14 ⼀BIOSTATISTICS/BIOETHICS Flashcards
What is [Root Cause Analysis] ?
[5-part QA tool] that analyzes then addresses Root Causes leading to an adverse medical event
DCRSA
What are QALY and DALY?
________________
Describe both
________________
Quality-Adjusted Life Years | Disability-Adjusted Life Years
BOTH measures burden of disease for individuals or populations
________________
[TTO (time trade off)] is used for calculating QALY
________________
[Yeas of Life Lost (from premature Death)] and [Years of Life Lived with Disability] are used for calculating DALY
A patient, recently tested for Huntington’s disease, now declines to learn of the test result
What are the ethics guidelines regarding genetic information? (2)
🔲 Always Remember: PATIENTS HAVE RIGHT TO REFUSE GENETIC INFORMATION
BUT
⊙physicians should also be sensitive to psych impact of predictive screening and be willing to explore reasons for that pt’s anxiety
- “Learning about your test results is a very personal decision; I’d like to understand more about what led you to change your mind.”*
describe Rate Ratio
_________________
what’s the purpose of Rate Ratio?
[event occurred less in treatment group than control] < [RR = 1.0(null)] < [event occurred MORE in treatment group than control]
the difference from 1.0 indicates amount benefited or lost
_________________
measures effect of an intervention on an outcome over time
The ⬜ and ⬜ are common [test for heterogeneity]. What are [test for heterogeneity] useful for? (2)
▶[Q statistic(NO heterogeneity if P > 0.05)] :
a (small P<0.05) suggest there is a difference between the groups studied and that the [null hypothesis H0] should be rejected. A (Large P>0.05) suggest there is NO difference between groups studied and [null hypothesis H0] can NOT be rejected
▶[I2 index(heterogeneity level: [25%=low]/[50%=moderate]/[75%=HIGH])]
_________________
- performing meta analysis (of several trials as it can provide insight about combinability of multiple studies)
- comparing different trials
What does overlapping [Standard Error of Measurement] suggest?
suggest [NO significant statistical difference between 2 data sets]
(two data sets are similar)
[Case Control Study] is a study of the (⬜ past | present | future) that looks at [⬜ and ⬜ groups] to determine ⬜
_________________
What question does [Case Control Study] ask?
past ; ([Diseased] v [NONDiseased controls]) ; [RISK FACTORS that caused the disease]
_________________
After comparing the [Diseasded] and the [NONDiseased control], [what risk factor] increased odds of having the disease ?
observational and retrospective
- ________________*
- ” After review of* [group with new GI illness] and [group without new GI illness], having [history of eating at a particular restaurant] increased odds of having [new GI illness] “
in Medical law, the GINA act stands for ⬜
What is the GINA act? (2)
[GINA act] = Genetic Information Nondiscrimination Act ⼀
- prohibits employers and health insurance from requesting genetic testing
and/or
- requiring genetic testing to determine future employment and health insurance eligibility
[T or F] Sample Size and Power of a Study are interdependent
_________________
Explain?
TRUE
_________________
[power ⇪] and/or [small difference between groups] ➜ [⇪ Sample Size required]
Mortality prediction curves are useful for ⬜. How do you properly interpret these curves?
providing mortality risk while accounting for multiple other variables; each variable must be accounted for to arrive at the accurate predicted mortality
[T or F] Patients have a right to refuse knowledge regarding their diagnosis
_________________
What should Physicians do about this?
TRUE
_________________
nonjudgmental exploration into underlying reasoning ⼀ in order to understand patient’s concerns
state the inferiority designation for each event
A good ⬜ test will have high Sensitivity
How is Sensitivity related to NPV?
SCREENING; [⇪ sN = ⇪ NPV]
_________________
[⇪ sN = ⇪ NPV = ⬇︎FN]
Criteria for giving out Pt medical information? - 3
Pt must… PDA
1st: be Present (or otherwise available prior to disclosure)
2nd: have Decision Making Capacity (CURE)
3rd: Agrees to disclose information
Name and describe the [5 Ethical Principles in Medicine]
BJPAN
Describe how to interpret Standard Deviation chart
[68% of all observations will lie within 1 SD]
[95% | 2 SD]
[99.7% | 3 SD]
In terms of Medical Errors, describe
Near-Miss event
What is Statistical power?
_________________
How do you mitigate low statistical power?
ability to detect an association if that association exist. Based on sample size. Larger sample size helps control all confounders ➜ ⇪ Statistical power
_________________
META ANALYSIS (pools data from several studies to INC statistical power)
T or F
It is NEVER acceptable to allow industry-sponsored programs to influence lecture content
TRUE
Physicians have to retain FULL CONTROL over psntn content
What is the current recommendation regarding informal treatment of friends or family? (3)
for friends/family not technically your patient…
- ONLY IF no other physician is available.. you can give
- ACUTE care ONLY
- LIMITED care ONLY
**writing a prescription automatically establishes a medicolegal physician-patient relationship; making MD liable for any/all outcomes
“I would like to help you, but I am uncomfortable prescribing for someone I am not treating.”
What are the guidelines regarding patients themselves requesting copies of their medical records? (3)
▶ADULTS CAN! Adult pts have the right to release their medical records even to themselves (for their own personal record/viewing).
▶PEDS REQUIRE PARENT CONSENT (unless emancipated or received care that did not require parental consent)
▶Ok to Charge “Records Fee” (for printing/mailing/etc)
which kind of study is used to backtrace a restaurant outbreak?
CASE control
What is the Formula for Positive Likelihood Ratio?
Are Positive/ Negative Likelihood Ratios dependent or indepedent of a disease’s prevalence?
P = N / (1-P)
“Number 1 Nigga, Positivity” ….. “Positivity… Number 1 Plan”.
Negative LR = (1 - seNsitivity) / P
Positive LR = seNsitivity / (1 - sPecificity)
INDEPEDENT
Medical encounters may be the only way trafficked victims can get help
Describe what to do once you suspect a patient is being Human Trafficked
How should physicians approach [Complementary and Alternative medicine] with patients? (2)
- have open, explorative and collaborative discussion
- adequately research risk, benefit, and [proven treatment alternatives] for each CAM
[Per-Protocol Analysis] (3)
- Excludes non-compliant participants = analysis of only data from participants who’ve followed rules Per Protocol
- estimates true effect of an intervention but overestimate effect of intervention in a real world setting vs
- opposite of [Intention-To-Treat analysis (which keeps participants in their allocated groups regardless of dropout or non-compliance = better estimate of real world)]
What is [Intention To Treat Analysis]? (3)
▶after subjects are initially randomized to tx vs control, those subjects are maintained to that intervention group regardless of what they do during study period [switch intervention/drops out]→ crossover/attrition …actually become apart of the subjects outcome data and are attributed to the intervention
▶ will provide conservative (but more valid) estimate of the intervention effect
▶preserves benefits of randomization in superiority trials
define SpeciFicity
_________________
~~~
SpeciFicity formula ?
