Ethics, Public Heath, Stats Flashcards
Difference between criminal, civil and administrative law
Criminal - nationwide; fine or jail
Civil - province wide; fine
Administrative - sanctions by regulators, eg college of physicians
Principles of the Canada health act
Public administration
Comprehensiveness
Universality
Portability
Accessibility
Public administration- the Canada health act
Provincial health insurance programs must be not for profit
Comprehensives - the Canada health act
Provincial health insurance must cover all medically necessary services
Universality - the Canada health act
All eligible residents must receive free health care
Portability - the Canada health act
Emergency health services must be paid by their home province when travelling outside of the province
Accessibility - the Canada health act
Provincial plans must ensure access to medical services without financial or other barriers
Federal government responsibilities
Indigenous peoples
Marine hospitals
Quarantine
Food and drugs
Medical devices
Provincial government responsibilities
Hospitals
Charities
Health professional licensing
Provincial health care plans
This outlines the national terms and conditions provincial health systems must meet to get federal payment
Canada Health Act
This states that the federal government gives provinces a single grant to split between healthcare, social programs and education at their discretion
Canada Health and Social Transfer Act
The Indian Act
Banned Indigenous culture and spirituality and gave the federal government complete control over Indian land
Fiduciary duty
Legal duty to act in another party’s interest
Competence vs capacity
Competence - determined legally by court
Capacity - determined by HCP
The four principles of medical ethics
Autonomy
Beneficence
Non-Maleficence
Justice
Autonomy
The patient makes their own decision
Beneficence
Maximizing patient benefits; working in the patients best interests
Non-maleficence
Do no harm
Justice
Fair benefits within a community regardless of geography or income
Privileged information
Information that cannot be used in court
Reasons to breach confidentiality
Child abuse
Fitness to drive
Communicable diseases
Death
Duty to inform/warn
When does duty to warn apply?
Imminent risk, identifiable person/group, serious bodily harm or death
Is duty to warn legally mandated?
Federally no but it is allowed
Provincially it varies but still allowed
Lock boxes
Situations where a patient expressly restricts a physician from disclosing health information to other people including healthcare providers (except where required by law)
Does a physician need to offer all choices for consent to be obtained?
Not necessarily. They don’t need to offer an intervention that would have no benefit
Consent vs assent
Consent - they have capacity to make a decision and agree
Assent - they lack capacity but still agree
4 requirements of consent
Voluntary
Capable
Specific
Informed
Battery vs negligence when it comes to consent
Battery - no consent was obtained or consent for the wrong treatment was obtained
Negligence - the consent wasn’t good enough
Exceptions to consent
Emergencies - unless prior signed documentation eg jehovas witness
Psych detaining pt
Communicable disease detaining pt
Tort
an act or omission that gives rise to injury or harm to another
Medical error
Preventable adverse events or an error that may have caused adverse events
Negligence vs medical error
Negligence is a legal determination. If a medical error is never brought to court it can’t be negligence
Apology act
Apologizing for something does not mean you are admitting to doing it
SPIKES protocol for breaking bad news
Setting - quiet alone space
Patient perceptions - do they understand?
Invitation from patient to receive info
Knowledge - provide facts
Empathize
Strategy, summarize
Therapeutic privilege
Withholding information because you think it will cause too much distress in your patient
Rarely acceptable now
At what gestational age is abortion illegal in Canada?
It’s never illegal at any gestational age. 39 weeks - still allowed
Euthanasia vs MAID
Euthanasia- ending someone’s life with or without their consent to relieve suffering
MAID - the person specifically requests it
MAID criteria
Patient is eligible for publicly funded health services
18 years old
Has capacity and gives consent
Medical condition without cure
Suffering intolerable
Natural death is reasonably foreseeable
MAID process
Patient signs and dates request with 2 independent witnesses (not benefiting from the patients death and not involved in their health care)
2 HCPs (physician or NP) have to approve it
10 days must pass from request to MAID (usually)
Express consent immediately prior to MAID
Can withdraw at any time
When do you need to notify a coroner if death occurs?
Violence, negligence, misconduct
Pregnancy
Sudden or unexpected
Disease not treated
Cause other than disease
Suspicious
MAID
OCAP principles
Principles created for research involving indigenous populations
Ownership: The community owns the info collectively
Control: The community controls all research that impacts them
Access: they can access info and data about themselves
Possession: They are stewards of the data
You’re doing a great job studying!!
Keep it up
Implicit bias
bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors.
