Changes to the Step 3 examination in 2014

The current Step 3 examination is administered in two 8-hour test sessions, which must be taken on consecutive days. The restructured examination will also be two test days; however, examinees will be able to schedule the two test days on non-consecutive days.  The examination days will consist of the following:

Step 3 Foundations of Independent Practice (FIP)this test day will focus on assessment of knowledge of foundational medicine and science essential for effective health care. Content areas covered will include applying foundational sciences; biostatistics, epidemiology/population health, and interpretation of the medical literature; and social sciences, including communication and interpersonal skills, medical ethics, and systems-based practice/patient safety. The test day will also include some content assessing knowledge of diagnosis and management. This test day will consist solely of multiple-choice questions and will include some of the newer item formats, such as those based on scientific abstracts and pharmaceutical advertisements.

Step 3 Advanced Clinical Medicine (ACM): this test day will focus on assessment of applying comprehensive knowledge of health and disease in the context of patient management. Content areas covered will include assessment of knowledge of history and physical examination, diagnosis and use of diagnostic studies, prognosis/outcome, health maintenance/screening, therapeutics, and medical decision-making. This test day will include multiple-choice questions and computer-based case simulations.

A single score (with graphical performance profile information) and a single pass/fail outcome will be reported following completion of both examination days.

The restructured Step 3 examination will be administered beginning November, 2014. During an approximately one-month period (October, 2014), it is likely that no Step 3 examinations will be administered.

Practice materials for the restructured examinations will be posted to the USMLE website in mid-2014. Examinees should anticipate a score delay following the introduction of the restructured examinations. Additional information will be posted as soon as it is available.

COMPREHENSIVE GUIDE STEP BY STEP GUIDANCE FOR US RESIDENCY MATCH PROCESS AND REQUIREMENTS

1 Month till Match season starts so reminded me of how it was last year for me so thought I should share my two cents on the topic. I am sure other seniors will have stuff to add here so here goes:

Resume:

In job applications, presentation of your experiences accounts to be one of the most important ingredient. You need to spend time to put in the best possible way all of your experiences. Try to elaborate and distribute them to as many headings in your ERAS cv. Don't write topped this gold medal that coz in the US they don't use that stuff.  Write your class ranking because everyone talked about mine. Also use Latin terms like magma cum laude etc. if you have got a distinction or something. Google them up :) Also put your social work experience, literary society, social welfare and all the other extracurricular stuff you love doing haha I was surprised when in most of my interviews they would love talking about that stuff. But write only if you have done something and not just for the heck of it because they will ask you details of what you did and how it benefited you

Personal Statement:
Well this was the hardest part of the application process as far as I think. It took me like forever writing it. Make sure you make it as personal as you can and don't take ask others or use those services to write your personal statement. But remember to show it to your seniors, friends etc. for feedback especially if they live in the US. I remember a PD during one of my interview talking about how touched he was with someone's story so seriously they read that. Because it gives them some idea about who you are, why you want to come to the US, why this specialty and why they should take you over someone. Make it sound so nice and special that anyone who reads it would want to meet you in person :) I remember sending mine to two three seniors and changed it based on their feedback. Also showed it to my cousin who is a Masters in English for grammatical correction and also to another friend who was super smart at writing stuff :) So basically mine got changed a gazillion times. Start working on it from now and don’t leave it for the last week. And no don't ask any senior for their personal statement because that'll change your mindset and you will start writing along the lines that person did and not what your personal story is. Also if you applying to multiple specialties, make sure you have different PS for different specialties.

Programs to apply to:

Apply widely and to as many programs as you can afford. I could only afford 75 but most people average around 130-150. I only applied to Medicine but I would seriously recommend applying to other fields too for backup. Fine if you get a lot of calls in the specialty you like, awesome. But what if you don't? It requires a lot of money going through the entire match so don't jeopardize it applying to only a few programs and one field. As a senior once recommended, apply to high tier programs, mid-tier programs and low tier programs. Apply wide and not to a specific area. Apply to programs who take a lot of img's and not just locals. High tier would say Harvard or John Hopkins haha I applied to Harvard coz I was like what if they like me, what if. And also how will I know if am good enough for them unless I apply right? haha But of course my application wasn't good enough for them, duh!!! :P BUt then I applied to a lot of mid-tier and also low tier programs and that worked out. The more the number of programs you apply to, more the number of interview calls you hopefully can acquire and more the chances of matching successfully. Apply to programs where you have seniors and other programs where you might know someone who can help you. I used to check each programs website from aamc, see their residents and go through their requirements given on their website. That way I would get a good idea about the program and then I would add it to my list. So make sure you go through all the programs you want to apply to. Get on it ASAP!

Crossing the Filter:

As mentioned in previous experiences your scores are one of the most important factor and the first hurdle you need to cross in order to secure residency. As from now on program will consider filtering application with three digit scores (as for most program filter is set around 220-230). So you will be in the pile of applicants who will cross initial score filter (they can be anywhere around 500 to 2000). Some programs filter by visa status so if you are a Green card or US resident you will get additional benefit. Anyhow after you have crossed initial filter what’s next. Either of the two things can happen, you can become lucky and program coordinator reviews your application and forward it to pd or your application will remain in the pile unchecked or reviewed till all the interview slots are filled.

Getting your application reviewed:

So this is the time you need to work your brains and be proactive. There are few ways you can do it.

* First if you can locate some seniors (most of them are simply awesome and helpful). They can forward your aamc id to program coordinator making it possible for program director to review it and if you match his expectations, that rewards an interview. Important thing is you keep a follow up with the seniors as their schedule is hectic; it may slip from their mind or they might have their own limitations. Also remember that a senior isn’t the Program Director. All he can do is forward your application and that's about it. Also, most seniors can only ask for a couple of people and not everyone. And they will be putting their own reputation at stake recommending you so don't feel offended if you don't hear back from their program.

*Second, try calling them yourself. You can call as early as end of September to first week of October. I maintained an excel sheet with all the programs I applied and the dates I called them with a brief note about the response.  Now the question is how you will approach the program coordinators. So I came up with some sources. You can obviously find phone numbers on ERAS itself. If you hear a human voice its good, most of the time it will go to voice mail, do leave a message some pc do listen to their voice mails. Calls are transferred to vm after 4 beeps (keep track of these as pc might pick up the phone so keep trying), sometimes it goes directly to vm. Other sources of contact numbers; websites (sometimes they try to avoid real numbers on eras due to floods of calls asking status); ACGME website (they have emails and phone numbers of pc and pd, most of the times they are different).