SPeciFicity= [true negative] = [TN / (TN + FP)] = used for test conFirmation
= “a test’s probability (in the absence of disease) a patient test negative”
What is [MLR (Multiple linear regression)] used for?
evaluates association between [1 quantitative dependent variable] and [≥2 independent variables of interest] while controlling for adjustment variables
What does setting statistical significance at [α = 0.05] actually mean?
statistical significance [α = 0.05] means…
Researchers are willing to accept that there’s a LOE5% chance that the observed differences they see will be considered significant when no difference actually exist
What are the recommendations regarding MD and teenager patients having sex.
Should MD discuss with parents?
MD should maintain confidentiality of sexually active teens and ensure teen access to healthcare and counseling
MD MUST BREAK CONFIDENTIALITY IF THERE’S RISK OF HARM TO SELF/OTHERS OR CHILD ABUSE
What is the Doctrine of Implied Consent? (3)
❗️In pts who LACK DECISION-MAKING CAPACITY
❗️but who require 9-1-1 Tx
❗️can receive 9-1-1 tx per [Doctrine of Implied (NO explicit necessary) consent] (and must be tx reasonable people in similar situation would expect)
What’s unique about Survival Analysis ? (3)
-it doesn’t just account for # of events for both the [control group] and [treatment group] …
-but also the TIMING OF THOSE EVENTS throughout the follow-up period for these 2 groups.
-This produces [TIME-TO-EVENT/DEATH] for the [control group] and [treatment group], which may reveal overall superiority between the 2
In research, what is Lead-time bias?
overestimation of survival only solely because patients were diagnosed earlier
_________________
when a screening test appears to prolong survival when actually it’s just informing the patient of their diagnosis earlier on …(and as a result…) time from diagnosis until death is longer ⼀even though there isn’t actual increase in survival (just earlier detection)
What is Number Needed to Harm?
_________________
formula? (2)
Number of people Needed to be exposed to a tx before a harmful event occurs
_________________
NNH
=[1 / ARI]
= {1 / [(AERTX) - (AERPLACEBO)]}
AER: Adverse Event Rate | ARI: Absolute Risk Increase
What is a Pragmatic study?
_________________
What is a Nested study?
seeks to determine whether intervention works in real life conditions
_________________
retrospective observational study in which subsets of controls are matched to cases and analyzed for variables of interest
What should a Specialist do if their plan does not coincide with PCP?
BEFORE MAKING ANY CHANGES, Specialist should call/discuss plan with PCP since PCP has primary responsibility for patient’s care
How is Likelihood Ratio used to stratify clinical significance?
LRs does not change as disease prevalence changes
and LR can be used to grade clinical significance of various results when >2 different test results are possible
_________________
LR = probability of a given test result occurring in a patient with a disorder compared to the probability of the same result occurring in a patient without the disorder
Elder abuse occurs in patients age ⬜, and if [risk factors ( ⬜4 )] are present, physicians should automatically screen these patients for [major signs of abuse ( ⬜4 )]
> >65[age>80], female, physical impairment, psych impairment(dementia/depression)
- spiral fx
- abrasions in unusual locations
- malnutrition
- pressure ulcers
interview patient alone and alert [Adult Protective Services] if elder abuse suspicion supported
Sensitive diagnostic test have lower false (⬜ negative | positive) results
________________
Specific diagnostic test have lower false (⬜ negative | positive) results
test with:
⇪ seNsitivity = ⬇︎false Negatives
________________
⇪ sPecificity = ⬇︎ false Positives
When are IV medications preferred over oral? (4)
- HDUS
- PO INtolerance
- PO meds failed
- < 2 yo
Main features of a DNR order -4
- ✔︎ [Ok to treat temporary or correctable conditions (i.e. sepsis)]
—-but NO VAP ——
- NO Ventilator dependency
- NO ACLS
- NO Prolongation of terminal illness
Recite the breakdown formula for Standard Deviation Curve (3)
[(mean) +/- (SD)] =
[(external SD)% chance > (mean + SD)] and
[(external SD)% chance < (mean - SD)]
In terms of research, describe the 3 characteristics of
Internal validity
[T or F]
It is paramount to determine guardianship status for all adult patients with intellectual disability
TRUE
_________________
especially as to clarify medical decisions
▨ What is a meta-analysis? (2)
_________________
◮ What is the disadvantage to using meta-analysis?
▨ -pooling data from several single studies in order to INC power of 1 LARGER COLLECTIVE study (as to INC that LARGER COLLECTIVE study’s ability to detect (if one exist) a difference in outcome between groups)
▨ If an outcome is rare (or difference between groups is super small), this will be difficult for single small study to detect ➜ unlikely to reach statistical significance = use meta analysis
_________________
◮ pooling from several studies will also pool their biases and limitations all into 1 analysis
Describe the 4 types of Disease Prevention
PSTQ = Prevent/Screen/Treat/Query
[Primary = Prevent future disease (* _P_revent future MI by reducing HLD*)]
[Secondary = Screen possible disease (_S_creen possible cervical CA with pap smear)]
[Tertiary = Treat current disease PATIENT CURRENTLY HAS to ⬇︎ disability from that current disease (_T_reat current severe CAD with CABG revascularization)]
[Quartenary = Query statistics of disease: to identify pts at risk for unnecessary treatment and prevent redundant or unnecessary therapies (shared EMR limits unnecessary or repeat procedures)
define Sensitivity
~~~
_________________
~~~
Sensitivity formula ?
seNsitivity = [true positive] = [TP / (TP + FN)]
= “a test’s probability (in the presence of disease) a patient test positive”
define
Specificity
sPecificity = [true negative] = Negative In Health
= “a test’s probability (in the ABSENCE of disease) a patient test negative”
What does Confidence Interval describe
⭐Range of values in which a [specified probability (usually 95%)] of the [means of repeated samples] are expected to fall within
⭐CI = mean +/- Z(Standard Error of Mean) (ex: [95% CI, Z=1.96] and [99% CI, Z=2.58]
⭐Statistical difference:
a.[95% CI for (mean difference between 2 variables)] that includes 0 = [NSD = H0 not rejected]
b. [95% CI for (odds|relative risk ratio)] that includes 1 = [NSD = H0 not rejected]
c.
CI of an [Odds Ratio] indicates (with a certain confidence level) whether a given OR is statistically different from [null OR = 1].
a CI that excludes [null OR = 1] is statistically significant
H0 = null hypothesis = [NO statistically significant difference exist]
In terms of research, describe the 3 characteristics of
EXTERNAL validity
if relationship is seen in populations outside study also??
