Practice management/Core 12-22, 24 Flashcards
Which of the following standard tools is most appropriate for reporting systematic reviews and meta-analyses that assess the benefits and harms of health care intervention?
A) Cochrane
B) Introduction, Methods, Results, and Discussion (IMRaD)
C) Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)
D) Quality of Reporting Meta-analyses (QUOROM)
E) Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)
The correct response is Option C.
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement has been published and endorsed by many high-impact medical journals as the standard tool to be used for systematic review and meta-analysis. The PRISMA standard supersedes the Quality of Reporting of Meta-analyses (QUOROM) standards. The Cochrane is a charitable group that conducts systematic reviews of health care interventions and diagnostic tests and publishes them in the Cochrane Library. Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) provides evidence-based recommendations for the minimum content of a clinical trial protocol. The Introduction, Methods, Results, and Discussion (IMRaD) format refers to standard structure for scientific writing.
Plastic surgery, like all surgical specialties, demonstrates a lack of racial and ethnic diversity in its workforce, including its resident workforce. According to the American Association of Medical Colleges’ definition of racial and ethnic under-representation in the medical profession, which of the following is the most appropriate description of the plastic surgery resident workforce as of 2017?
A) Asian people are proportionally represented
B) Black people are underrepresented
C) Latinx people are proportionally represented
D) White, non-Latinx people are overrepresented
The correct response is Option B.
Since 2000, the white residency population has been appropriately represented, meaning commensurate with the population as a whole in the United States. The Latinx and Black populations are represented at about half of their population in the United States. The Asian populations are represented at four to five times their population in the United States. The Pacific Islanders, Native/First Peoples, and Mixed Races percentages are too small to make meaningful analysis about whether they are appropriately represented or under-represented.
A 34-year-old woman presents for evaluation for a large abdominal pannus, frequent rashes, and skin breakdown as a result of excess skin. BMI is 41 kg/m2. While in the waiting room awaiting consultation, the patient picks up patient education pamphlets on abdominoplasty and panniculectomy. According to the National Institutes of Health and the American Medical Association recommendations, readability of patient education materials should not exceed the reading level of which of the following grades?
A) Fourth
B) Sixth
C) Eighth
D) Tenth
E) High school graduate
The correct response is Option B.
Health literacy is defined as “the capacity to obtain, interpret, and understand basic health information and services and the competence to use such information and services to enhance health.” Low health literacy is associated with a poor understanding of personal disease, worse overall health, and increased hospitalizations. Most adults read between the eighth and ninth grade level, but as many as 20% of adults read at the lowest reading level, which is approximately fifth grade.
Several studies have shown that patient education materials are routinely written at a grade level above the recommendations by the National Institutes of Health (NIH) and the American Medical Association (AMA). In this vignette, patient literature written at a reading level that is too advanced may contribute to misunderstanding between the reconstructive nature of a panniculectomy and the cosmetic nature of abdominoplasty.
The ABPS Continuous Certification Program in Plastic Surgery includes yearly self-assessment and assessment of knowledge and skills. Which of the following additional criteria need to be met in order to maintain certification?
A) 300 continuing medical education (CME) credits within 3 years
B) Oral board exam after 5 years of practice
C) Verification of unrestricted state medical license
D) Written exam every 10 years
The correct response is Option C.
The ABPS Continuous Certification Program, previously known as MOC-PS, includes continuous yearly self-assessment and learning throughout the certification period(s). The requirements include four basic components: (1) professionalism, (2) life long learning and self-assessment, (3) assessment of knowledge, judgment, and skills, and (4) improvement in medical practice. Therefore, an unrestricted state medical license is mandatory, and 150 continuing medical education credits on a 3-year cycle are needed.
Of note, medical specialty certification in the United States is a voluntary process.
A 37-year-old woman comes to the office desiring breast augmentation mammaplasty, mastopexy, and abdominoplasty. The surgeon is trying to promote “mommy-makeover” procedures and asks the patient if she would be willing to participate in a video recording of her operation to be posted on social media. Which of the following statements is correct regarding the informed consent process when obtaining and posting a video to social media that includes protected health information and reveals patient identity?
A) ASPS guidelines recommend that surgeons should not participate in the posting of sensitive content via social media because of the inherent risks to patient privacy
B) A detailed consent documenting the dynamic nature of individual social media sites should be formally discussed and documented in the patient’s medical record prior to proceeding
C) Standard hospital or surgery center consent can be modified to include language about social media and should release the physician for unrestricted use of content on any platform
D) Verbal consent should be obtained the day of the operation and must be witnessed by a nurse
The correct response is Option B.