Early in the season coordinators are (most of the times) super friendly as the real trauma of hundreds of call daily has not started asking in a monotonous voice, “What is the status of my application?” Guys you need to be different in that situation. In majority of the programs coordinators play a significant role in selection of candidates. So you should understand your mission to get hold of interview starts the very moment when coordinator picks up the phone. Try to be nice and come up with some good queries for the program (which can be answered by pc), you can mention about your credentials (briefly about scores, electives, research publications) asking do they match the criteria they have set. Try to communicate your aamc id. That’s the most important part, if you can make the program coordinator open your application on eras, that’s what you are looking for (I received few iv calls right on spot). But your struggle is not over at this point. You need to maintain your communication call her again, with some more queries. Regarding how frequently you can call, you might call them each week to twice a week. As end of October will arrive you will find a significant change in pc’s attitude, as major bulk of applicants will start calling asking for status. That’s where you need to be smart don’t start with the same questions what every other applicant is asking. You need to develop a healthy relation with them so come up with some plan, something different which will hold you separate from other applicant. Most of the pc will note your aamc id but almost none will review your application because on average they receive 200 plus calls each day (that’s what one coordinator told me).

*Emails:

Along with calls send emails. Same rule is applicable here as well, be different. You need to pay special attention to the subject of your email (“application status” is not a good subject). Try to come up with something different, I am sure you can do it but be relevant. During the end of season I even sent emails to pc and pd with subject like ‘Regarding interview invitation’: well everything is fair in love, war and residency. It’s all about survival. I am sure they receive hundreds of emails daily, they will not go to each email, they will just go through the subjects (as some important emails do pop up in the pc email account, rest assure a different subject may compel pc to review your application). If your email subject is routine it will be deleted without even being reviewed. You can get hold of different email id of pc and pd as well from website and acgme website. I secured few interviews by this method. But make your emails short and to the point. Don't write your entire resume in the mail. Just 3-4 lines max. Mention that you applied and are interested in your program. And would love to hear back positively from their side. And your aamc id and name. 

What’s next:

If everything is going according to plan and you get your application reviewed will it guarantee an interview? Answer is in present competitive situation most likely No. You application must be strong enough with really good clinical and research experience. Each year many bright imgs remain unmatched, so you have to compete with applicants with great scores, lot of US clinical research/experience. If you already have all the stars the next important thing is how you will put it in your application. 

How to improve your CV and chances of match:

So if you are still a student try to secure electives. If you are already done with step 1 then you can manage to get hold of electives at many different places. Remember try for those places which do have imgs, going to big university programs e.g. mayo most of the time is not very helpful as you don’t have a real chance to match into that program. Some may argue letters from big programs matters, well if you compare it with real chance of matching in a mediocre program I will go with the second option. I will recommend for students to do at least 3 months of electives at different hospitals. During elective try to be proactive be there sharp at 6, ask residents to assign patient to you and participate in patient care. This will improve chances of getting hold of good letter of recommendation and good relationship with attending which can be used latter to acquire interviews. During your electives if your attending is active in research, ask him for opportunity and show enthusiasm to do research with him. If not search the directory get hold of doctors active in research, set appointment or just visit their office. You have to make the best use of time you spend in US. Always remember a sub-internship (elective rotation in internal medicine) is most recommended. Although it is hard to secure but if you perform well, it insure matching in the same program.

For graduates, search for externship positions (some noteworthy hospitals, St Vincent charity Cleveland, Wayne state cardiology and peds Detroit….) if unable to locate go for observership. Start sending emails to attending, asking for volunteer research and later on ask them if you can observe with them in their clinic or floor. Try to spend time in multiple hospital rather than spending 6 months at one place (exception; if you foresee solid chances to match into the same program).

Remember to make good impression with attending you work with, try to stay in contact with them. If you have good relationship with them, they might make phone calls/ emails to program directors. This will increase your chances. If you are working closely with some fellows, try to ask them to recommend you for residency program they graduated from. It is all about developing contacts and using them. Never shy off or perceive that it is not right to ask them, you won’t lose anything if you will.

Good luck everyone for a successful Match InshAllah. Hit us up if you have any queries! :)

Application process for Residency (ERAS)

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  Application process for Residency (ERAS)

  
  

  
  

  OBTAIN  ERAS TOKEN

  1. Go to www.ecfmg.org
  2. Click on OASIS and sign in
  3. Click on ERAS SUPPORT SERVICES
  4. Click on ERAS TOKEN REQUEST

  You will be charged  $100

  Use your token to log on at the link below:http://www.aamc.org/audienceeras.htmGo to “For Residency Applicants” and click “MyERAS Login”After you have logged on at MyERAS and established your account, the Token is of no further use. Each ERAS applicant is issued only one Token. Once a Token has been issued, it cannot be replaced by a new one

  1. When you have established an account you will be issued an AAMC ID. Use this number for all communications in ERAS whether sending LORs, MSPE, Transcripts.

  • As soon as you get your ERAS token, you can start uploading stuff. You can do that in any order and take your time but remember that it takes a week at least before the stuff becomes available online so don't push things to the September. Stuff you have to upload:

  1. MSPE( Medical School Performance Evaluation)
  2. Transcripts,
  3. At least 4 Letters of Recommendations to ECFMG who will scan and upload them. Send the documents as soon as possible as ECFMG takes time to upload the documents. (Allow a period of 4 weeks from the time ECFMG receives your documents to the time they get uploaded) You can send as many LORs as you want and they will all be uploaded but you can choose only 4 of them to apply on one program. Get LORs from people preferably in the field you are planning to apply in and from people who will write personalized LORs. Attach a cover letter/cover sheet. A cover letter/cover sheet contains instructions for letter writers. To print a cover letter, log onto www.aamc.org/eras and click the section marked ERAS for residency applicants. Then click on resources to download. There you will find a link for the cover sheet. Print the one which says ‘for Internal Medical Graduates’. The one for US graduates is different and is also available on the same page so make sure you print the correct one.
  4. Best way to get LORS submitted is not by mail coz that takes 3-4 weeks to get uploaded. Better way is to request the person electronically. All he has to do is click on the link which he'll get in his email and upload the LOR as a PDF. That way it gets uploaded and available within a week.
  5. All documents sent to ERAS require a Document Submission Form (DSF) to be attached as well. To access this form go to www.ecfmg.org, log into OASIS and click on ERAS Support services. There you will find a link for the DSF. You can print one DSF form for all the documents you wish to send at one particular time.
  6. Write your personal statement and choose programs and fill the ERAS application carefully
  7. Very Important to start working on your Personal statement from now and don't leave it for the last minute. Get it checked by some seniors in the US for their feedback on it.
  8. Upload your photo

  
  

  15th September

  APPLICATION PROCESS FOR PROGRAMS STARTS

  • $ for applying in programs
    Residencies Under the Same SpecialtyPrograms Up to 10 - $92Programs 11-20 - $9 eachPrograms 21-30 - $15 eachPrograms 31 or more - $26 each
    Example 130 Emergency Medicine programs [$92 + ($9 x 10) + ($15 x 10)] = $332Example 220 OB/GYN programs [$92 + ($9 x 10)] + 10 Family Medicine programs [$92] = $274

  Apart from the money charged above the NBME chares $70 fee for transmitting USMLE/NBME transcripts for applicants to programs, regardless of the number of transcripts requested.