[T or F] Romantic relationships between pediatric physicians and parents of their patient is ethically acceptable with full disclosure
_________________
Why or Why not? (3)
FALSE
- Pediatricians dating their patients’ family members is ethically PROBLEMATIC.
- Physicians are ethically obligated to act in best interest of patient .. so intimate involvement may blur judgment =
- these pediatricians need to transfer patient care
In the Kaplan-Meier survival curve graph, ≥2 study groups can be compared and are associated with p-value
What does p-value delineate?
p ≥ 0.05 means
the study groups are NOT statistically different
In terms of Medical Errors, describe the difference between
[Preventable adverse event] and [Negligent adverse event]
PAE = preventable event 2/2 faulty human Practice
NAE = preventable event 2/2 Not adhering to Standard of Care
Recall the [2 x 2 Test vs. Disease] diagram
[Cross Sectional Study] is a study of the (⬜ past | present | future) that looks at [⬜ and ⬜ groups] to determine ⬜
_________________
What question does [Cross Sectional Study] ask?
present ; ([Group with Risk Factor] v [Group wihout Risk Factor]) ; PREVALENCE of a disease
_________________
How prevalent is this [disease and its risk factors] right now??
________________
Collects data from a group of people to determine [frequency of disease and its risk factors] at a specific point in time
________________
what is the Hawthorne effect
when pts modify their behavior just because they know they’re being studied
What are the ethical guidelines regarding receiving gifts from patients? (4)
Since these influence professional judgment, it is Unethical to accept patient gifts that are ___X___
- given with expectation of preferential tx (vs genuine tokens of appreciation)
- LARGE
- EXPENSIVE
- intimate
A patient’s Employer hands you a signed “release of information” for that patient’s medical information.
How does this affect HIPPA?
If given written authorization, HIPPA allows MDs to give the minimum necessary information to satisfy the employer’s request
What is Hazard Ratio?
HR = the likelihood an event will occur in a treatment group (relative to the control)
[not likely/protective] < HR 1.0 < [LIKELY/DETRIMENTAL]
________________
[EVENT less LIKELY to occur in the treatment group than the control group] < HR 1.0
HR 1.0 < [EVENT MORE LIKELY to occur in the Treatment Group than the control group]
Sampling bias
selection bias that → unrepresentative sample
What is [External Validity] ?
how generalizable the results of a study are to other populations
(i.e. a study for middle aged women has low external validity for elderly men)
A 95% Confidence Interval that does not include the [null value 1.0] corresponds to p-value ⬜
<0.05
_________________
95% | <0.05
Describe the ANOVA test (2)
_________________
ANOVA: Analysis Of Variance
▶compares the mean between ≥3 groups
_________________
▶requires [quantitative dependent variable (outcome)] and [quaLitative independent variable (exposure/risk factor)]
▶[Standardized Mortality Ratio] is ⬜
▶▶Formula?
________________
Explain the overall takeaway
▶adjusted measure of overall mortality
——-▶▶by calculating ——–
[observed # of deaths in population of interest]
➗
[expected # of deaths in population of interest]
________________
SMR of 1.75 = “observed # of deaths (in this population of interest) is 75% higher than expected”
What is Number Needed to Treat?
_________________
formula? (2)
of patients needed to treated in order to [prevent 1 disease] or [cure 1 condition] = measures efficacy of a therapy
_________________
NNT
= [1 / ARR]
= {1 / [(failure ratePLACEBO) - (failure rateTX)]}
ARR: Absolute Risk Reduction
What are Advance directives used for?
AD (living will, DNR/DNI) are invoked ONLY WHEN PATIENT LACKS DECISION-MAKING CAPACITY
If patient still retains Decision-Making Capacity, M.D. should still ask patient if they want to refuse intervention (like Intubation) in the treatment of temporary / reversible illness (like PNA).
Describe the recommendations regarding Physicians asking for financial support from patients?
MD altogether should avoid soliciting financial support from patients (espeicially for personal endeavor)
talking about personal experiences is fine, as long as its relevant to patient
What’s the major takeaway with interpreting a ROC Curve Graph? -2
They use (1-specificity)
so
[⇪ (1-specificity) by 12%] actually = [⬇︎ specificity by 12%]
________________
moving up-and-right on ROC = [⇪ N but ⬇︎P]
What are the 5 primary components of a safe and effective patient handoff?
PCPAF
Patient
Clinical_Status
Plan of Care/Summary with anticipated d/c
Anticipated problems with recommended mitigation
Follow ups/Pending Actions/TO DOs
What is the difference between doing research with Incarcerated individuals vs general population? (2)
- IRB requires ADDITIONAL OVERSIGHT than gen pop (to ensure fairness to this vulnerable population)
- otherwise, same rights to refuse or consent to participate
In terms of disclosure, how should physicians approach medical errors? (4)
- ERRORS DISCUSSED WITH PATIENT AND FAMILY IN TIMELY MANNER = OLBIGATION!
- Empathetic apology
- Explanation
- Event prevention discussed
Your colleague’s patient informs you that your colleague performs inappropriate breast exams, that to which your colleague denies
What should you do?
REPORT SUSPECTED (SEXUAL) MISCONDUCT TO STATE MEDICAL BOARD FOR INVESTIGATION = ETHICAL OBLIGATION
_________________
advising your colleague to terminate their physician-patient relationship is NOT ENOUGH
Relative Risk measures ⬜
_________________
What’s the Formula?
ratio between (probability of event<sup>ET</sup> : probability of event<sup>cp</sup>)]
RR = [IET / Icp]
RR = [Incidence of disease in (Exposed/Treated) group] / [Incidence of disease in (control/placebo)* *group]
T or F
- Patient p/w financial hardship at end of her visit.*
- You tell her that Co-pays can be 100% completely waived or partially adjusted based on standardized proof of need*
[T or F] ?
Explain
TRUE
⼀(True if there is standardized proof of need - but note: waiving copays for ALL patients = insurance fraud due to total charge discrepancy and potential inducement of unnecessary medical services)
In Research, describe what a [Type 1 error] is (3)
⭐detecting a difference between groups when a difference does NOT in fact exist lol
or (AKA)
⭐: Mistakenly rejecting [a null hypothesis] … that is actually true and should NOT be rejected = false positive(since rejecting = positive)
⭐{probability of [Type 1 error] occurring = α } and this reflects significance of a test
On a Central Tendency Graph below Identify
Mean, Median, Mode
cOIN
central tendency graph =
1: mOde
2: medIan
3. meaN
What case control statistical device can be used to measure association (if one exist) between a Disease and a specific [exposure or risk factor] ?
Odds Ratio
[(aD) / (bc)]
[(DISEASEOOE)/ (controlOOE)]
_________________
• OOE = Odds of Exposure
• first draw contingency table | • [(OR >1) indicates there IS an association between a DISEASE and the [exposure or risk factor] in question
What is the difference between [Case fatality rate] and [Mortality rate]?
