Ethics, Safety & Communication — USMLE Step 2 CK Notes

Why this section is worth your time

These items are US-specific, formulaic once learned, and the area IMGs most reliably underprepare. They are also unusual in that the right answer is often a sentence rather than a drug.

Four heuristics that solve most items

1. Explore before you inform or act. If one option asks the patient about their concern and another gives information or takes action, the exploring option usually wins.
2. Autonomy beats beneficence. A competent patient may refuse anything, however unwise.
3. Fix the system, not the person. Where one option redesigns a process and another retrains or disciplines, choose the system.
4. Never conceal. Disclosure, honesty and reporting are correct even when the outcome was good.

Capacity

Four components: communicates a choice, understands, appreciates it applies to them, reasons. Capacity is decision-specific and clinical; competence is legal. A psychiatric diagnosis does not remove capacity, and refusing treatment is not evidence of incapacity. Always look for a reversible cause — delirium, hypoxia, hypoglycaemia, pain.

Surrogates and end of life

Hierarchy: the patient's current wishes → advance directive → healthcare proxy → surrogate. A valid directive outranks family preference. Withdrawing and withholding are equivalent. Double effect permits adequate analgesia even if it may shorten life, because the intent is comfort.

Minors

Generally need parental consent, with important exceptions: STI care, contraception, pregnancy care, substance use treatment, mental health care, plus emancipated minors. Encourage parental involvement but never make care conditional on it. A parent may refuse treatment for themselves, but not life-saving treatment for their child — that goes to court.

Patient safety vocabulary

• Active error — at the sharp end  ·  latent error — in the system
• RCA is retrospective; FMEA is prospective. This pair is examined directly
• Effectiveness hierarchy: forcing function > automation > simplification > checklist > education
• Just culture — report without fear, but recklessness is still accountable

Quality improvement

Donabedian: structure → process → outcome. PDSA: small, rapid, iterative. QI is local; research seeks generalisable knowledge and needs IRB review.

Communication

SPIKES for bad news. Ask what the patient already understands before explaining. Use silence. Name the emotion. Confirm with teach-back. Use a trained medical interpreter — never a family member, never a child — and address the patient, not the interpreter.