The most correct answer is that a detailed consent documenting the dynamic nature of individual social media sites should be formally discussed and documented in the patient’s medical record prior to proceeding.
In the systematic review and ethical analysis of current plastic surgery publications regarding posting of online video content, Dorfman et al. describe in detail their recommendations for posting sensitive content online.
Although there are no consensus guidelines documented in the American Society of Plastic Surgeons (ASPS) Code of Ethics, social media continues to evolve as an important part of a plastic surgery practice, as more patients report searching online to find their physicians. Authors document five ethical principles to follow when posting content online in order to “protect patients, surgeons, and the public perception of our specialty:”
Ask the patients about posting the content online and obtain a formal written consent. Full disclosure with the patient must involve specific social media sites and that the patient will have the ability to withdraw consent at any time. Legal advice may improve the quality of the consent form.
In understanding the dynamic between the physician and patient and possibility for coercion, the patient must be made aware that they may refuse consent without any punishment, penalty, and delivery of an inferior product, i.e., worse operative result.
The patient must be made aware of the dynamic nature of social media platforms, and must be fully aware that their videos will become public and permanent at the time of publishing online. Withdrawal of consent does not equate to removal of online content because even if the surgeon removes the video, it may persist online indefinitely.
Always follow the standards of professionalism published by the ASPS Code of Ethics.
The surgeon is ultimately responsible for all content disseminated online.
A study compares a new injectable neuromodulator drug against placebo for the treatment of glabellar lines. The authors of the study report that if this drug performs no differently than placebo, there is a 0.4% chance that repeating the study will show the same or greater calculated differences between the two groups. Which of the following terms refers to this concept?
A) Alpha
B) p-value
C) Power
D) Type I error
E) Type II error
The correct response is Option B.
The p-value is a calculated value that quantifies the probability of obtaining data equal to or more extreme than the data observed on a study, should the null hypothesis be true (eg, the new drug in reality is NOT more efficacious than placebo).
Type I error is the erroneous rejection of a true null hypothesis (eg, a study shows that a new drug is more efficacious than placebo, when in reality it is not).
Alpha is the probability of making a type I error (rejecting a true null hypothesis). It is an assigned value determined by the researcher. A value of 5% is often chosen in medical literature.
Type II error is the failure to reject a false null hypothesis (eg, a study shows that a new drug is no different than placebo, when in reality it is more efficacious). Beta is an assigned value by the researcher that represents the probability of making a type II error. Power of a test of statistical significance is the probability that it will reject a false null hypothesis. It decreases as beta increases (power = 1–beta).
Power of a test may be influenced by multiple factors, including sample size and magnitude of the measured effect.
A physician is considering different locations to perform a specific medical procedure. According to the Centers for Medicare & Medicaid Services, a higher number of relative value units would be attained by performing this procedure in which of the following places of service?
A) Ambulatory surgical center
B) Community mental health center
C) Inpatient hospital
D) Outpatient hospital
E) Physician’s office
The correct response is Option E.
A physician will obtain a higher number of relative value units (RVUs) for a specific medical procedure by performing it in a “non-facility” or “office” setting, such as a physician’s office, compared with performing it in a “facility” setting (hospital, ambulatory surgical center, community mental health center, etc.), according to the fee schedule by the Centers for Medicare & Medicaid Services (CMS).
Physician services are described by CPT codes and Healthcare Common Procedure Coding System codes. CMS determines the number of RVUs assigned for each physician service by adding three subcategories of RVUs:
Physician Work RVUs: reflect the relative time and intensity associated with furnishing a specific medical service. It may reflect not only the “intra-service” time, but also the time needed to prepare for the service beforehand and to document it afterwards.
Practice Expense RVUs: reflect the costs of maintaining a practice (such as renting office space, buying supplies and equipment, and staff costs).
Malpractice RVUs: reflect the costs of medical liability insurance.
When a physician provides a service in a facility (eg, hospital, ambulatory surgical center), the costs of clinical personnel, equipment, and supplies are incurred by the facility, not the physician’s practice. Therefore, CMS assigns to these services a “facility-based” Practice Expense RVU amount that excludes the practice expenses and is typically lower than the “office-based” Practice Expense RVUs for the same service.
CMS uses a formula to determine payment amounts for each covered medical service. First, each of the three RVU subcategories is multiplied by the corresponding geographic practice cost indices, which are designed to account for geographic variations in the costs of practicing medicine in different areas of the country. Then the three adjusted RVU subcategories are added together and multiplied by a conversion factor in dollars.
Which of the following is most likely to be specified in a durable power of attorney document?