Enfranchisement (Indigenous context)
Taking away an individuals Indian status and giving them a Canadian citizenship - In cases where an a indigenous person got a university degree, joined the armed forces or married a non-Indigenous person
Leading cause of death in Canada
Cancer
50% of Canadians will get it, 25% will die from it
Impairment vs disability vs handicap
Impairment - a deviation from normal function in an organ or system
Disability - a restriction or lack of ability to perform an activity considered normal for a human being
Handicap - a social disadvantage for an individual resulting from an impairment or disability. I.e their disability prevents them from filling a role
An impairment could lead to a disability which could lead to a handicap
Illness vs sickness vs disease
Illness - the experience of disease; subjective feeling of being unwell
Sickness - socially defines status of people who are sick, eg. stigma
Disease - the pathological process of a patients illness
Response shift
Changing your expectations to match your declining health to maintain satisfaction with life
The four sacred medicines
Sweet grass
Tobacco
Cedar
Sage
How does the WHO define health
A capacity to respond to challenges
Illness behaviour
The pattern of reactions a patient has to their perception of being sick. Eg seeking care, complying with recommendations, taking meds
Population vs public health
Population - how we think; why are some people healthier than others?
Public - what we do; promoting physical activity
Social gradient in health
There is a steady rise in longevity across income levels. I.e the more you make the longer you live
Social determinants of health
The circumstances in which people are born, grow up, live, work and age
Health inequity
A disadvantage that is correctable or could have been avoided
Inequalities in health that are unfair and stem from injustice
Three elements of equity
Equality
Fairness
Amendability
Equality
Equal access to opportunities
Fairness
The most qualified person for a job should get it regardless of their race, gender, etc
Amendability
Something should be done to fix situations in which inequities arise
Absolute poverty
Lacking the resources to meet basic needs for shelter, nutritious food, clothing and education
Health literacy
The patients ability to understand health information and to follow guidelines for their treatment
Distal, intermediate and proximal factors
Distal - free immunization clinics
Intermediate - accessibility of clinics
Proximal - choosing to get immunized
Determinants vs risk factor
Determinants - population based factors
Risk factor - individual based factors
Risk marker/indicator vs risk factor
Marker - Associated but not the cause, eg. Increased age associated with disease
Factor - A direct cause; eg smoking is a factor for cancer
The health belief model
Factors that influence whether a person will participate in preventative measures:
1. motivation to take action (threat of the disease)
2. The cost and effectiveness of the action (benefit minus barriers)
3. A cue triggering change (eg symptoms, raised awareness, etc)
What is the single best predictor of behavior?
Perceived barriers
Theory of planned behaviour
Includes everything in the health belief model (motivation, effectiveness and cues to action for the behavior) plus societal views on the behavior and beliefs on self efficacy
Eg quitting smoking
I want to quit
Quitting is an effective way to prevent cancer
My dad just died from lung cancer
Society says smoking is bad
I think I’m able to quit
Predisposing, enabling and reinforcing factors example
Predisposing - awareness and attitude towards drugs
Enabling - receiving funding for rehab
Reinforcing - feeling better when sober
The interacting triad of causal factors
Agent (eg. A virus, addictive quality of drugs)
Environment (eg. Poor sanitation, growing up around addicts)
Host (eg. Poor immunity, addictive personality)
Aleatory chance vs epistemological chance
Aleatory - completely unpredictable
Epistemological - we can’t yet explain due to limits in our current scientific understanding
Upstream vs downstream analyses
Up - the cause of incidence rates; looking at the population
Down - the cause of causes; patterns of health in individuals
Being conscious of similarities and differences between cultural groups and understanding how culture may affect a patients approach to health, illness and healing
Cultural awareness
Being aware of and understanding how your own culture may shape your approach to patients from other cultures
Cultural sensitivity
Attitudes, knowledge and skills of practitioners necessary to become effective HCPs for patients from diverse backgrounds
Cultural competence
Understanding power imbalances and institutional discrimination between people of different cultures and how this may affect patient care
Cultural safety
The sense that one’s own beliefs, values and way of life is superior than others
Ethnocentrism
Attempting to be unbiased by ignoring the race and culture of your patient.