  
  

  • Apply as soon as possible, preferably 1st September. Don’t wait for your LORs to reach ERAS before you apply.
  • Just assign LORs writers on ERAS and the LORs will reach the programs as soon as the LORs are uploaded.

  1. Sign in to ERAS
  2. Click on DOCUMENTS TAB
  3. Click on LETTERS OF RECOMMENDATION tab
  4. Click on DESIGNATE A NEW LETTER OF RECOMMENDATION WRITER tab and designate a letter writer

  You can check whether ECFMG has received your mailed documents by following the steps below

  • Go to www.ecfmg.org
  • Click on OASIS and sign in
  • Click on ERAS SUPPORT SERVICES
  • VERIFY RECIEPT OF ERAS DOCUMENTS

  Also if you are waiting for your result just select the option that the result is pending and submit the application because the program will get your result as soon as it’s released. If you have completed all your exams and are certified your number of interview calls will be more than if u have given only one exam at that time or have applied very late.

  
  

  REGISTER AT NRMP

  • Go to www.nrmp.org
  • Register yourself before November otherwise you have to pay a fine. You need to register with NRMP to submit your ROL (Rank Order List)
  • It will cost around $50

  
  

  Late Oct-Early Feb

  INTERVIEW SEASON

  • Programs start contacting you regarding interviews from the first week of October. Some may call you very late in the season
  • The actual interviews start from late October to early February depending on the program

  Late Febuary (February 26, 2014)

  SUBMIT YOUR ROL (RANK ORDER LIST)

  • Rate the programs in which you have interviewed according to your choice. Dont rank them in order in which you think you will get in but in order in which you like them and want to get into them
  • Dont wait till the last day to aubmit your ROL

  March 17, 2014

  MATCH DAY

  • If the program likes you and you like them, then ITS A MATCH! You have gotten into a residency program. The way it works is that program rank candidates and you also rank the program of your choice. The computer matches both the program and the candidate’s choice and matches.

KAPLAN USMLE STEP 2 CK QBANK SURGERY , MEDICINE (BREAST MASS)

A 41-year-old woman comes to the physician 3 weeks after a vaginal delivery, complaining of a lump in her right breast. She states that over

the past few days, she has noticed increasing redness in the area and that the site is painful and feels somewhat firm to her. She also

complains of fever and chills. She is concerned because she is currently breast-feeding her child. She has no medical or surgical history. She

uses acetaminophen occasionally for headaches and is allergic to sulfa drugs. Her temperature is 37.8 C (100.1 F), blood pressure is

110/70 mm Hg, pulse is 98/minute, and respirations are 12/minute. The right breast has an area of erythema and edema that is tender with

no fluctuance.

Question 1 of 4

Which of the following is the most likely diagnosis?

/ A. Breast carcinoma

/ B. Eczema

/ C. Fibroadenoma

/ D. Mastitis

/ E. Trauma

Explanation - Q: 1.1

Close

The correct answer is D. Mastitis represents a parenchymatous infection of the mammary glands. It is most often seen in postpartum women who are breast-feeding, and the symptoms typically appear 3-4 weeks postpartum. Most women with mastitis complain of pain in the breast with an area of redness and "hardness." Women also often have fever and chills, myalgias and arthralgias, and tachycardia. Examination shows erythema, edema, and tenderness. Patients with breast carcinoma (choice A) often present with an asymptomatic mass. While it is possible for patients with breast cancer to have erythema and edema of the breast and tenderness on exam, this presentation in a postpartum, breast-feeding woman is most consistent with mastitis. Eczema (choice B) does not present with a lump, as this patient has. It is a superficial disorder involving the top part (epidermis and upper dermis) of the skin only. It is also characterized by scale with erythema and not associated with fever, chills, and systemic symptoms like this patient has. Fibroadenoma (choice C) represents a proliferation of fibrous tissue in the breast. It is the most common tumor in young women. Patients with fibroadenoma typically present with complaints of a breast lump. The mass is usually small, unilateral, firm, and freely mobile. Patients with fibroadenoma do not usually present with erythema, edema, pain in the breast, and systemic signs of infection. Trauma (choice E) to the breast can lead to a condition called fat necrosis. Patients with breast trauma usually complain of a firm area of the breast, sometimes mobile, and occasionally with induration. However, patients with fat necrosis from breast trauma usually recall a prior incident of trauma.

Question 2 of 4

Histological examination of diagnostic tissue from this patient would reveal which of the following?

/ A. A Iocalized area of acute inflammation

/ B. Cellular, fibroblastic stroma enclosing cystic spaces lined by epithelium

/ C. Edema fluid within the intercellular spaces of the epidermis

/ D. Hemorrhage enclosed within the tissue

/ E. Strands of infiltrating tumor cells

Explanation - Q: 1.2

Close

The correct answer is A. This patient has a presentation that is most consistent with mastitis, which represents an acute localized infection. Histologic evaluation would, therefore, reveal a localized area of acute inflammation with edema and neutrophil emigration. Cellular, fibroblastic stroma enclosing cystic spaces lined by epithelium (choice B) would be the histology of a fibroadenoma and not mastitis. Edema fluid within the intercellular spaces of the epidermis (choice C) is the histologic finding in eczema. Hemorrhage enclosed within a tissue (choice D) describes a hematoma and would be the expected histologic finding in a patient with trauma to the breast with a resultant hematoma. This patient's presentation is more consistent with mastitis than trauma. Strands of infiltrating tumor cells (choice E) would be the expected finding in a patient with certain types of carcinoma of the breast. This is not the histologic finding in mastitis.

Question 3 of 4

Which of the following is most likely responsible for this pathologic process?

