Item #4
A 68-year-old woman with end-stage renal disease comes to the office for a follow-up examination. She has required hemodialysis for the past year. Initially, she did well, but within the past 3 months, she has been admitted to the hospital for fluid overload because of poor adherence to fluid and salt restrictions. She says, “I’m so sick of being on dialysis. Following the restrictions is really hard.” Which of the following is the most appropriate initial response by the physician?
(A) “I imagine being on dialysis is frustrating, but you don’t want to die from kidney disease, do you?”
(B) “I know that this is challenging, but do you remember how difficult it is to be hospitalized?”
(C) “It is tough to change your diet and fluid intake, but what sorts of things were you doing at first when you were following the recommendations?”
(D) “Making these changes is so difficult. Can you imagine how good you will feel once you make the changes again?”
(E) “This is very hard to do, but you may have an easier time if you met with the dietician again.”
(C) “It is tough to change your diet and fluid intake, but what sorts of things were you doing at first when you were following the recommendations?”
Sample Communication Item #5
A 45-year-old woman comes to the office because of a 6-month history of hot flashes, night sweats, and insomnia. She has not had a menstrual period during this time. She thinks she is going through menopause and asks the physician if there are any medications that will alleviate her symptoms. Physical examination shows no abnormalities. The result of a urine pregnancy test is negative. The physician explains that hormone therapy likely will help and explains the risks to the patient. Which of the following is the next most appropriate physician statement?
(A) “Could you tell me your thoughts about the hormone treatment option we have discussed?”
(B) “I have many patients with similar symptoms, and everyone responds to hormone therapy differently.”
(C) “I will give you some written information to review, and then I can answer any remaining questions.”
(D) “If your symptoms are really severe, the risk of hormone therapy may be worth it.”
(E) “Would you like me to tell you what I think you should do?”
(A) “Could you tell me your thoughts about the hormone treatment option we have discussed?”
Sample Communication Item #6
A 26-year-old woman comes to a busy emergency department because of a 2-day history of runny nose. She has no history of major medical illness and takes no medications. Her vital signs are within normal limits. The patient has to wait 6 hours before she is seen by a physician. She is angry with the staff and says the only reason she had to wait this long is because she does not have insurance. In addition to apologizing to the patient, which of the following is the most appropriate opening remark by the physician?
(A) “It is harsh to suggest that you waited because you don’t have insurance, but how can we help you feel better today?”
(B) “It sounds like you are angry; shall I come back in a few minutes?”
(C) “Our wait time has nothing to do with insurance, so let’s talk about the reason you are here.”
(D) “The reason you waited so long is because we need to triage by severity.”
(E) “Thank you for waiting. How can I help you today?”
(E) “Thank you for waiting. How can I help you today?”
Sample Communication Item #7
A 75-year-old woman with type 2 diabetes mellitus and hypertension is brought to the office by her daughter because of a 4-month history of loss of appetite. The patient has had a 6.8-kg (15-lb) weight loss during this time. She immigrated to the USA from Argentina 35 years ago. She is fluent in Spanish and has limited English language proficiency. The patient’s daughter is bilingual. The physician studied Spanish in high school. The clinic receptionist is bilingual. A certified interpreter is not available at the clinic, but a telephone interpreter service is available. Which of the following is the most appropriate person to serve as an interpreter for this patient encounter?
(A) Bilingual staff member
(B) Patient’s daughter
(C) Physician
(D) Telephone interpreter
(D) Telephone interpreter
Sample Communication Item #8
A 19-year-old man with asthma comes to a new physician for an initial examination. He has been treated in the emergency department multiple times during the past 7 months because of acute exacerbations of asthma. The patient says that he has received care only from emergency department physicians on an almost monthly basis during the past 4 years, and he has managed his symptoms with inhaled β2-adrenergic agonists. The patient says, “All the doctors I’ve seen just don’t understand me. They keep prescribing inhalers that don’t work, including that steroid inhaler they gave me recently.” He has no other history of major medical illness. He does not appear to be in respiratory distress. Mild end-expiratory wheezing is heard over all lung fields. Which of the following is the most appropriate statement by the physician at this time?
(A) “Are you sure that you’re taking your medications appropriately?”
(B) “I’m confident that I can help you with your asthma. I will order pulmonary function tests to see exactly what the problem is.”
(C) “Tell me what you know about the steroid inhalers and how they are supposed to work.”
(D) “Your asthma seems particularly difficult to control. I’d like to refer you to an asthma specialist.”
(E) “You’re probably allergic to something at your home, so we’ll need to figure out what that is before your asthma can get better.”
(C) “Tell me what you know about the steroid inhalers and how they are supposed to work.”
Sample Communication Item #9
A 74-year-old man with mild chronic obstructive pulmonary disease comes to the physician for a follow-up examination. Current medications include a short-acting β2-adrenergic agonist by metered-dose inhaler as needed. Physical examination shows no abnormalities. At the end of the examination, he tells the physician, “I enjoy coming to see you because you remind me of my daughter. She died 35 years ago this month.” He has been a patient of this physician for 5 years. Which of the following is the most appropriate response by the physician?
(A) “I may have to refer you to another physician who doesn’t remind you of your daughter so you can focus more on your medical condition and its treatment.”
(B) “I’d like to refer you to a grief counselor so that you can work out your unresolved feelings about your daughter’s death.”
(C) “I’m sorry you lost your daughter. Unfortunately, since we only have a limited amount of time, we must now move on to your medical condition.”
(D) “That makes me feel a little uncomfortable. I hope you understand.”
(E) “You must miss your daughter very much. Tell me about her.”
(E) “You must miss your daughter very much. Tell me about her.”