Cultural blindness
NOT a good thing
Distress that occurs when being exposed to something not part of your culture
Culture shock
When the rules of one culture and contraindicated by the rules of another culture
Cultural conflict
Imposing values of your culture on another without consideration of their beliefs
Cultural imposition
Aka cultural assimilation
Aka colonialism
Collectivist vs Individualist cultures
Collectivist - family-centered, group decisions. Eg Chinese traditionally have parents live with their adult children
Individualist - values autonomy. Eg. North Americans usually put their parents in an old age home
Primordial prevention
Actions to modify population health determinants and prevent environmental, economic, social and behavioural factors that increase the risk of disease
Eg. Subsidized fitness programs
Primary prevention
Preventing the onset of specific diseases via risk reduction
Eg. Smoking cessation
Example of active vs passive primary prevention
Active - brushing your teeth
Passive - adding fluoride to municipal drinking water
Secondary prevention
Screening for and treating disease
Eg. Mammograms to detect early breast cancer and preventing it from spreading
Tertiary prevention
Once a disease has been established, decreasing the impact of the disease. Eg. A cardiac patient losing weight
Health protection
Actions that help to eliminate the risk of adverse consequences for health attributable to environmental hazards, or unsafe food, water, drugs, etc
Health promotion
Enhancing health by developing healthy public policies, healthy environments and personal resiliency
Health protection vs health promotion
Protection - removing negative influences on health
Promotion - adding positive influences on health
Aspects of critical appraisal
Falsifiability
Logic
Comprehensiveness
Honesty
Replicability
Sufficiency
Falsifiability in critical appraisal
For a conclusion to be based on evidence it has to be possible to disprove the claim
Eg. God is not falsifiable because you can’t prove he doesn’t exist
Comprehensiveness in critical appraisal
All available evidence must be considered; you can’t ignore evidence that contradicts you
Sufficiency in critical appraisal
Evidence must be adequate enough to establish truth
Eg someone’s opinion isn’t sufficient
Evidence based medicine
Using best evidence derived from research to treat your patients and taking into account their specific circumstances
Includes the science and art of medicine
The 5 A’s of evidence based medicine
Assess - what’s the patients problem
Ask - make a question
Acquire - look at research
Appraise - is the research legit
Apply - treat the patient that way
Ordinal vs interval scale
Ordinal - they are ordered but not necessarily evenly spread numbers. Eg on scale 1 to 10 of pain
Interval - the difference between numbers is constant. Eg temperature
Criteria for inferring a causal relationship
Chronological - the exposure came before the disease
Strength of association - all those with the disease were exposed
Intensity/duration - the longer the exposure the higher the likelihood of disease
Specificity of association- the exposure consistently only relates to this disease
Consistency - different populations show the exposure causing the disease
Coherent/plausible findings - is there an explanation
Cessation of exposure - If the exposure is removed does the disease incidence decline
Random vs systematic error
Random - an error due to chance
Systematic - an error due to bias
A challenge in interpreting a study due to the effects of two processes not being distinguished from each other
Confounding
Types of experimental studies
RCTs
Non-randomized experiments
Types of observational studies
Cohort
Case-control
Cross-sectional
Descriptive
Cohort vs case control
Cohort - sampling based on an exposure
Case-control - sampling based on an outcome
Quasi-experimental studies
Allocation to groups is not fully random
Eg. Comparing people living in one town to another town
Equation for measuring RCT intervention effectiveness
The change in the intervention group minus the change in the control group
Efficacy vs effectiveness
Efficacy - the impact of a treatment based on optimal experiment conditions
Effectiveness - the impact of a treatment in the real world
N of 1 trial
The same patients receives both interventions one after the other to see what one works better
Phase 1 intervention study
New treatment is tested in a small group for the first time to determine safe dosage and side effects
Phase 2 intervention study
The treatment is given to a larger group at the recommended dosage to determine safety
Phase 3 intervention study
A series of randomized trials for a new treatment
Phase 4 intervention study
After the treatment becomes available, data continues to be collected about the safety of a drug
Post-marketing surveillance
No formal RCT
 Descriptive studies
Using descriptive statistics to summarize results - percentages, mean, or median value.
How do you descriptive studies differ from analytic studies
Analytic studies test a hypothesis while descriptive studies just describe what’s happening
Cross-sectional studies
Studies that use a single time reference for the data collected.
Example, if patients seen in the past two weeks were stressed or not
The main disadvantage of cross-sectional studies
You cannot show temporal sequence, rather that there is an association between the variables in that timeframe
Ecological studies
Studies that measure variables at the level of populations rather than individuals
The ecological fallacy
Drawing conclusions about individuals based on population data
Cohort study
Following a cohort of people without the disease and then seeing if they get the disease based on if they were exposed not exposed to something
How can you get the incidence of disease for exposed and unexposed patients and the relative risk in a 2 x 2 table?