Explanation - Q: 1.3

Close

The correct answer is E. Staphylococcus aureus is a catalase-positive, coagulase-positive, and beta-hemolytic organism that is the most common cause of mastitis. The source of the organism is almost always from the nursing infant's oropharynx. Enterotoxin F, or Toxic Shock Syndrome Toxin, has been reported to cause toxic shock syndrome in some patients with mastitis caused by Staphylococcus aureus. Blunt force injury (choice A) to the breast might be expected to cause a hematoma or fat necrosis. This patient has a presentation that is consistent with mastitis, and not traumatic injury to the breast. Chlamydia trachomatis(choice B) is an obligate intracellular organism. It is most commonly found in the genital tract and is associated with cervicitis and pelvic inflammatory disease in women, urethritis in men, and pneumonia and conjunctivitis in newborns. It is not normally associated with mastitis. Hormonal exposure (choice C) is not considered causative of mastitis. There is some evidence that hormonal exposure may contribute to the development of breast cancer. This patient, however, has a presentation more consistent with mastitis than breast cancer. Neisseria gonorrhoeae(choice D) is a gram-negative coccus that can cause cervicitis, pelvic inflammatory disease, arthritis, pharyngitis, and urethritis. It can also cause neonatal conjunctivitis. It is not commonly associated with mastitis.

Question 4 of 4

The patient is started on dicloxacillin. This medication works via which of the following mechanisms?

/ A. BIocking cell wall synthesis

/ B. Inhibition of bacterial dihydrofolate reductase

/ C. Inhibition of bacteriaI DNA gyrase

/ D. Inhibition of protein synthesis

/ E. Inhibition of resorption of sodium and chloride

Explanation - Q: 1.4

Close

The correct answer is A. Dicloxacillin belongs to the general class of penicillin antibiotics. Penicillins interfere with bacterial cell wall synthesis by binding to bacterial penicillin binding proteins, resulting in eventual bacterial cell lysis. Bacterial resistance to penicillins results when bacterial beta-lactamases disrupt the beta-lactam ring contained within these antibiotics. Dicloxacillin (like methicillin and nafcillin) is synthesized to be resistant to beta-lactamases. However, resistance to these antibiotics is increasing as well. If a patient with mastitis does not respond to dicloxacillin, bacterial resistance should be suspected and vancomycin should be used. Inhibition of bacterial dihydrofolate reductase (choice B) is the mechanism of action of trimethoprim and pyrimethamine. Inhibition of bacterial DNA gyrase (choice C) is the mechanism of action of the fluoroquinolones and quinolones. Inhibition of protein synthesis (choice D) is the mechanism of action of the lincosamines (clindamycin, lincomycin). These drugs bind the 50S subunit of ribosomes to inhibit the bacterial protein synthesis. Inhibition of resorption of sodium and chloride (choice E) is the mechanism of furosemide (a loop diuretic).

A 37-year-old woman undergoes a routine breast examination. During the breast examination, the physician is aware that the skin of the

breast moves together with the underlying breast tissue, rather than being obviously separate from it.

Question 1 of 6

The breast tissue is normally attached to the overlying skin via which of the following?

/ A. Cooper's ligaments

/ B. Cruciate ligaments

/ C. Falciform ligament

/ D. Poupart's ligaments

/ E. Rhomboid ligaments

Explanation - Q: 2.1

Close

The correct answer is A. The suspensory ligaments of Cooper are fibrous condensations of connective tissue stroma that attach the mammary gland to the dermis of the overlying skin. These are particularly prominent in the superior aspect of the breast, and help to support the breast tissue. The cruciate ligaments(choice B) are in the knee. The falciform ligament (choice C) attaches the peritoneum to the liver. Poupart's ligament (choice D) is an alternative name for the inguinal ligament. The rhomboid ligament (choice E) is another name for the costoclavicular ligament.

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Question 2 of 6

Careful examination of the central depressed area of the nipple demonstrates multiple small openings. These openings are from which of the

following?

/ A. Areola

/ B. Lactiferous ducts

/ C. Montgomery's glands

/ D. Sweat glands

/ E. Terminal ductules

Explanation - Q: 2.2

Close

The correct answer is B. The lactiferous ducts open into the nipples. The area of each of these ducts immediately below the nipple is usually dilated, forming a lactiferous sinus, which can store a droplet of milk that helps to initiate the baby's sucking reflex during nursing. The areola (choice A) is the ring of darkly pigmented skin around the nipple. Montgomery's glands (choice C) are modified eccrine glands (described incorrectly by some authors as sebaceous glands) that provide oil and moisture for the skin of the nipple and areola. They open into the areola in small tubercles rather than the nipple. Sweat glands (choice D) are common in the skin of the breast generally, but are too small to be able to seen by the unaided eye. The terminal ductules (choice E) of the breast system are at the deep end of the duct system of the breasts, and receive milk from the lobular tissue.

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Question 3 of 6

The physician identifies a palpable mass in one breast, and the patient is scheduled for a "Iumpectomy." The reason that "Iumpectomies" for

breast lumps can be safely performed in some patients is that the breast is divided into multiple lobes, each of which contains a separate

duct system with connecting lobules. The normal breast usually contains how many lobes?

/ A. 2 to 3

/ B. 5 to 7

/ C. 10 to 12

/ D. 15 to 25

/ E. 30 to 50

Explanation - Q: 2.3

Close

The correct answer is D. The normal breast contains 15 to 25 lobes. Each lobe can be thought of as having an "inverted tree" composed of a "trunk" made of the lactiferous duct, "branches" made of smaller ducts that feed into the lactiferous duct, and "leaves" made of lobular tissue. Depending on the clinical setting, surgeons will also sometimes excise the duct system under the nipple along with the lump in the breast.

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Question 4 of 6

The surgical specimen is sent fresh from the surgical suite to the laboratory for frozen section examination. Before cutting into the specimen,

the pathologist makes a careful gross examination, which demonstrates that most of the specimen has replacement of the normally fatty

breast tissue with strands of dense, white, firm tissue. In a few areas, roughly spherical lesions up to 3-cm diameter with a bluish hue to them

are seen. Palpation of these areas produces a fluctuant sensation. Which of the following is the most likely diagnosis based on the gross

evaluation?