For (Event J)…
Case fatality rate = [proportion of people with (Event J) who die from (Event J)]
_________________
Mortality rate = [proportion of general population who die from (Event J)]
What is the [Family Medical Leave Act]?
[solid employees > half time ≥1y] of [Large companies > 50 employees] have legal federally protected [≤12 weeks unpaid leave] if :
- postpartum
- serious illnes
- caring for immediate family with serious illness
What is Correlation Coefficient (r)?
[{r < 0} indicates ⬜]
& [{r>0} indicates ⬜]
describes
[Direction {neg inverse} vs {positive direct}]
and
[STRENGTH (-1 0 1) - furthest from 0 = stronger]
- of two quantitative variables to each other*
- _________________*
- [{r<0} = {neg inverse} = {A⇪ ⼀B⬇︎}]* 🆚 [{r>0} = {pos direct} = {A⇪ ⼀B⇪ }]
Cross sectional studies are majorly used to determine ⬜, but may also be used to ⬜
prevalence of disease;
obtain snapshots = examines associations between risk factors and outcomes in a well-defined population at one particular time
=takes snapshot of a population and measures freq of risk factors and outcomes simultaneously
although this leaves out temporal relationship between the two
Describe the 3 key components of the “Affordable Care Act”
- Uninsured pts who don’t qualify for [Medicaid federal health insurance] but also can’t afford [private health insurance] – can purchase insurance through the [ACA Health Insurance Marketplace Exchange]
* * * -
ACA asserts all insurance plans adhere to 3 guidelines:
a. can not deny coverage/INC premium due to preexisting health condition
b. must coverfull or partial the [10 essential health benefits (i.e. Rx, mental health)] ⼀pt may incur copay on certain benefits
c. must coverFULL100% all [Preventative Health Care] services = $0 copay
* * * - ACA applies to both HMO and PPO
_________________
HMO: Health Maintenance Organizations / PPO: Preferred Provider Organizations
In terms of Medical Errors, describe
Sentinel event
Conflict arises between multiple children of a terminally ill patient regarding his medical decisions
Management?
Hospital ETHICS Committee
What is the IRB? (3)
✏️IRB = Institutional Review Board
✏️primary authority on human research
✏️that approves research protocol initiation and/or modifications
Predictive values varies based on disease prevalence
How does disease Prevalance affect Positive Predictive Value?
and Negative Predictive Value?
⇪ Prevalence = ⇪ PPV
and
⇪ Prevalence = ⬇︎ NPV
highly SPecific test are useful for test [⬜ (screening | confirmation)]
PCD = [ProoF|ConFirmation|Diagnostic]
_________________
sPeci_F_icity= [true negative] = [TN / (TN + FP)] = used for PCD test
= “a test’s probability (in the absence of disease) a patient test negative”
PCD = [ProoF|ConFirmation|Diagnostic]
[T or F]
[Preventative Health Care (i.e. mammograms)] cost is covered 100% by all health insurance companies, and patient’s don’t have to pay anything.
Explain
TRUE
For [Preventative Health Care (i.e. screening mammogram)], Federal law mandates ALL insurance plans cover 100% the cost so that patients incur $0 out-of-pocket co-pay!
How do you manage a breach of patient privacy? (5)
- Patients must be notified IN WRITING about:
- breach mechanism
- information disclosed
- actions taken to [fix current breach]
- actions taken to [prevent future breach]
_________________
breach = disclosure of patient info to unauthorized person or for improper purpose
What is EMTALA?
EMTALA = [Emergency Medical Treatment Active labor Act] enacted by Congress 1986, imposes
[3 (SSS) primary requirements of Hospitals to EVERY patient before discharge (regardless of payment)].
Hospitals MUST :
- SCREEN patient- medical exam
- STABILIZE patient prn
- SEND patient/transfer only after patient stabilized
What is the Kappa Statistic?
measures inter-rater RELIABILITY (or Concordance).
represents the extent to which inter-rater agreement is an improvement on chance agreement alone.
What is the [two-sample t-test]? (2)
[compares MOQVGroup 1 to MOQVGroup 2]
(I.e. comparing mean of a construct score between 2 intervention groups
_________________
MOQV: [mean (of the quaNtitative variable)]
A 99% Confidence Interval that does not include the [null value 1.0] corresponds to p-value ⬜
<0.010
_________________
99% | <0.010
What is a [Kaplan Meier graph] used for?
survival analysis that [real-time analyzes⼀throughout the study] period from [entry into study] to the [event of interest (death)] and compares the rate at which [events of interest] occur for different participants.
- HR
- CI that EXcludes [null = HR = 1] is statistically significant
Selection bias occurs when ⬜. This often seen in ⬜ and ⬜.
_________________
Explain
a sample is unrepresentative of the target population (this leads to incorrect measures of association) ; Surveys / Polls
_________________
In Survey/Polls, nonresponses may cause selection bias, as responders may have responded 2/2 a particular bias = sample group is unrepresentative of target population
Treating a friend or family member involves ethical issues that compromise both [beneficence (⬜)] and [nonMaleficence (⬜)]
_________________
When is it Ok to consider treating friends or family? (3)
acting in pts best interest;
do no harm
_________________
- ONLY IF no other physician is available.. you can give
- ACUTE care ONLY
- LIMITED care ONLY
**writing a prescription automatically establishes a medicolegal physician-patient relationship; making MD liable for any/all outcomes”
“I would like to help you, but I am uncomfortable prescribing for someone I am not treating.”
AUC of a ROC curve is a reflection of ⬜. Explain
diagnostic accuracy;
Greater AUC = Greater Accuracy and discrimination (outperforms)
describe Observer bias (3)
- occurs in the absence of blinding,
- observers misclassify data due to preconceived expectations about the tx
- usually occurs when studied outcome is QUALitative
What is the Formula for Negative Likelihood Ratio?
Are Positive/ Negative Likelihood Ratios dependent or indepedent of a disease’s prevalence?
NLR⊝ = [(1-N) / P]
_________________
INDEPENDENT
“Number 1 Nigga, Positivity”….
Positive LR = seNsitivity / (1 - sPecificity)
Negative LR = (1 - seNsitivity) / P
This type of study (known as ⬜ ) can only provide what type of information?
[ecologic correlational study] ;
population-level information
guidelines regarding patients refusing treatment (2)
- patients with untreatable disease and poor quality of life, who’ve already tried different therapies, may sometimes refuse to accept any types of treatment (including general). Under principle of autonomy, this is ok.
- -Unless court rules pt is incompetent*, principle of autonomy includes a patient’s right to refuse treatment, which must be respected
How should Warfarin be adjusted if a patient starts taking amiodarone?
⬇︎Warfarin by 25% (since amiodarone inhibits CYP2C9)
What is Sensitivity Analysis?
modifying sensitivity of a study’s criteria .. and then repeating the initial analysis ⼀in order to determine if those modifications played a significant role initially
Define | Formula?
