Week 1 Flashcards
1
Q
Sequence of a typical patient encounter
A
- Medical interview
- Examine the patient; physical exam
- Perform testing
- Determine the diagnoses
- Develop a plan with the patient
- Patient education and counseling
2
Q
Disease
A
– disruption in normal biological function
- Objective – eg. abnormal test results
- Defined by scientists/physicians
- Within a biomedical context
3
Q
Illness
A
– a change from patient’s idea of “healthy”
- Subjective
- Defined by the patient
- Within a psychosocial context
- might not be in the biomedical context
4
Q
Disease-centered Interview
A
• Physician determines agenda
• Patient’s concerns are secondary
• Solely focused on diagnosis and treatment of the diagnosed disease
• Less focus on patient experience with illness
• Little understanding of patient emotions
• Limited development of physician-patient relationship
* a side-effect of looking through only the biomedical lense
5
Q
Illness-centered interview
A
- Allows patient to lead and direct conversation
- Patients have multiple, complex reasons to seek care (mix of biological and psychosocial)
- Encourages patient to express what is most important
- Recognizes the psychosocial context
- Recognizes patient thoughts and emotions
6
Q
Benefits of a Patient-Centered Approach
A
- Improved patient understanding
- Improved patient adherence to medication
- Improved health outcomes (HTN, depression, diabetes)
- Decreased malpractice claims
7
Q
Limitations of Patient-Centered Interviewing
A
- Medical emergencies (time constriction)
- Severe alterations of mental status (can’t participate meaningfully in this type of interaction)
8
Q
Components of the Medical Interview
A
- Introduction (Introduction)
- Chief Concern (CC)
- History of Present Illness (HPI)
- Past Medical History (PMH)
- Family History (FH)
- Social History (SH)
- Review of Systems (ROS)
9
Q
Patient Centered Interview – Kalamazoo Model
A
- Build a relationship
- Open the discussion
- Gather Information
- Understand the patient’s perspective
- Share Information
- Reach Agreement
- Provide Closure
10
Q
Interview Introduction
A
Wash/sanitize your hands
Greet the patient and show interest in them as a person
Ask the patient what he/she wishes to be called
Introduce self and role as a medical student
Explain that the physician will see the patient following the student interview.
Obtain the patient’s permission for the interview
11
Q
History of Present Illness (HPI)
A
- Location of sensation
- Quality
- Severity (0 to 10 scale, or other method)
- Timing (time of day, frequency)
- Context (environment, preceding activity to sensation i.e. car crash, exercise, meals)
- Associated symptoms
- Modifying factors (what makes symptom better or worse)
- Treatment (“have you tried any medications?”)
- Impact of illness → can indicate what the patient is most concerned about; can reveal information that the patient might not have otherwise shared without this prompt
- Patient perception
- Summarization
12
Q
Confidentiality
A
trust that information will not be disclosed
13
Q
Exceptions to confidentiality
A
- consent to disclose
- harm to others/self
14
Q
Tarasoff Key Elements
A
- High probability of harm
- Serious harm
- Intervention likely to prevent harm
- Last resort
- Illegal conduct - about to break the law
15
Q
Criteria for disclosure of confidential info
A
- High probability
- Serious harm
- Disclosure likely to prevent harm
- No alternatives
16
Q
Biomedical model
A
Individual level, biological mechanisms, health as absence of disease
- negative notions of disease as we saw in what is health lecture
17
Q
Behavioral model
A
Health and illness consequence of individual or household actions and beliefs
18
Q
Political economy approach
A
Health and illness are an outcome of political, social, and
economic structures and relations
19
Q
models of health and disease
A
- biomedical model
- behavioral model
- political economy model
20
Q
effect of federal war on poverty on asthma
A
Assuaged poverty-hunger, poor health, economic insecurity, and lack of opportunity for 10 million (assuage: make (an unpleasant feeling) less intense)
21
Q
improvements in asthma due to
A
- The replacement of housing stock
- Medicaid
- Establishment of an outpatient allergy and asthma clinics at
- Charity Hospital
- Availability of a new generation of asthma drugs.