/ A. Breast cancer

/ B. Changes of pregnancy

/ C. Fibroadenoma

/ D. Fibrocystic disease

/ E. Mastitis

Explanation - Q: 2.4

Close

The correct answer is D. While a careful pathologist will wait for appropriate frozen or permanent tissue histologic examination, the description given in the question stem is most suggestive of fibrocystic disease. The fibrous part of the lesion forms the dense, white tissue strands, while the blue lesions are what are called "blue-domed cysts. The blue color comes from the presence of darkly colored fluid (which usually means old hemorrhage) within the cyst. The interior cyst wall is usually smooth. These blue-domed cysts are a favorite of examiners because they produce a distinctive gross picture and should be specifically associated with fibrocystic disease, but you should be aware that in real life they do not occur with anything near the frequency of fibrocystic disease without obvious large cysts grossly (but many smaller cysts on microscopic examination). Fibrocystic disease of the breast is a very common lesion, and a frequent source of palpable lumps in the breast, which may require further evaluation through either excisional biopsy (as in this case), Tru-cut needle biopsy (producing a thin core about 1 cm long), or needle aspiration (producing fluid or cells for cytology). While a diagnosis of breast cancer should obviously be confirmed microscopically before telling the clinician, invasive breast cancer (choice A) can be suspected when there is a hard, white, nodular area of the breast that has irregular (but often reasonably well-defined - in contrast to the fibrotic areas of fibrocystic disease) boundaries. The changes of pregnancy (choice B) cannot be reliably picked up on gross examination of the breast. Fibroadenoma (choice C), like breast cancer, tends to produce a well-defined mass lesion, but it typically has smooth borders and may have a slightly gray and slightly mucoid (e.g., shiny or oily appearing) surface on cross-section. Long-standing mastitis (choice E) can cause breast fibrosis, but will not cause blue-domed cyst formation. More acutely, mastitis can produce abscesses (which appear white rather than blue).

Question 5 of 6

Frozen section examination demonstrates fibrosis and cystic spaces. AIso seen are areas of compressed glands with a lobular orientation.

The glands are lined by a single layer of epithelial cells with oval nuclei and regular arrangement. No true invasion of glands into the adjacent

stroma is seen. This patient probably has which of the following?

/ A. Atypical ductal hyperplasia

/ B. Ductal carcinoma in situ

/ C. Lobular carcinoma in situ

/ D. Sclerosing adenosis

/ E. Usual ductal hyperplasia

Explanation - Q: 2.5

Close

The correct answer is D. The lesion described is sclerosing adenosis. The tip-offs in the description are the references to compressed glands and lobular orientation. Sclerosing adenosis is a common component of fibrocystic disease, and occurs when fibrosis distorts the normal lobular architecture. The result can be some fairly bizarre, but completely benign, compressed glands that may mimic carcinoma on both frozen and permanent sections. Low power examination is often helpful, as this emphasizes the lobular character of the lesion. Lesions actually involving the epithelium of the duct system typically have multiple layers of cells and range from usual ductal hyperplasia (choice E, with low risk of invasive carcinoma and characterized by the presence of both myoepithelial cells and epithelial cells within the duct) through atypical ductal hyperplasia (choice A, with medium risk of invasive carcinoma and characterized by ductal carcinoma in situ-like features only involving portions of a duct) to ductal carcinoma in situ (choice B, with relatively high risk of invasive carcinoma and characterized by clearly abnormal features such as loss of myoepithelial cells and formation of cribriform patterns involving complete cross-sections of ducts). Lobular carcinoma in situ (choice C) typically produces lobular units whose lumina are completely filled with epithelial cells. In practice, while you may be asked to distinguish classic examples of the different lesions mentioned in the choices on examinations, you should be aware that this whole area can be very problematic in real-life microscopic examinations of breast tissue, and one piece of breast tissue sent to different experts in breast pathology may be returned with a variety of diagnoses.

Question 6 of 6

Which of the following breast lesions is considered to have the greatest potential for eventual progression to a malignant lesion?

/ A. Apocrine metaplasia

/ B. BIue dome cyst

/ C. Epithelial hyperplasia

/ D. Fat necrosis

/ E. Fibrosis

Explanation - Q: 2.6

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The correct answer is C. While fibrocystic disease may have many components, including cyst formation (choice B), apocrine metaplasia (choice A, a benign alteration of cyst epithelium to resemble that of apocrine sweat glands), sclerosing adenosis, and fibrosis (choice E), only the epithelial hyperplasia (usual, atypical, or carcinoma in situ) is thought to indicate significant premalignant (or malignant, for carcinoma in situ) potential. For this reason, most pathologists pay particular attention to the epithelial lining of the ducts and lobules when evaluating breast biopsy specimens with fibrocystic disease. Fibrocystic breasts without any evidence of epithelial changes do not appear to have any significant increased risk of progression to breast cancer. (You should, however, be aware that a fibrocystic breast may make both breast palpation and mammography more difficult and make it more likely to miss a small lesion.) Fat necrosis (choice D) is seen after breast trauma, and has no significant malignant potential.

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A 47-year-old man presents to his physician because he has noticed that his right breast is noticeably larger than his left breast. Breast

examination demonstrates that the right breast is diffusely enlarged. The breast tissue is freely mobile and without distinct masses. The

patient reports that the breast has been slowly enlarging over a period of several years.

Question 1 of 7

Which of the following is the most likely diagnosis?

/ A. Ductal carcinoma in situ

/ B. Fibroadenoma

/ C. Gynecomastia

/ D. Invasive ductal carcinoma

/ E. Lobular carcinoma in situ

Explanation - Q: 3.1

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The correct answer is C. The most common cause for male breast evaluation in the United States is gynecomastia, or benign breast enlargement. Gynecomastia may involve one or both breasts. Male breasts can also develop ductal carcinoma in situ (choice A), invasive ductal carcinoma (choice D), and fibroadenoma (choice B), but these lesions are much less common than gynecomastia. The glands in male breasts do not have lobular tissue, so lobular carcinoma in situ (choice E) does not occur.

Question 2 of 7

AIso noted on physical examination is the presence of multiple spider angiomata. These are most closely associated with disease of which

of the following organs?

/ A. Liver

/ B. Prostate

/ C. Stomach

/ D. Testes

/ E. Thyroid

Explanation - Q: 3.2

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The correct answer is A. Spider angiomas are small vascular lesions with small blood vessels radiating from a central point. They are specifically associated with liver disease, particularly due to alcohol abuse. They are not specifically associated with diseases of the other organs listed in the choices.

Question 3 of 7

The presence of the spider angiomas should specifically trigger a question to the patient about his history of use of which of the following?

/ A. AIcohol

/ B. Caffeine

/ C. Cigarettes

/ D. Heroin

/ E. Marijuana

Explanation - Q: 3.3

Close

The correct answer is A. Spider angiomas are most often associated with liver disease related to alcohol abuse. Abuse of the other items listed in the choices does not predispose for spider angioma formation.

