Management And Legal Issues In Surgery Flashcards
When is it mandatory to involve an independent mental capacity advocate ?
When a patient requires a significant intervention, time permits and the patient lacks capacity to decide for themselves When a patient cannot decide on the best treatment When parents disagree about treatment of a child When two doctors disagree about the best treatment option When a patient has lost trust in their clinician
When a patient requires a significant intervention, time permits and the patient lacks capacity to decide for themselves
The Mental Capacity Act (MCA) requires doctors to involve an independent mental capacity advocate (IMCA) for serious medical treatment decisions when:
a best interests decision is required because the doctor has assessed the person as not having the capacity to make the decision themselves
the person does not have family or friends with whom it is appropriate to consult about the decision.
A 6 year old is hit by a car and is brought to the emergency department. He is haemodynamically unstable with bilateral femoral shaft fractures and concerns that he may have a ruptured spleen. The parents have refused blood transfusions on religious grounds. What is the correct course of action?
Proceed with treatment Do not proceed with treatment Apply to court Apply for an IMCA Contact the PALS service
Proceed with treatment
In the UK, the GMC and common law advises that emergency life saving treatment can be given to a child irrespective of the parents views. There is clearly insufficient time here to apply to a court.
Which of the statistical tests listed below is most appropriate to use with data which follows a normal distribution?
T Test Fishers exact test Spearmans rank test Mann Whitney U test Bonferroni test
A T Test is most suited to data which follows the normal distribution as the others are non parametric tests. The Bonferroni test is used to provide correction when multiple tests are used.
A consultant surgeon is undertaking increasingly complex neonatal surgery. However, this is in breach of guidance following a series of adverse outcomes. Previously it had been stated that these should be performed with close supervision. Two further babies die and the surgeon still refuses to undertake these procedures under supervision. What is the correct course of action?
Review the cases at the next mortality and morbidity meeting Discuss the situation with the coroner Arrange for it to be discussed at the consultants next appraisal Discuss the matter with the General Medical Council Discuss the matter with the British Medical Association
Discuss the matter with the General Medical Council
It is likely that the practice restrictions were imposed by the GMC and given that there is an ongoing risk to patients and the surgeon is in breach of those practice restrictions, it would be appropriate to raise this with the GMC.
A surgeon has conducted a piece of research and is trying to make his non parametric data appear interesting for publication. To do this he is conducting multiple analyses of sub group data using multiple tests. Which of the tests listed below should be considered?
LSD post hoc test Bonferroni correction Unpaired T test Paired T test Chi squared test
Bonferroni correction
This is a process referred to as data dredging and can lead to erroneous results. Post hoc testing in general can be a problem in research and to try and minimise the potential for error some advocate the use of the Bonferroni method. This adjusts the test to take account of the number of tests that have been performed on the data.
Which of the following tests is most appropriate for correcting against multiple statistical analyses that might provide an erroneous result (i.e. to correct against data dredging)?
LSD post hoc test Bonferroni test T Test Fishers test Spearmans rank test
Bonferroni test
As more types of side effects are considered, it becomes more likely that the new drug will appear to be less safe than existing drugs in terms of at least one side effect. Methods are available to adjust the p value to reflect the multiple comparisons being made, the aim being to avoid spurious results. A frequently applied correction is the Bonferroni method in which the observed p values are multiplied by the number of tests performed, any resulting p value which is greater than 1 is set to 1 and any which remains at less than 0.05 can be considered significant at the 5% level.
If a sample is normally distributed which of the following is true?
Mean = standard deviation Mean = standard error of the mean Mean = median Mean = variance The mode and standard error of the mean have the same value
Mean = median
In a normally distributed sample, the mean, median and mode are the same.
What is the reciprocal of absolute risk reduction?
Odds ratio Number needed to treat False positive False negative None of the above
Number needed to treat
In epidemiology, the absolute risk reduction, or risk difference is the decrease in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat.
You have been asked to investigate the potential benefit of setting up a service to help patients with stomas in the local area. What is the most important factor when determining how many resources will be required?
Incidence Bayesian factor Prevalence Denominator data P value
Prevalence
In medical statistics, which of the following does a p value of 0.04 represent?
Risk of type 1 Error Risk of type 2 Error Size of power of the study Sample size Number of degrees of freedom
Risk of type 1 Error
P values are related to the significance levels of a statistical test and therefore are in effect measuring the risk of a type 1 error.
Which of the following statements relating to quantitative data is false?
Discrete data cannot be sub divided The median is less susceptible to extreme outliers than the mean The mean is susceptible to extreme outliers Data that fits the standard distribution perfectly will have a mode that is half the value of the mean Values obtained have a numerical scale
Data that fits the standard distribution perfectly will have a mode that is half the value of the mean
Data that fits the standard distribution perfectly will have a mean, median and mode that are all the same value.
A surgical department wishes to determine whether it is using types of prosthetic mesh material for incisional hernia surgery in the most effective manner. Recently there have been cases of non mesh usage and loss of material as a result of the implants being ‘out of date’. What is the most appropriate method to investigate this?
System based audit Standards audit Peer review Financial audit Operational audit
System based audit
This is primarily an issue of stock control. However, the system by which the materials are used within the theatre will need evaluation. Because it is the usage and stock that are a problem, rather than the sourcing the systems based audit will be more effective than an operational audit.
As the SpR in general surgery you wish to determine whether your breast cancer unit is complying with the British Association of Surgical Oncology guidelines for management of high grade ductal carcinoma in situ. What is the best course of action?
Undertake a clinical audit Undertake a clinical review Undertake a service evaluation Discuss the case with the ethics committee Discuss selected cases at joint histopathology meetings
Undertake a clinical audit
Since this comparison with practice against an agreed standard, the correct course of action is to undertake an audit.
What is the main impact of the Montgomery ruling in consenting patients for surgical procedures?
It clearly states that all risks however minor with a frequency of 10% or greater be disclosed It states whether a reasonable person in the patients position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it It states all procedures should be performed by a consultant It covers the decision making for minors who need to be consented by proxy It replaces the Gillick competency test
It states whether a reasonable person in the patients position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it
The new legal judgement recognises this individual approach to warning patients about risk. Rather than taking into account the percentage possibility of a risk arising, doctors need to bear in mind the significance of a given risk for that particular patient, and the nature of the risk, such as the effect it would have on the patient’s life if it were to occur. The assessment is therefore considered to be both fact-sensitive and sensitive to the characteristics of the particular patient.
A surgical team wish to conduct a meta analysis of randomised controlled trials of the use of low molecular weight heparins in the prevention of post operative deep vein thrombosis. How would these results be best displayed graphically?
Forest plot Box Whisker plot Violin plot Kaplan Meier graph None of the above
Forest plot
Data from multiple RCT’s are best displayed using Forest plots. Funnel plots may be used to determine the effect of small studies and their overall effect on the data. Violin plots and Box Whisker plots are often used to graphically display non parametric data from single studies and are not generally used to display data from meta analyses.
A rapid finger-prick blood test to help diagnosis deep vein thrombosis is developed. Comparing the test to current standard techniques a study is done on 1,000 patients:
DVT present DVT absent
New test positive 200 100
New test negative 20 680
What is the specificity of the new test?
680/880 200/220 680/780 680/700 200/300
680/780
Specificity = true negatives / (true negatives + false positives)
= 680 / (680 + 100)