22
Q
social violence
A
social science of disease; structural differences that provide harm to groups
23
Q
Epidemiology
A
The study of the distribution and determinants (i.e., causes) of health and diseases, morbidity, injuries, disability, and mortality in populations
24
Q
Objectives of Epidemiology
A
- Identify the etiology or cause of a disease or condition and the relevant risk factors
- Determine the extent of disease found in the community
- Study the natural history and prognosis of disease
- Evaluate existing and newly developed preventive and therapeutic measures and modes of health care delivery
- Provide the data and foundation for developing public policy relating to disease prevention and health promotion
25
Descriptive epidemiology
distribution of health and diseases, morbidity, injuries, disability, and mortality in terms of person, place and time
26
Analytic epidemiology
determinants of health and diseases, morbidity, injuries, disability, and mortality
27
Hypothesis Generating and Testing
- case series and case reports
- cross-sectional studies
- case-control studies
- cohort studies
- randomized trials
28
Guidelines for Judging Whether an Association is Causal
1. Temporal relationship*
2. Strength of association*
3. Dose-response relationship
4. Replication of the findings
5. Biologic plausibility
6. Consistency with other knowledge
7. Cessation of the exposure
8. Consideration of alternate explanations
29
Evidence- Based Medicine Defined
conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients; looks at the individual patient
30
Overarching Principles of EBM
1. Evidence is never enough -- a really great study should not change care automatically
o Benefits v. risks
o Patient’s values and preferences
2. Hierarchy of evidence - some evidence is better than others
31
trends of evaluating validity and risk of bias in study types
validity and risk of bias are inverse of one another (as one increases, the other decreases)
32
EBM Process 5 A's
```
Assess
o Determine your knowledge gap
o what do I need to know
Ask
o Develop an answerable question
Acquire
o Find the best available evidence
o looking at available data and studies
Appraise
o Determine the quality of that evidence
o evaluate for validity and bias
Apply
o Apply the evidence to your patient
o deciding on how to care for the patient
```
33
"Ask" stage of EBM process
PICO -- patient, intervention, comparison, outcome
34
3 components of the Appraise Stage in the EBM process
Are the Results Valid?
Are the Results Important?
Are the Results Applicable?
35
process of looking at upstream determinants of health
ask "why" a few times back
36
The Disease Continuum
Health → Risk Factors → Disease → Death
37
negative definitions of health
absence of something (disease, disability, unhealthy behaviors); see as the "problems" list in health records
38
Positive definitions of health
```
presence of something
• Physical fitness
• Social relationships
• Psychosocial well-being
• Function
• Will-power, self-control
• Energy/vitality
```
39
Domains of Knowledge in healthcare
- basic mechanisms
- clinical trials
- epidemiology
- tools for evaluating evidences
40
RCT acronym
randomized controlled trial
41
regression to mean
phenomenon that if a variable is extreme on its first measurement, it will tend to be closer to the average on its second measurement
42
Interventions Bias
thought that if you did something and got better then that thing made you better
43
placebo results can be due to:
- natural healing (and regression to the mean)
- Hawthorn effect (changed behavior during study)
- reporting bias
- true placebo
44
Establishing Causality -- Bradford Hill criteria
Smoking Example
- strength - 23x risk
- consistency -- what groups are being affected
- specificity -- what fraction of cancer deaths are among smokers
- temporality -- lung cancer after tobacco
- gradient -- risk over pack-years
- plausibility - known carcinogens
- coherence -- tar causes skin cancer in mice
- EXPERIMENT? → unethical
45
Two characteristics of models
1. all models are wrong; some are more wrong than others
| 2. all types of evidence are relevant for creating your model
46
Characteristics of Multiple Testing
- small sample, large effect size
| - data mining
47
Primary Prevention
- all things that are being done to prevent disease, if even multiple steps removed
- precedes pathological onset
48
Secondary Prevention
- how do we prevent disease progression
- screening for diseases that may already exist in a patient
- between pathological onset and 1st symptoms
49
Tertiary Prevention
- preventing a worse outcome
| - after onset of symptoms
50
The Public Health Approach from Problem to Response
Surveillance: what is the problem? → descriptive epidemiology
Risk Factor Identification: what is the cause? → analytic epidemiology
Intervention evaluation: what works? → looking at the data, studies
Implementation: how do you do it? → how do we use this, what’s our context
51
Null Hypothesis
There is NO association between the independent and dependent variables expressed as Ho
52
Alternative Hypothesis
There is an association between the independent and dependent variables expressed as HA
53
Association
The statistical dependence between 2 variables
54
Hypothesis Testing
1. define the Ho (null hypothesis)
2. Calculate probability of observed data if H0 were true
3. Evaluate P-value
55
Type I error
conclude treatments are different when in reality they are not different (prob = alpha)
56
Type II error
conclude that treatments are not different when in reality they are different (probs = beta)
57
Statistical Power
```
The probability of correctly concluding that there is a difference (1 minus β)
• Depends on:
– Magnitude of the true difference
– Sample size
– Set alpha value (conventionally 5%)
```
58
Incidence
– The number of new cases of a disease in a population during a specified period
– Reflects transition from disease free to affected state
59
Prevalence
– The number of existing cases of a disease in a population at some point in time
60
Incidence Rate
- A measure of how quickly cases of a disease of interest occur
- looking at the incidence as it compares to a period of time
IR = number of new cases / person-time (i.e. person-year)
61
Risk
Probability that an event will occur
62
Rate
A measure of how quickly something happens
63
Relative Risk
Indicates the likelihood of developing the outcome for those who are exposed relative to those not exposed
RR = rate of exposed / rate of not exposed
64
Absolute risk reduction (ARR)
difference between rate of exposed and rate of unexposed
65
Number needed to treat (NNT)
how many patients need to be treated with experimental treatment to prevent one adverse outcome. (Inverse of “ARR”)
NNT = 1 / (rate exposed - rate unexposed)
66
Attributable Risk
- amount of risk that occurs because of the exposure
| (risk exposed - risk unexposed) / risk exposed