Question 4 of 7

Which of the following is the most likely mechanism causing a relative excess of hormone leading to the breast enlargement in this patient?

/ A. Decreased production of testosterone secondary to primary hypogonadism

/ B. Drug that inhibits testosterone synthesis

/ C. Drug with estrogen-Iike activity

/ D. Increased peripheral conversion of androgens to estrogens

/ E. Increased production of estrogen by a cancer

Explanation - Q: 3.4

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The correct answer is D. Peripheral conversion of androgens (testosterone and androstenedione) to estrogens occurs mainly in adipose tissue, muscle, and skin. In patients with chronic liver disease, malnutrition, and hyperthyroidism, this peripheral conversion is increased, and may be associated with feminization (seen as changes in hair distribution, body fat distribution, and breast size). Conditions that cause primary or secondary hypogonadism (choice A) can cause gynecomastia by the mechanisms of decreased production and/or action of testosterone. These conditions can include Klinefelter syndrome, congenital anorchia, testicular trauma or torsion, viral orchitis (e.g., mumps), pituitary tumors, and renal failure. Drugs that can cause gynecomastia by inhibiting testosterone synthesis (choice B) or action include ketoconazole, metronidazole, cisplatin, spironolactone, and cimetidine. Drugs that can cause gynecomastia because of their estrogen-like activity (choice C) include diethylstilbestrol, digitalis, and estrogen-containing foods and cosmetics. Gynecomastia can also be seen as a consequence of increased estrogen production by some tumors (choice E), including testicular tumors and cancers secreting ectopic hCG (from lung, kidney, GI tract, and extragonadal germ cell tumors). Gynecomastia can also occur as a normal physiologic variant, particularly during puberty and in older men.

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Question 5 of 7

Which of the following enzymes converts androgens to estrogens?

/ A. ALA synthase

/ B. Aromatase

/ C. Branching enzyme

/ D. MethylmalonyI CoA mutase

/ E. PRPP synthetase

Explanation - Q: 3.5

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The correct answer is B. The enzyme aromatase is found in adipose tissue (and hence is increased in fat people), muscle, and skin. It acts on androgens to form estrogens by adding double bonds to make a benzene-like ring. It is this enzyme whose activity is relatively increased in liver disease. ALA synthase (choice A) is an important early enzyme in heme synthesis. Branching enzyme (choice C) is used in glycogen formation. Methylmalonyl CoA mutase (choice D) is involved in the propionic acid pathway leading to synthesis of succinyl CoA. PRPP synthetase (choice E) occurs in purine synthesis.

Question 6 of 7

Which of the following is a genetic syndrome associated with this patient's condition and a 10- to 20-fold increased incidence of breast

cancer?

/ A. Cushing syndrome

/ B. Down syndrome

/ C. Hashimoto disease

/ D. KIinefelter syndrome

/ E. Turner syndrome

Explanation - Q: 3.6

Close

The correct answer is D. The genetic condition Klinefelter syndrome (47,XXY) is fairly unique among the causes of gynecomastia in that it is accompanied by an increased incidence of male breast cancer. In most types of patients with gynecomastia, the incidence of breast cancer is not increased, and there are no adverse medical complications of the gynecomastia (although social and psychological problems may occur). Gynecomastia is usually only treated (with surgery) in patients in whom the breast either continues to enlarge or is personally troubling to the patient. Gynecomastia may occur in Cushing syndrome (choice A) and hyperthyroidism related to Hashimoto disease (choice C), but these are not genetic diseases. Gynecomastia is not usually a feature of Down syndrome (choice B), or Turner syndrome (choice E).

Question 7 of 7

The normal male breast differs from the normal female breast in which of the following ways?

/ A. Adipose tissue is absent

/ B. Dermis is absent

/ C. Ductal tissue is absent

/ D. Lobular tissue is absent

/ E. Muscle is absent

Explanation - Q: 3.7

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The correct answer is D. The normal male breast (and the male breast with gynecomastia), unlike the normal female breast, lacks lobular tissue. Both male and female breasts contain ductal tissue (choice C), adipose tissue (choice A), dermis (choice B), and small amounts of smooth muscle tissue (choice E).

A 53-year-old woman consults a physician after discovering a mass in her breast. Physical examination demonstrates a 1.5-cm diameter,

firm mass lesion in the upper, outer quadrant of her right breast. The mass is surgically removed and pathologic examination of tissue

obtained at surgery reveals invasive breast cancer.

Question 1 of 5

What percentage of breast masses are discovered by the patient, rather than by mammography or physician examination of the breasts?

/ A. 5%

/ B. 20%

/ C. 50%

/ D. 80%

/ E. 95%

Explanation - Q: 1.1

Close

The correct answer is D. Breast cancer accounts for the greatest number of new cancer cases in women each year. Mammography is the screening method used to detect subclinical breast cancer-the stage at which breast cancer is least likely to have spread, but about 80% of breast masses are discovered initially by the patient, which it is why it is important to continue to stress breast self-examination.

Question 2 of 5

While about 75% of the lymphatic fluid from the breast drains first to the axilla, most of the remaining lymphatic fluid drains first to which of the

following groups of lymph nodes?

/ A. Anterior internal thoracic nodes

/ B. Internal inferior thoracic nodes

/ C. Lateral intercostal nodes

/ D. Superior mediastinal nodes

/ E. Tracheobronchial nodes

Explanation - Q: 1.2

Close

The correct answer is A. The anterior internal thoracic nodes, also known as the internal mammary nodes, are a pair of chained lymph nodes running superiorly to inferiorly along the chest wall near both sides of the sternum. They are inaccessible for surgical removal during mastectomy, but may contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice C) may contain metastatic breast cancer. The inferior internal thoracic nodes (choice B) drain the liver and diaphragm. The superior mediastinal nodes (choice D) drain the trachea, esophagus, and heart. The tracheobronchial nodes (choice E) drain the lung.

Question 3 of 5

Which of the following will most likely be identified at pathologic examination of this woman's breast mass?

/ A. Ductal carcinoma

/ B. Lobular carcinoma

/ C. Medullary carcinoma

/ D. Paget disease

/ E. Tubular carcinoma

Explanation - Q: 1.2

Close

The correct answer is A. The anterior internal thoracic nodes, also known as the internal mammary nodes, are a pair of chained lymph nodes running superiorly to inferiorly along the chest wall near both sides of the sternum. They are inaccessible for surgical removal during mastectomy, but may contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice C) may contain metastatic breast cancer. The inferior internal thoracic nodes (choice B) drain the liver and diaphragm. The superior mediastinal nodes (choice D) drain the trachea, esophagus, and heart. The tracheobronchial nodes (choice E) drain the lung.