[(LR+) Positive likelihood ratio]
________________
[(LR-) Negative likelihood ratio]
what is Length-Time Bias
[progressive benign] disease cases have LONGER lifetime duration -> they are more likely to be detected incidentally by a screening xm -> artificially inflates the “detection success” of that screening xm
a laboratory facility that reimburses a physician for each test ordered is an example of ⬜ , which is an [⬜ acceptable | unacceptable] type of referral practice.
kickback; UNacceptable
_________________
kickback = financial incentive paid to referring physician for each referral sent
What is Effect modification?
_________________
Give an example
▶occurs when magnitude or direction of the [independent variable’s effect] on the [dependent variable outcome] varies based on level of a third variable = EFFECT MODIFIER
▶ Separate Stratified Analysis should be conducted for each level of the EFFECT MODIFIER
Example: “Study showing Vitamin D’s outcomes on Cancer Mortality in patient groups separated by BMI”
- independent variable = Vitamin D
- dependent variable = Cancer Mortality
- EFFECT MODIFIER = BMI[<25 / 25-29 / ≥30]
- ⼀each level (i.e. BMI<25, BMI 25-29, BMI ≥30) will have separate stratified analysis for [independent Vitamin D’s effect] on [dependent outcome Cancer Mortality]*
Explain what the [Principle of Beneficence and Nonmaleficence] means for Doctors
Doctors have ethical duties to prioritize patient global well being (beneficence)
while also [AVOIDING (either directly or indirectly by inaction) causing unwarranted patient harm] (nonmaleficence)
(ie so…DOCTORS must EXPLICITY and clearly state recommendations against or in support) Patient autonomy does NOT extend to the recommendations by the Doctor
Typically, risk and benefits of thrombolysis are discussed with patients to obtain consent for treatment
When is there an exception to this informed consent? -3
life threatening emergencies
▶i\ [inadequate time]to obtain consent
or
▶i\ [inadequate capacity of patient’s mentation]to obtain consent
🔎i\ = in the setting of
[Cohort Study] is a study of the (⬜ past | present | future) that looks at [⬜ and ⬜ groups] to determine ⬜
_________________
What question does [Retrospective Cohort Study] ask?
What question does [Prospective Cohort Study] ask?
[past (retrospective)] and [future (prospective] ; ([group WITH Risk Factor] v [group WITHOUT Risk Factor]) ; [INCIDENCE (development)] of a disease
_________________
{Analyzes records between [GWF] and [GWOF] to determine… 🔲
⛞retrospective = who developed the disease?
OR
⛞Prospective = Who WILL develop disease?
“Smokers (exposed/risk factor group) had higher RISK of developing COPD than Nonsmokers (NOT exposed/NO risk factor group) had” – in the Prospective cohort study
What kind of screening test are good for identifying individuals with NO disease? (2)
HIGH SPECIFICITY
High Negative Predictive Value
Observational studies are classified as [Observationaldescriptive] or [Observationalanalytical]
_________________
_________________
A: Name the 3 types of [Observationaldescriptive] studies? (3)
_________________
B: What do [Observationaldescriptive] they do?
A: [cAse report] , [cAse series], [cRoss-sectional]
_________________
B: [Observationaldescriptive] studies describe disease patterns by time, place and person and GENERATE HYPOTHESIS about the association between risk factors and disease
* (i.e. study showing high proportion of people with lung CA also smoked cigarettes)*
a child, brought in by their grandmother needs non-emergent care
What are the guidelines for this?
For minors, in NON-emergent situations, informed consent should be obtained from parent or legal guardian (written > verbal) before intervention
_________________
if 911 situation: consent does NOT need to be obtained before intervention (as long as reasonable attempts to contact parent/legal guardian are made)
What kind of study should be used to investigate an
acute infectious disease OUTBREAK?
Case-Control Study
________________
allows quick localization of outbreak source
How do you deal with a patient who has a large family system?
have family establish [primary POINT OF CONTACT who will communicate concise questions/concerns from family] to careteam
Describe the PDMP (Prescription Drug Monitoring Program) (3)
- STATEWIDE interoperable (clinician, pharmacy, inpatient, outpatient) database with patient’s complete controlled substance hx
- accessed by clinicians to avoid duplicate Rx and to identify high-risk drug use
- clinicians accessing PDMP database (for patient care) = exempt from HIPPA = does NOT require patient consent
how do you mitigate Observer bias
Blinding
(Observer bias = Observer [researcher] alters elements of the study (like over reporting a dz) either consciously or subconsciously)
Draw a [Specificity/Sensitivity contingency table]
Adverse Hospital events can be divided into 4 Major groups
What are they?
In Non-Surgical population, Which group occurs most frequently?
- Surgical (operation/procedural)
- [MEDICATION = MOST FREQUENT in non-surgical population (1/5 of all Adverse Hospital Events)]
- Gen Care
- Hospital-acquired infection
In terms of sharing a pt’s PHI with family members …
when can physician-patient confidentiality be broken?
If sharing a patient’s PHI with family can/will resolve an imminently modifiable risk to those family members = potential duty to relatives
Define
Internal Validity (3)
- IV = causality (did your [independent variable-EFFECT] Cause the ∆ in the [dependent variable-OUTCOME] you observed?
- If Yes = [⇪ Internal Validity] 👍
- If No ➜ [solution = double blind]
Define
EXTERNAL Validity (2)
- EV = GENERALIZABILITY ( is the observed relationship seen in the study GENERALIZEABLE (meaning can we see the SAME observed relationship OUTSIDE THE STUDY-IN THE REAL WORLD?
- If Yes ➜ ⇪ External Validity)
Observational studies are classified as Descriptive or Analytical
Name the Analytical Observational studies? (3)
_________________
What do they do?
[(some) cRPoss-sectional]uses Risk Factors to determine Disease Prevalence [who HAS disease right now]
_________________
[cARse control]Determines Risk Factors for a Disease
_________________
[CODHORT R/P] Uses Risk Factors to determine who DID and who WILL develop Disease
_________________
[Analytical observational studies] TEST HYPOTHESIS about association between risk factors and disease
(i.e. study determining that smoking cigarettes is a statistically significant risk factor for Lung CA)
what are the rules regarding Physicians observing misconduct from another Physician ? -5
Physicians are ethically obligated to report colleagues (to State Medical Boards) who are
- impaired
- incompetent
- unethical
- or who [subject patients to potentially harmful tx]
In research, what is a confounder? (2)
▶Confounder = extraneous variable a/w both the [dependent variable-OUTCOME] … and the [independent variable-EXPOSURE] …… individually
▶If Study does not correct for the potential skewed effect these confounders may have (Randomization helps to remove confounding variables) = Confounding Bias
characteristics of
Crossover design (4)
- smaller sample size
- more precise estimates of treatment effect than studies with parallel design - (since crossover = each subject gets ALL TREATMENTS = acts as their own control) (versus parallel = subjects receive single treatment thoughout entire study)
- takes longer to complete (since subjects have to move from 1 phase to another multiple times during the study)
- carryover effect (1st treatment effect carrysover into the 2nd treatment phase - can be avoided with lengthy washout)
what is sampling bias?
sampling pts in a NON-random manner -> lky to exclude certain members of the target population than others
[T or F] It is inappropriate for Physicians attending a pharmaceutical conference to accept travel reimbursement from that pharmaceutical company
_________________
Is there any caveat to this?
