Clinical Medicine

Question 1

What is association?

Answer 1

rceived relationship between two variables, but does not necessarily indicate a causal relationship due to the presence of possible confounding variables, chance, or false associations

Question 2

What are the criteria for causation?

Answer 2

Demonstrated association
Temporality - cause precedes effect
Altering the cause alters the probability of the effect

Question 3

What can both case-control and cohort studies do?

Answer 3

Both studies are able to determine associations between an exposure and an outcome when a randomized controlled trial is not feasible

Question 4

What is a cohort study?

Answer 4

A study population is defined by whether or not they have had an exposure (exposure-based) and then followed for a period of time to determine whether or not they develop an outcome - must be free of outcome at the start of the study

Question 5

What is a case control study?

Answer 5

Study population is defined by whether or not they have an outcome (outcome-based with selected controls) and then look back to see whether or not they had an exposure - ALWAYS retrospective

Question 6

What are strengths of a cohort study?

Answer 6

Best available when RCT isn’t possible, can look at multiple outcomes for a single exposure, exposure status is measured before outcome, can study many risk factors, can establish disease incidence

Question 7

What are weaknesses of cohort study?

Answer 7

Often require large populations, difficult with rare events, can be limited to pre-collected data, expensive, potential for bias (recall, measurement, loss to follow up)

Question 8

What are strengths of case control studies?

Answer 8

Efficient for studying rare outcomes and long latency, can look at multiple exposures, less time consuming/expensive, easy to set up and execute quickly

Question 9

What are weakness of case control studies?

Answer 9

Susceptible to bias given retrospective nature, cannot give information on prevalence/incidence, not good for rare exposures, frequently executed poorly, more sensitive to risk of misclassification/confounding

Question 10

What is the relative risk ratio?

Answer 10

a/(a+b)/c/(c+d)

Question 11

What is the odds ratio?

Answer 11

ad/bc

Question 12

When can the odds ratio approximate the RR?

Answer 12

when incidence is low

Question 13

What is attributable risk?

Answer 13

a/(a+b) - c/(c+d)

Question 14

What is the NNH (number needed to harm)?

Answer 14

1/AR

Question 15

What is sampling bias?

Answer 15

bias in which a sample is collected in such a way that some members of the intended population have a lower sampling probability than others

Question 16

What is selection bias?

Answer 16

bias introduced by the selection of individuals, groups or data for analysis in such a way that proper randomization is not achieved, thereby ensuring that the sample obtained is not representative of the population intended to be analyzed

Question 17

What is a confounder?

Answer 17

variable that influences both the dependent variable and independent variable, causing a spurious association (causal concept)

Question 18

What is recall bias?

Answer 18

atic error that occurs when participants do not remember previous events or experiences accurately or omit details: the accuracy and volume of memories may be influenced by subsequent events and experiences

Question 19

What is measurement bias?

Answer 19

systematically overstates or understates the true value of the measurement

Question 20

What is surveillance bias?

Answer 20

arises when patients in one exposure group have a higher probability of having the study outcome detected, due to increased surveillance, screening or testing of the outcome itself, or associated symptoms

Question 21

What is spectrum bias?

Answer 21

each arm (cases and controls) had to have an equal opportunity to have the exposure (spectrum of possible exposure)

Question 22

What is planned care?

Answer 22

pre visit chart review

for each problem listed, consider SOAP

Question 23

What is discovery phase?

Answer 23

Genome-wide association studies (GWAS) to discover SNPs and potentially pathogenic variants that affect therapeutic drug response

Question 24

What is clinical testing based on variant type?

Answer 24

Individual-specific genetic testing assays (e.g. del/dup, NGS, single allele assays, etc.) that test for variants of phenotypic importance that affect therapeutic drug response

Question 25

What is a disadvantage of assays?

Answer 25

assays will not cover all genotypic outcomes (e.g. if patient has a rare variant that affects metabolism, then it might not get caught)

Question 26

Why are translation tables important?

Answer 26

Diplotype tables (a.k.a translation tables) detail the potential outcomes for combinations of diplotype: will tell you dosing information based on alleletypes of patient

Question 27

What is the goal of TDM (therapeutic drug monitoring)?

Answer 27

To optimize the drug dose so that the patient’s drug concentrations remain within the therapeutic range; generally performed when drug reaches steady-state

Question 28

What are four attributes of drugs that make them amenable to therapeutic monitoring?

Answer 28

Known relationship between dose & blood/serum/plasma concentrations
Narrow therapeutic window
High patient variability in pharmacokinetics
Severe adverse effects

Question 29

What is the innovative Medicare model?

Answer 29

adds outside-the-visit chronic care management (often done by non-physician team members).

Question 30

What is the traditional Medicare model?

Answer 30

Medicare reimbursed with the focus on acute, episodic care

Question 31

What are the basic principles of the chronic care model?

Answer 31

lower cost, better care and better health

health care and community provide interactions between informed/activated patient and prepared proactive practice team

Question 32

List the components of the Patient-Centered Medical Home?

Answer 32

Personal Physician - each patient has an ongoing relationship with a personal physician trained for first contact and continuous care.
Physician-directed medical practice - personal physician leads a team of individuals at the practice level who take responsibility for the ongoing care of patients
Payment and Med Economics: payment appropriately recognizes the added value provided to patients who have a PCMH and work that’s done outside of face-to-face.
Quality and Safety - advocacy for attainment of optimal, patient centered outcomes defined by a collab care planning process. EBM and CD support tools guide decision making - QI is key here.
Whole person orientation - physician responsible for the patient’s: health care needs, learning of self-management principles, and arranging f/u care
Enhanced access to care – access is available through systems such as open-access scheduling, extended hours, and new options for communications between patients and staff.
Care coordination and integration - care coordinated across all elements of the health system facilitated by tech to assure they get the care when they need it.
(PPP-QWEC)

Question 33

What is the Ask-Tell-Ask method of motivational interviewing?

Answer 33

Ask: assess the pt’s baseline knowledge
Tell: use simple, clear, concise language; avoid medical jargon; speak slowly; “chunk” info by pausing after a concept; limit 1-3 key messages and emphasize these messages; use visual aids and written instructions to reinforce key messages.
Ask: request teach-back (ask the pt to repeat the instructions they have just been given); expect questions: “What questions do you have?” instead of “Do you have any questions?”

Question 34

Why do we share information in MI?

Answer 34

Optimize outcomes (better outcomes if patients know what’s going on/why the plan is the way it is)
Promote pt autonomy by allowing patients to share in decision-making
Promote pt self-efficacy

Question 35

What is shared decision making?

Answer 35

A strategy of partnership between doctor and pt that helps pts make “an evidence-based treatment choice”

Question 36

When is shared decision making applicable?

Answer 36

appropriate for preference-sensitive conditions in which there is more than one choice of therapy, including the choice of no intervention

Question 37

What encounters in which MI would be beneficial?

Answer 37

adherence to medication, smoking cessation, diet and exercise, risky sexual behavior, alcohol use disorder, blood pressure

Question 38

What are the techniques of MI?

Answer 38

OARS:
Open ended questions
Affirmative statements
Reflections
Summary statements

Question 39

What is the Righting Reflex?

Answer 39

When the physician tells the patient how to fix a behavioral problem

Question 40

What is Roll with Resistance?

Answer 40

It is best to sidestep any resistance and to avoid trying to fix and solve every problem

Question 41

What is the Develop Discrepancy?

Answer 41

Highlight areas of inconsistency between behavior and goals or values

Question 42

What is Decisional Balance?

Answer 42

Think about costs and benefits of changing behavior vs. not changing behavior