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Question 3 of 5

Which of the following will most likely be identified at pathologic examination of this woman's breast mass?

/ A. Ductal carcinoma

/ B. Lobular carcinoma

/ C. Medullary carcinoma

/ D. Paget disease

/ E. Tubular carcinoma

Explanation - Q: 1.3

Close

The correct answer is A. There is a cumulative risk in women of developing breast cancer of 1 in 8 by age 95; 1/3 to 1/2 of the patients die of the disease. Breast cancer may occur in a ductal or a lobular pattern. Invasive ductal carcinoma, not otherwise specified, is the most common histological type of invasive breast cancer. Risk factors for breast cancer include positive family history, early menarche, late menopause, late first pregnancy, and history of in situ or invasive breast cancer. Women who develop breast cancer before age 35 tend to have more aggressive disease. Two breast cancer genes, BRCA1 and BRCA2, have been identified; 5% of women with breast cancer carry one or the other of these genes. Male breast cancer is much less common than female, but has a high mortality rate Lobular carcinoma (choice B) is the second most common type of breast cancer. It may occur bilaterally in some patients. Medullary carcinoma (choice C) and tubular carcinoma (choice E) are histological variants of ductal carcinoma with statistically better prognoses than ductal carcinoma, not otherwise specified. Paget disease (choice D) is the presence of individual adenocarcinoma cells within the skin overlying a breast cancer.

Question 4 of 5

Immunohistochemical examination of paraffin-embedded sections through the tumor demonstrates that it stains for estrogen receptors (ER)

and progesterone receptors (PR). This finding specifically suggests that the tumor may respond to which of the following drugs?

/ A. 5-FIuorouracil

/ B. Cyclophosphamide

/ C. Doxorubicin

/ D. Methotrexate

/ E. Tamoxifen

Explanation - Q: 1.4

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The correct answer is E. Treatment with adjuvant tamoxifen for 5 years in ER positive tumors can reduce the risk of death by 25% in both pre- and postmenopausal women with or without axial lymph node involvement. Breast cancers that express the Her-2/neu receptor may respond to a new drug, trastuzumab, which is a monoclonal antibody directed against the receptor. The other drugs listed are all used for breast cancer chemotherapy, but work because they are cytotoxic rather than because they affect the hormonal response of the cancer.

Question 5 of 5

The patient's physician suggests that she immediately begin chemotherapy treatment. The patient dismisses his suggestion and says, "I do

not need any medicine, all l need is bedrest." This statement is most consistent with which of the following responses to illness?

/ A. Acceptance

/ B. Anger

/ C. Bargaining

/ D. Denial

/ E. Grieving

Explanation - Q: 1.5

Close

The correct answer is D. Denial is a coping mechanism to defend against overwhelming anxiety. Pathologic and extreme denial can interfere with accurate diagnosis, impede treatment, and consequently perpetuate the disease state. Denial is common in the early stages of dealing with a terminal illness and is not necessarily pathologic. Less extreme forms of denial may even serve the patient in positive ways. "I'm as strong now as I was when I was 20 and I'm gonna make it." Notably, the stages of grieving over the loss of a loved one (bereavement) are very similar to grieving over the loss of one's health (stages of dying). Acceptance (choice A) is a realistic perspective concerning the consequences of illness. "Coming to terms" with the illness restores emotional equilibrium and patients appear to return to their baseline personality and emotional functioning. Anger (choice B) is often directed at fate, God, themselves, their caretakers, and their families and, if taken to the extreme, may result in isolation from much needed support. Bargaining (choice C) entails promises to buy additional time. Grieving (choice E) is a process of changing affective states over time and includes five stages as described by Elisabeth Kubler-Ross (denial, anger, bargaining, depression, and acceptance). Denial, anger, anxiety, depression, and dependence can all be abnormal responses to illness (when extreme).

A 23-year-old woman comes to the physician because of a lump in her right breast. She states that she first noted the lump about a year ago

and that it has seemed to enlarge over the past year. She notes some occasional tenderness in the area, usually at the same time during her

menstrual cycle. She has no medical problems. She had an appendectomy at the age of 18. She takes no medications and is allergic to

penicillin. Examination of the breast demonstrates a freely mobile, smoothly contoured, discrete mass in the upper outer quadrant of the

breast. UItrasonography demonstrates a smooth mass with circumscribed margins and homogeneous echo pattern, consistent with a solid

Iesion.

Question 1 of 4

Which of the following is the most likely diagnosis?

/ A. Breast abscess

/ B. Fibroadenoma

/ C. Fibrocystic breast changes

/ D. Mastitis

/ E. Pregnancy

Explanation - Q: 2.1

Close

The correct answer is B. Fibroadenomas are the most common breast lesions found in women under 25 years of age. Fibroadenomas are the second most common cause of benign breast lesions (second only to fibrocystic changes) in women of all ages. Patients with a fibroadenoma typically present complaining of a palpable lump, often with some gradual growth. There may be some occasional cyclic tenderness. Management is with biopsy or close observation. If the lesion is palpable, increasing in size, or psychologically disturbing, biopsy should be performed. If the woman is less than 25 years of age with small fibroadenomas that appear "classic" by imaging, then expectant management with careful continued observation can be considered. A breast abscess (choice A) can also present as a lump in the breast. However, an abscess represents a localized collection of pus resulting from an infection. Therefore, patients with a breast abscess will often have erythema, edema, pain, and tenderness around the area of the mass. Such patients may also have systemic signs of infection, including fever and tachycardia. This patient has no evidence of infection. Fibrocystic breast changes (choice C) are the most common, benign condition of the breast. They can be present in young women, become more common as a woman approaches the menopause, and often regress during and after the menopause. The most common symptoms are pain and tenderness, and the masses are usually bilateral. Mammography and ultrasound of the breast often reveal the fibrocystic changes. Mastitis (choice D) is an infection of the breast. It can occur in any woman, but most often occurs in lactating women during the postpartum period. Patients with mastitis will often present with tenderness and erythema of the breast along with fever. Treatment is with antibiotics. Pregnancy (choice E) is associated with a number of changes in the breast, especially as the breast prepares for lactation. Fibroadenomas may grow rapidly during pregnancy, but the primary diagnosis, and hence the best answer, is still fibroadenoma

Question 2 of 4

Histological examination of diagnostic tissue from this patient would reveal which of the following?