TRUE ⼀physicians are NOT ALLOWED TO ACCEPT travel expense reimbursement from pharmaceutical companies
_________________
…unless….they are the [faculty physician LECTURER] ⼀who can accept reasonable honoraria and/or travel reimbursement
What is the purpose of [Home Health Services]?
HHS = PT/OT/wound care
allows patients that are both [infirmed (weak in health)] and [homebound**] to receiveskilled care at home
_________________
- **homebound = ≥1 of*
- -[uses mobility device (wheelchair/cane/walker)]*
- -can only leave home with assistance*
- -leaving home medically contraindicated*
what’s the most effective way to optimize
[patient sign out/handoff] between providers?
“PCPAF”systematic template checklist
How do you deduce predictive value from [(r) correlation coefficient]? (3)
- [(r) correlation coefficient] range from {-1 to +1} with [0 = NO CORRELATION AT ALL].
- The closer to +1 = VERY POSITIVELY CORRELATED
- The closer to -1 = VERY NEGATIVELY CORRELATED
Briefly describe each term:
a. Premium
b. copayment
c. coinsurance
Briefly describe each term:
d. deductible
e. Out-Of-Pocket Maximum
d. [deductible = (Out-Of-Pocket minimum)] = min patient has to pay before health plan starts to cover any part of health expenses
e. [Out-Of-Pocket MAX] = MAX patient has to pay before health plan starts to cover ALL (100%) of health expenses
Both RR and OR measure the association between ⬜
_________________
Name the difference
Relative Risk | Odds ratio
exposure and outcome
RR = observational / experimental / follow up studies / cohort
OR = case-control / cross-sectional studies
Name and describe the 8 components of (writing) a Prescription
DP dRIVRS
lead toxicity levels ⬜ are a/w permanent cognitobehavioral problems and levels of ⬜ require Chelation therapy
10-20 ; ≥45
note: Chelation does not improve cognitive complications
What does the [standardized incidence ratio] describe?
_________________
Formula?
SIR describes if occurrence of a disease in a small population is high or low relative to an expected value derived from a larger comparison population
_________________
SIR = [observed cases] / [expected cases]
Treating a friend or family member involves ethical issues that compromise both [beneficence (⬜)] and [nonMaleficence (⬜)]
_________________
List reasons for why this is true (3)
acting in pts best interest;
do no harm
_________________
disadvantages friend/family from MD possibly ___
- treating conditions beyond expertise/training
- lack of follow up and documentation
- inadequate assessment of sensitive H/P
Medical encounters may be the only way trafficked victims can get help
If you suspect human trafficking, recite the 8 questions you can use to screen for it
Interview Patient ALONE
Medical encounters may be the only way trafficked victims can get help
Name the common warning signs for Human Trafficking (5)
Interview Patient ALONE
what does [Intention To Treat analysis] describe?
Compares tx groups in a randomized trial by including
- [all subjects],
- [their first (randomized) tx group allocation] and
3. any personal acts of attrition (dropout, loss to f/u, crossover)
to overall benefit of the drug = conservative estimates of effect if acts of attrition are significant, however, results will better reflect expectefd effect in practical clinical (i.e. real world) setting
What is the purpose of Palliative Care? -2
★ [interdisciplinary ⬇︎of unnecessary medical interventions] while [⇪ quality of life for terminal/seriously ill patients (and their family)].
★ Can occur concurrently with life-prolonging tx
What are the 2 absolute requirements for hospice eligibility?
_________________
Name the other main features of hospice (4)
RQ1. [PATIENT (or Patient’s Surrgate) FOREGOS ALL CURATIVE TX]
RQ2. prognosis LOE6mo
_________________
- interdisciplinary palliative team
- Patients can leave hospice for curative tx then return later if desired
- [comorbid conditions /non-curative interventions are OK]
- [Full informed consent from patient is NOT required (since, if needed, Patient’s Surrogate can offer substituted judgment on pt behalf)]
What is the Formula for Positive Likelihood Ratio?
Are Positive/ Negative Likelihood Ratios dependent or indepedent of a disease’s prevalence?
P = N / (1-P)
“Number 1 Nigga, Positivity” ….. “Positivity… Number 1 Plan”.
Negative LR = (1 - seNsitivity) / P
Positive LR = seNsitivity / (1 - sPecificity)
INDEPENDENT
In research, how does [Double Blinding] (which means ⬜ ) affect a study’s internal validity?
keeping individuals involved unaware of participants’ treatment assignments
________________
[Double Blinding] ⇪ internal validity
In Research, describe what a [Type 2 error] is (4)
_________________
What is the formula for [Type 2 error]
- failure to detect a difference between groups when a difference does in fact exist
- or (AKA): failure to reject a null hypothesis … that is actually false and should be rejected = false negative (since rejecting = positive)
- *
- *
—{probability of [Type 2 error] occurring = β } and this is inversely related to [power (which is how large a study has to go to detect a difference when a difference does exist)**]
- smaller study = ⬇︎power = [⇪ β = INC chances of Type 2 Error occurring]
- _________________*
[T2E = β = (1 - power)]
what is lead time bias
occurs when, even though [pt Test A] and [pt Test B] both die 5 years after the same disease..
bc [pt Test A] test diagnosed their dz 2yrs earlier…it’ll SEEM like [pt Test A] had longer survival time when actually they’re both only 5 years
Boundary Violations are defined as ⬜
How are they managed? -3
serious transgressions against physician safety and/or well-being (such as unwanted touching)
_________________
1st: reinforce hospital code of conduct with patient
2nd: REASSIGN PHYSICIAN
3rd: document alert in patient’s chart
What is Recall bias?
inaccurate recall of past exposure by participants ➜ MISCLASSIFICATION OF EXPOSURE (applies mostly to case control studies)
_________________
individuals with dz are more likely to search their memories for (possibly inappropriate) association between an exposure and their dz ⼀compared to individuals w/out dz
In statistics, what is [Power]?
the ability to detect an effect
________________
(depends on sample size = larger sample size ➜ INC power)
Describe the central role of each Medicare entity (A, B, C, D)
A = [inpatient (includes SNF, Hospice and Home health)]
B= Outpatient
C = (Medicare Advantage) ⼀allows private health care to provide Medicare benefits
D= prescription drugs
explain how [chi-square] is related to [significance level α]?