A) Agreement to donate organs and tissue
B) Appointment of a health care proxy
C) Do not resuscitate (DNR) orders
D) Permission for mechanical ventilation
E) Withholding of artificial nutrition and hydration
The correct response is Option B.
An advance directive allows a person to express his or her desires related to end-of-life medical care. There are two types of advance directive: power of attorney and living will. A durable power of attorney is a document which allows a person to appoint an individual, known as a health care proxy or agent, who can make decisions regarding medical care for that person, in the event that he or she is no longer able to make those decisions for himself or herself. A living will, on the other hand, is a document that outlines a person’s values and preferences for life-sustaining treatments. These may include use of particular equipment (mechanical ventilator or dialysis machine), instructions in the use of CPR, preferences regarding artificial hydration and nutrition (such as tube feeding or withholding nutrition), palliative or comfort care, and tissue and organ donation wishes.
A surgeon is tasked with designing a prospective research study investigating whether there is any causality between breast implants and the development of breast implant illness (BII). The surgeon plans to study a group of women with implants and a group without implants and determine whether they develop BII. Which of the following best describes this type of study?
A) Case series study
B) Case-control study
C) Comparative cohort study
D) Cross-sectional study
E) Randomized controlled trial
The correct response is Option C.
A comparative cohort study investigates a particular exposure (implants or no implants) to determine correlation to a disease (breast implant illness [BII]).
A case-control study retrospectively identifies cases (BII) and controls (no BII) from the same source population (women) to investigate differences in exposures or risk factors (implants or no implants).
A randomized controlled trial randomly assigns participants into an experimental or control group.
A cross-sectional study is an observational study that analyzes data from a population at a specific time point.
A case series study is one that tracks participants who have received an exposure and tracks outcomes.
Which of the following scenarios represents a medical “near miss” event?
A) A patient consented for a right carpal tunnel release is surgically prepped for a left carpal tunnel release
B) A patient describes breast firmness and asymmetry three months after implant augmentation
C) A patient develops an asymptomatic pneumothorax after central venous catheter placement
D) A patient prescribed hydroxyzine is treated with hydralazine
E) A patient with a penicillin antibiotic allergy is treated with a cephalosporin antibiotic
The correct response is Option A.
This patient has the potential to suffer a wrong site surgery if time-out protocols were not established. The surgical preparation error is a near miss. A “near miss” is an unplanned event that does not result in injury, illness, or damage, but has the potential to do so.
It is within the standard of care to treat patients who report penicillin antibiotic allergies with a cephalosporin antibiotic. Patient with a true penicillin allergy have about a 10% cross-reactivity with cephalosporin antibiotics. Treating a patient prescribed hydroxyzine with hydralazine is a look-alike, sound-alike medication error. Pneumothorax after central venous catheter placement is a complication of the procedure. Breast implant contracture is an inherent risk of breast implant augmentation.
A plastic surgery intern is reviewing patient’s charts for the week’s upcoming surgical cases on her service. She realizes that a 55-year-old immediate breast reconstruction patient with diabetes and hypertension, scheduled for surgery in 4 days, was not scheduled for an anesthesia preoperative evaluation and, therefore, had no laboratory studies or electrocardiography scheduled. The intern informs the attending physicians, schedules the appointment, and then calls the patient. She and the scheduler then implement a system by which all patients age 50 years or older who have pre-existing medical problems get an anesthesia preoperative evaluation. This is an example of which of the following core competencies?
A) Interpersonal and communication skills
B) Medical knowledge
C) Patient care and procedural skills
D) Professionalism
E) Systems-based practice
The correct response is Option E.
This is an example of systems-based practice. According to the Accreditation Council of Graduate Medical Education (ACGME) milestones, system-based practice subcompetencies include the ability to:
Work effectively in various health care delivery settings and systems relevant to their clinical specialty,
Coordinate patient care within the health care system relevant to their clinical specialty,
Incorporate considerations of cost awareness and risk/benefit analysis in patient care,
Advocate for quality patient care and optimal patient care systems,
Work in interprofessional teams to enhance patient safety and improve patient care quality,
Participate in identifying systems errors and in implementing potential systems solutions.
In this scenario, the intern is demonstrating the ability to “coordinate patient care within the health care system relevant to their clinical specialty” and “participate in identifying systems errors and in implementing potential systems solutions.” The other core competencies are not as relevant as systems-based practice in this scenario.
A multi-institutional clinical trial is gathering data on the ability of a test to determine the number of women who develop a new breast disease, and comparing this with age-matched controls. The specificity of the test is defined as which of the following?