Incidence of exposed = exposed with disease present / number of people exposed overall
Incidence of unexposed = unexposed with disease present / number of people unexposed overall
Relative risk/risk ratio = incidence of exposed / incidence of unexposed
How to interpret relative risk
RR of 1 = people exposed are no more or less likely to get the disease as those not exposed
RR > 1 = exposed increased risk of disease
RR <1 = exposed decreases risk of disease
Advantages and disadvantages of cohort studies
Advantage - temporal making it more likely causation
Disadvantage – takes a long time to complete and is expensive
Case-control studies
Studies that pair a group of patients with a disease to an otherwise similar group of people without the disease to see if there was any difference in an exposure
Infant mortality rate equation
Number of deaths of infants <1 in a given year divided by number of births that same year x 1000
Perinatal mortality rate equation
deaths of >28 WGA until 1 week after birth divided by (deaths of >28 WGA and live births) x 1000
Neonatal mortality rate
Deaths of infants <28 days old divided by live births in the same year x1000
Crude mortality rate equation
Number of deaths in a year divided by the population at a certain point in that time frame x 1000
Standardized mortality ratio
The ratio of deaths in a population compared to the expected number of deaths if the population had the same structure as a reference population
SMR 100 means the deaths are the expected level
SMR 110 means the death rate is 10% higher than expected
Potential years of life lost
Some diseases that kill younger are worse than diseases that kill older in terms on potential years of life lost. Eg. Suicides are often in younger people so have a higher rate of potential years of life lost compared to heart disease
Quality adjusted life years
The idea that not every year of life is worth the same amount. If a treatment prolonged your life by 10 years but you had severe disability after the treatment, you would give them a year value less than the 10 years
The standard gamble
Asking someone with a disability if they could get a surgery that would either completely cure them or kill them, what percentage mortality rate would they accept to gamble the cure
The time trade off
How many years of life expectancy would you give up to have years without disability
Reliability
Reliable - something is consistent, not necessarily right.
Validity
Is the test measuring what we are intending to measure
Sensitivity
How well the test detects disease. The probability that a person with the disease will test positive
True positive divided by (True positive + false negative)
Specificity
How well a test identifies those who don’t have the disease
True negative divided by (true negative + false positive)
Positive predictive value
What portion of patients with a positive test actually have the condition
True positives divided by all positive test results
Negative predictive value
What portion of patients with a negative test actually do not have the condition
True negatives divided by all negative test results
Ruling in and ruling out a disease based on test sensitivity and specificity
Think SNNOUT and SPPIN
SNNOUT - a negative test with high sensitivity rules out a disease
SPPIN - a positive test with high specificity rules in a disease
Positive likelihood ratio
How much more likely someone with a disease is to have a positive test as someone without the disease
Sensitivity divided by (1-specificity)
How much a positive test increases the odds of having the disease
Negative likelihood ratio
How much more likely someone without a disease is to have a negative test as someone with the disease
(1 - Sensitivity) divided by specificity
How much a negative test decreases the odds of having the disease
Likelihood ratio cut off values for ruling in or out a disease
<0.2 for negative likelihood ratio rule out the disease
> 5 for positive likelihood ratio rule in the disease
Attributable risk
Incidence in the exposed group - incidence in the unexposed group
Exposed attributable fraction
(Incidence of exposed - incidence of unexposed) divided by incidence of exposed
Number needed to treat
The number of people with a condition who must follow a treatment regimen in order for one person to get the desired outcome
Calculating number needed to treat example
A medication cures 35% of people but 20% of people are cured spontaneously. The difference is 15%. 1/0.15 = 7
You need to treat 7 people for 1 person to benefit
Passive surveillance
The surveillance agency waits for info to come to them. Eg. Death certificates, notifiable diseases etc
Active surveillance
Surveillance agencies seek data. Eg sending out surveys to physicians about cases of a specific disease
Continuous source
A prolonged source of a disease, eg. Contaminated drinking water. The cases will not grow exponentially like they would if it was spread person to person
Intermittent exposure
People are getting a disease at certain time intervals. Suggests it’s not transmitted person to person
Propagated spread
One person infects another who then infects a few people and then all of them infect a few people and it grows exponentially
Cost minimization analysis
Picking the cheaper option. Eg choosing generic drug over brand name
Cost benefit analysis
Seeing if by spending money it actually saves money in the long run
Cost effectiveness analysis
Assesses the benefit of the outcome (not monetary value) compared to the cost
Cost utility analysis
The same as cost effectiveness but includes a standardized scale to compare across different populations
Length bias
Slowly progressing diseases are picked up more on screening tests and have longer survival rates
Lead-time bias
Screening leads to an earlier diagnosis so it looks like the patient lives longer but it’s possible they would’ve died at the same time regardless of knowing they had the disease
Systemic matters
Policies involving the health system overall.
Eg should government pay for health care
Programmatic matters
Policies that involve health care programs and how resources should be allocated
Organizational matters
Policies that involve how resources can be used productively in organizations
Instrumental matters
Policies that concern management of organization, eg electronic health records