[chi-square] determines whether distribution of a categorical variable is different across ≥2 independent groups = p-value
IF
• [chi-square p] ≥ [significance level α] = NO SIGNIFICANT DIFFERENCE between distribution of categorical variable between groups = NOT ENOUGH EVIDENCE TO REJECT NULL HYPOTHESIS = NOT STATISTICALLY SIGNIFICANT
When can a Physician reveal PHI about a patient to family members? (3)
PCP can share PHI when patient p-C-p…
1. is [present (or otherwise available prior to disclosure)]
- has Capacity
- gives permission
describe [Factorial Study fully crossed Design]
study design that utilizes ≥ 2 interventions and all combinations of these interventions
In terms of [Correlation Coefficient ( r )], the null is ⬜. Why is this?
_________________
How is this related to Confidence Interval? (3)
[null = r = 0] ⼀since this indicates no linear relationship _________________
- a CI for r is statistically significant if it EXcludes 0
- CI of a r indicates, with a certain confidence level, whether r is significantly different from its [null= r =0]
- so… if study states [linear relationship between 2 variables ( r )] is significantly different from 0 (i.e. statistically significant | p<0.050) ➜ further illustrated by [CI for that ( r ) must EXclude 0]
You have a patient admitted to Hospice
Which 3 groups of drugs should be discontinued?
________________
Why?
[CV prevention] / anti-HTN / [PRN Insulin]
________________
meds taken at end of life should be comfort meds only
negative likelihood ratio (LR-) represents ⬜ and
positive likelihood ratio (LR+) represents ⬜
________________
What does this mean?
[NLR-] = value of a negative test result = [(1-N) / P]
[PLR+] = value of a positive test result = [N / (1-P)]
________________
LR varies from 0 to infinity. [⇪LR = ⇪ likelihood disease is actually absent/present]
In research, what is a Case Series?
purely observational study in which small group of patients with [similar dx or similar tx] is described [at one point in time] or [over period of time/followed].
There is no comparison group
Sensitivity
Formula(2) & meaning
Explain How:
to determine 95% Confidence Interval
for the difference in percentage of patients who achieved primary efficacy endpoint between Drug X and Drug Y? (4)
Confidence interval contain [sample value (∆ between 2 sample percentages) at the center of the interval] = [sample value +/- margin of error]
1st: determine sample value [(Drug X 74.0%) - (Drug Y 85.4%) = (-11.4%)]
2nd: determine if [p < 0.001] –(if yes)-> significantly different from 0 and excludes 0 = CI% will also not include 0
3rd: Find range that does not include 0 and has [sample value -11.4%] its the center =
(-13.9% to -8.9%)
Between assigning team roles with redundancy vs specific team roles, which is preferred and why?
_________________
SPECIFIC;
task overlap between team members may ➜ duplication errors! [Ideal = clear specific roles with continuous refinement of clinical processes via quality improvement and by tracking outcomes]
What kind of study should be used to investigate an
acute infectious disease OUTBREAK?
Case-Control Study
________________
allows quick localization of outbreak source
Explain how Confidence Intervals work? (4)
Confidence interval contain the [sample value (∆ between 2 sample percentages) at center of the interval] = [sample value +/- margin of error]
_________________
when comparing ≥2 groups (i.e. treatment 1 vs treatment 2), if their Confidence Intervals DO NOT overlap = There is a Statistically Significant Difference ✔︎ between those 2 groups
_________________
when comparing 1 group to placebo, if that groups’ Confidence Interval DO NOT contain the null value (0) = Overall Statistically Significant
_________________
If 2 groups’ CI overlap = there may or may not be a statistically significant difference between those 2 groups
Between Median and Mean, which is a better measure of central tendency in strongly skewed distributions?
MEDIAN
How do you calculate ARR?
[ARR= (riskPLACEBO - riskTreatment)]
How do you calculate RRR? (2)
RRR=
[ARR/riskCTRL]
–or–
[(riskCTRL - riskTreatment)/riskCTRL)]
_________________
[ARR: Absolute| RRR: Relative _ Risk Reduction]
How do you calculate NNT? (2)
[ARR= (riskCTRL - riskTreatment)]
[RRR = ARR/riskCTRL ]
- [ARR: Absolute| RRR: Relative _ Risk Reduction]*
- *
NNT = [1 / ARR] = {1 / [(failure ratePLACEBO) - (failure rateTX)]}
Describe the major difference between Confounding bias and [Effect modification interaction bias]
[extraneous (3rd) variable] that’s associated with both the [independent exposure] and the [dependent outcome] ____x____ the effect the [independent exposure] has on [dependent outcome]
C: [CONFOUNDS(obscures)]
E: [MODIFIES direction & strength]
- Separate stratified analysis should be conducted for EACH level of an Effect modifier*
A good ⬜ test will have high Specificity
How is Specificity related to PPV?
PCD ; [⇪ sP = ⇪ PPV]
_________________
[⇪ sP = ⇪ PPV = ⬇︎FP]
PCD = [Proof/Confirmatory or Diagnostic]
What does [ARP - Attributable Risk Percent] measure? (2)
_________________
formula?
In a [group with an outcome], the percentage of that group that can attribute that outcome to a specific exposure
_________________
ARP = [(RiskEXPOSED - Risknonexposed) / RiskEXPOSED] x 100
_________________
Risk = Risk of getting outcome
[T or F]
Referrals to Specialist physician (from a referring physician who personally knows the Specialist physician) is generally considered unethical
FALSE
referrals to specialist, even when specialist personally known to the referring physician, is OK as long as it is medically indicated and there’s no financial compensation exchanged for said referral
What does [PARP - Population Attributable Risk Percent] measure?
_________________
formula?
estimates proportion of the [population with disease] that actually acquired that disease from the exposure
_________________
PARP = [{(Prevalence) x (RR-1)}] / [{(Prevalence) x (RR-1)} + 1]
the [chi square test] and the [Fisher’s exact test] evaluate ⬜
_________________
What is the primary difference?
association between [2 categorical (quaLitative) variables] (i.e. study evaluating association between sex and [Y/N presence of MI])
_________________
FET is commonly used to analyze 2x2 contingency tables when the sample sizes are small
In most states, if there is no [advance directive (i.e. DPOA)], default surrogates are prioritized via “Surrogate” hierarchy.