/ A. A classic cribriform pattern with neoplastic epithelial cells

/ B. Cystically dilated ducts plus stromal fibrosis

/ C. Irregular steatocytes and intervening necrotic material and inflammatory cells

/ D. Lobular hypertrophy

/ E. Proliferating ducts and stromal cells

Explanation - Q: 2.2

Close

The correct answer is E. Fibroadenomas have a typical microscopic appearance. The predominant feature is the fibroblastic stroma. This is a delicate, cellular, fibroblastic stroma resembling intralobular stroma. Within this fibroblastic stroma are seen proliferating ducts. These ducts are usually compressed and are lined by benign-appearing epithelium. If the margin includes surrounding tissue beyond the fibroadenoma, compressed breast connective tissue forming a "capsule" to the mass may be seen as well. A classic cribriform pattern with neoplastic epithelial cells (choice A) is what would be revealed by histological examination of an intraductal carcinoma of the breast. The epithelium in a fibroadenoma is benign-appearing. Histologic examination of a biopsy specimen from a patient with fibrocystic breast changes would demonstrate cystically dilated ducts plus stromal fibrosis (choice B). Irregular steatocytes and intervening necrotic material and inflammatory cells (choice C) describes the findings on pathologic evaluation of a biopsy specimen from a patient with fat necrosis. Fat necrosis is most commonly caused by trauma, but can also occur after surgery or radiation therapy. Lobular hypertrophy (choice D) is seen in pregnant women. This lobular hypertrophy occurs during the pregnancy to allow for lactation in the postpartum period.

Question 3 of 4

If the histologic examination revealed similar findings as in this patient, but demonstrated increased cellularity, an elevated mitotic rate,

stromal overgrowth, and infiltrative borders, then which of the following is the most likely diagnosis?

/ A. Fat necrosis

/ B. Fibrocystic changes

/ C. Mastitis

/ D. Normal breast tissue

/ E. Phyllodes tumor

Explanation - Q: 2.2

Close

The correct answer is E. Fibroadenomas have a typical microscopic appearance. The predominant feature is the fibroblastic stroma. This is a delicate, cellular, fibroblastic stroma resembling intralobular stroma. Within this fibroblastic stroma are seen proliferating ducts. These ducts are usually compressed and are lined by benign-appearing epithelium. If the margin includes surrounding tissue beyond the fibroadenoma, compressed breast connective tissue forming a "capsule" to the mass may be seen as well. A classic cribriform pattern with neoplastic epithelial cells (choice A) is what would be revealed by histological examination of an intraductal carcinoma of the breast. The epithelium in a fibroadenoma is benign-appearing. Histologic examination of a biopsy specimen from a patient with fibrocystic breast changes would demonstrate cystically dilated ducts plus stromal fibrosis (choice B). Irregular steatocytes and intervening necrotic material and inflammatory cells (choice C) describes the findings on pathologic evaluation of a biopsy specimen from a patient with fat necrosis. Fat necrosis is most commonly caused by trauma, but can also occur after surgery or radiation therapy. Lobular hypertrophy (choice D) is seen in pregnant women. This lobular hypertrophy occurs during the pregnancy to allow for lactation in the postpartum period.

Question 3 of 4

If the histologic examination revealed similar findings as in this patient, but demonstrated increased cellularity, an elevated mitotic rate,

stromal overgrowth, and infiltrative borders, then which of the following is the most likely diagnosis?

/ A. Fat necrosis

/ B. Fibrocystic changes

/ C. Mastitis

/ D. Normal breast tissue

/ E. Phyllodes tumor

Explanation - Q: 2.3

Close

The correct answer is E. Phyllodes tumors are similar to fibroadenomas in that they arise from intralobular stroma. Furthermore, on pathologic evaluation, low-grade phyllodes tumors can resemble fibroadenomas. However, there are important differences. First, most phyllodes tumors present in the sixth decade, whereas fibroadenomas most commonly present in young women. Also, while most phyllodes tumors are low-grade tumors that only rarely metastasize, some are aggressive high-grade lesions that commonly recur locally and do metastasize hematogenously. These aggressive lesions are often called cystosarcoma phyllodes. Some phyllodes tumors are small, while others may be large enough to involve virtually the entire breast. Grossly, these tumors often have leaf-like projections off of them. On histologic evaluation, the keys to distinguishing between fibroadenoma and phyllodes tumor are the increased cellularity, enhanced mitotic rate, stromal overgrowth, nuclear pleomorphism, and infiltrative borders that are seen in phyllodes tumors and are absent in fibroadenomas. Fat necrosis (choice A) demonstrates necrotic fat cells that are surrounded by lipid-filled macrophages and an infiltration of neutrophils. It does not resemble a fibroadenoma. Fibrocystic changes (choice B) are characterized by cysts, and do not closely resemble fibroadenomas, as low-grade phyllodes tumors do. Mastitis (choice C) is an infection of the breast, usually by Staphylococcus aureus. It is characterized by acute inflammation and does not resemble fibroadenoma. Normal breast tissue (choice D) is not characterized by a pattern similar to fibroadenoma, except with increased cellularity, elevated mitotic rate, stromal overgrowth, and infiltrative borders. These are characteristics of phyllodes tumors.

Question 4 of 4

If the patient were instead found to have an aggressive breast carcinoma with a poor prognosis, the Kubler-Ross model predicts that she will

go through which of the following stages?

/ A. Acceptance, anger, ambivalence, deniaI, depression

/ B. BIues, depression, psychosis, treatment, resolution

/ C. DeniaI, anger, bargaining, depression, acceptance

/ D. DeniaI, anger, psychosis, homicide, suicide

/ E. Realization, infantilization, socialization, condemnation

Explanation - Q: 2.4

Close

The correct answer is C. Elisabeth Kubler-Ross is the psychiatrist who authored the groundbreaking "On Death and Dying" in 1969. She was born in Switzerland, but moved to the United States in the 1950s, where she worked with dying patients. Her model identified five stages that occur when individuals are confronted with death: 1) Denial, 2) Anger, 3) Bargaining, 4) Depression, and 5) Acceptance. While she originally described this process as it relates to facing death, others have used these 5 steps to describe reaction to grief or loss. While these stages are useful to understand and contemplate the experience of grief or dying, it is important to recognize that not all people will go through these steps. Those who do go through each of these steps may also not go through them in the "order" described by the Kubler-Ross model. No model is perfect for explaining the intricacies of every different human being's response to grief or death. The Kubler-Ross model does provide a nice framework and starting point for understanding these difficult issues. None of the other choices correctly describes the stages proposed by Kubler-Ross.