Recite the [Surrogate Hierarchy] (8)
_________________
DPOA: Durable Power Of Attorney
**P-C-P-A-P-AAU**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. **P**t designated
2. **C**ourt appointed<sup>*(only occurs if multiple surrogates disagree, none is designated or surrogate acting in self interest)*</sup>
3. **P**artner/Spouse
4. **A**dult children
5. **P**arents
6. **A**dult siblings
7. **A**dult relatives*other*
8. **U**nrelated friends
## Footnote
<sub>*✏️Court-appointed guardianship only occurs if multiple surrogates cannot agree, no healthcare surrogate is identified, or surrogate is clearly acting in his/her own self-interest*</sub>
What are the guidelines regarding [Reproductive Sterilization]? (2)
▶THE PATIENT THEMSELF has to freely consent to [reproductive sterilization] on their own
▶ legal guardians/appointed health care decision-makers CAN NOT consent on patient’s behalf for [reproductive sterilization]
Involuntary sterilization (especially in retarded patients) is unethical
highly Sensitive test are useful for test [⬜ (screening | confirmation)]
screeNing
_________________
seNsitivity= [true Positive] = [TP / (TP + FN)] = used for test screeNing
= “a test’s probability (in the presence of disease) a patient test positive”
Length-time bias
Since [slow progressive benign cases] outlive [rapid progressive malignant cases], Length-time bias occurs when a test only ends up detecting those [slow progressive benign cases (which naturally have better prognosis)] ➜ false appearance that the test actually INC survival benefits
_________________
survival benefits of a screening test are overstated due to detection of a disproportionately higher # of [slowly progressive benign cases]
A good ⬜ test will have high Specificity
How is Specificity related to False Positives?
PCD ; [⇪ sP = ⬇︎False Positives] ⼀which is why good Confirmatory test have HIGH sPecificity
_________________
[⇪ sP = ⇪ PPV = ⬇︎FP]
PCD = [Proof/Confirmatory or Diagnostic]
Define [p-value] and its relation to Null hypothesis
[p-value] = Chance that study results happened randomly
[(At CI 95%) [p-value] < 0.05] means you can Reject Null hypothesis since it means there’s lil chance the results happened randomly
what does Odds ratio indicate?
_________________
if H Pylori infection has [OR=0.351] in a study for stomach bleeding. what does that indicate?
[exposure has lower ODDS of causing Outcome] ⬅︎ [OR 1.0] ➜ [exposure has HIGHER ODDS of causing Outcome]
if (OR = 1) = exposure NOT ASSOCIATED with Outcome
_________________
[1.0 - (0.351)] = (0.649) = 64.9% = [[exposure (HPylori+)] has 64.9% lower ODDS of causing [Outcome (stomach bleeding)] …as compared to [non-exposure(HP-)]
What are the components of [Root Cause Analysis]? -5
DCRSA
- Data Collection
- [Causal Factor flow chart] (main steps leading up to event that, if eliminated, could have prevented or reduce adverse event)
- Root Cause (reason behind each causal factor)
- Solutions recommended (for each root cause)
- Assessment (assess success of Recommendations)
What does overlapping [Standard Error of Measurement bars] indicate?
Non-Statistically significant difference between the two data sets being compared
What kind of test are best to rule out a diagnosis? (2)
SnNOut
Sensitivity HIGH + Negative test result = rules Out a disease
[T or F]
Referrals that result in financial gain (gifts, kickbacks, fee-splitting) for the referring physician are illegal
TRUE
- Physician Referrals resulting in financial gain for that Physician are generally illegal and/or unethical* .
- Routine referrals should only be made to facilities with evidence-based & medically-indicated care*
Define__X__ (2)| What’s the Formula?
[(NPV) Negative Predictive Value]
NPV= [TN / (TN + FN)] = probability (in the presence of a Negative test result) a patient DOES NOT actually have the disease = ability of test to accurately predict Negative test result_
How much can we trust this test?
A physician (⬜ can | cannot) unilterally terminate a patient solely for nonpayment
_________________
When is a physician considered “abandoning” a patient? -2
CAN
_________________
“pt must have [⊕time & ⊝911 needs] before they can be terminated
Abandoning Patient if:
- Patient terminated whilst in immediate medical need
- Patient NOT given reasonable time to find alternate provider
[T or F] Pt confidentiality shuld be maintained even when a pt is having Active suicidal ideation
FALLLSEE!!!!
Active (i.e. plans to hang themself) suicidal or homocideal ideation warrants breaking confidentiality and informing parents or whomever
What is Verification bias?
using gold standard testing to verify/confirm results of a preliminary test (which ➜ over/underestimation of seNsitivity or sPecificity)
Asymmetry in a funnel plot suggest ⬜ bias
publication
Standardized Mortality Ratio
Explain the overall takeaway
SMR of 1.75 = “observed # of deaths (in this population of interest) is 75% higher than expected”
In the terms of [dose response relationship]
An association between a risk factor and a disease is more likely to be causative if what?
If the [disease strength] increases as [risk factor exposure level] increases = dose response relationship = likely causative
{although this is not necessary to infer causation}
Describe the Approach to a patient who’s resistant to disclosing genetic test results with relatives also at risk? -2
[acknowledge their resistance] + [open ended questioning/motivational interviewing]
________________
“You have reasons for not wanting to contact your brother; what are some possible benefits of sharing the results?”
How do you describe a survival analysis study, in which although [80% control group died] and [80% of treatment group died] also, investigators still reported treatment was more effective than the control?
investigators must have analyzed [TIME-TO-EVENT/DEATH] data instead and saw that, although both groups had 80% die ultimately, the treatment group must have had longer [TIME-TO-DEATH] = Treatment group lived longer = Treatment overall more effective
[TIME-TO-EVENT/DEATH] often used in survival analysis
Describe the current recommendations regarding Sex between a physician and patient
UNETHICAL PROFESSIONAL MISCONDUCT
_________________
SEX/ROMANANCE between physician and [patient (current OR former✳)] is UNETHICAL PROFESSIONAL MISCONDUCT
✳ = if MD exploits pre-existing knowledge
What is the majority recommendation for Romantic or Sexual relationships between Physicians and current Patients?
________________
what about former patients?
current patient = UNETHICAL 100%
________________
former patient = Unethical if MD exploits knowledge or influence derived from previous professional relationship
Define__X__ | What’s the Formula?
[(PPV) Positive Predictive Value]
PPV = [TP/ (TP+FP)] = probability (in the presence of a Positive test result) the patient actually has the disease = ability of test to accurately predict Positive test results_
________________
PPV = ability of test to accurately predict Positive test results
How much can we trust this test?
Odds Ratio
formula
[(aD) / (bc)]
[(DISEASEOOE)/ (controlOOE)]
_________________
• OOE = Odds of Exposure
• first draw contingency table | • [(OR >1) indicates there IS an association between a DISEASE and the [exposure or risk factor] in question
What type of Nonnormal distribution is this?
_________________
How does it affect Mean, Median and Mode?
POSITIVE skew
( “it’s skewing away from the POSITIVE direction = POSITIVE SKEW)
mea(N) > med(i)an > m(O)de