A) The ratio of healthy subjects diagnosed as negative and the total number of healthy patients
B) The ratio of healthy subjects diagnosed as positive and the total number of sick patients
C) The ratio of sick patients diagnosed as negative and the total number of healthy patients
D) The ratio of sick patients diagnosed as negative and the total number of sick patients
E) The ratio of sick patients diagnosed as positive and the total number of sick patients
The correct response is Option A.
The sensitivity of a test is defined as the ability of a test to correctly classify an individual as diseased (positive in disease).
Sensitivity = a / a + c
The specificity of a test is the ability of a test to correctly classify an individual as disease free.
Specificity = d / b + d
A 24-year-old man who is hearing impaired requests to be evaluated for left cubital tunnel syndrome. The patient currently lives 2 hours away, and his mother, who usually helps interpret for him, is unable to attend the appointment. The office does not have anyone who is capable of interpreting sign language. Which of the following is the most appropriate next step?
A) Arrange a video interpreter to be available during the appointment at the office’s expense
B) Decline to schedule an appointment because the office does not offer the language services requested
C) Help the patient arrange for an interpreter to be present at the appointment at his expense
D) Require the patient bring a friend or family member to help interpret during the appointment
The correct response is Option A.
The Americans with Disabilities Act (ADA) requires that reasonable accommodations are provided by businesses and in public areas to allow people with disabilities to participate in daily activities. Public places include doctors’ offices. The building and spaces should accommodate all individuals regardless of disability. As a business and a public space, a doctor’s office must be in compliance with the ADA. Services cannot be denied to a patient with a disability because of the disability if services could otherwise be provided. Accommodations should be made to examine the patient with a disability as any other.
In this case, treatment for a cubital tunnel syndrome, something offered routinely by this office, cannot be declined based on the patient’s hearing deficit. In this case of a patient with a hearing issue, an interpreter must be provided to help with the appointment upon the patient’s request. This does not necessarily need to be in-person; a video interpreter can be acceptable. The patient cannot be charged for the interpreter services whether in-person or by video. The health care provider is expected to make a reasonable effort to provide the service. While having the patient bring a friend or family member to the appointment would make the appointment easier for the physician, a patient is not required to bring anyone to help interpret for him/her.
In a single physician private practice establishment, which of the following descriptions of a Privacy Official meets the US Department of Health & Human Services (HHS) expectations as delineated in the Health Insurance Portability and Accountability Act (HIPAA)?
A) A group of employees who function as a privacy board
B) An individual who functions as the privacy official and office manager for the practice
C) An outside consultant with expertise in HIPAA-related privacy policy
D) A student intern who functions solely as the privacy official for the practice
The correct response is Option B.
The Health Insurance Information Portability and Accountability Act (HIPAA)—also known as the Kennedy-Kassebaum Act—was passed into law in 1996 during the Clinton Administration by the 104th US Congress. HIPAA provides a framework for the security of private health information and how it may be used and shared by health care providers, researchers, payers, and assistants to these entities. There is some scalability built into the law so that large entities such as regional health maintenance organizations (HMOs) and hospital systems have different expectations of how they will accomplish the rules governing privacy compared to a private practice.
According to the U.S. Department of Health and Human Services on its website:
“Responsible health care providers and businesses already take many of the kinds of steps required by the Rule to protect patients’ privacy. Covered entities of all types and sizes are required to comply with the Privacy Rule. To ease the burden of complying with the new requirements, the Privacy Rule gives needed flexibility for providers and plans to create their own privacy procedures, tailored to fit their size and needs. The scalability of the Rule provides a more efficient and appropriate means of safeguarding protected health information than would any single standard.
For example, the privacy official at a small physician practice may be the office manager, who will have other non-privacy related duties; the privacy official at a large health plan may be a full-time position, and may have the regular support and advice of a privacy staff or board. The training requirement may be satisfied by a small physician practice’s providing each new member of the workforce with a copy of its privacy policies and documenting that new members have reviewed the policies; whereas a large health plan may provide training through live instruction, video presentations, or interactive software programs.
The policies and procedures of small providers may be more limited under the Rule than those of a large hospital or health plan, based on the volume of health information maintained and the number of interactions with those within and outside of the health care system.”
Which of the following is consistent with the recommendations of The Joint Commission and the Centers for Medicare and Medicaid Services regarding practitioners’ orders and patient-related communication?
A) Computerized provider order entry (CPOE) is not an acceptable method for order submission as it allows providers to directly enter orders into the electronic health record (EHR)
B) Health care organizations should allow the use of unsecured text messaging—that is, short message service (SMS) text messaging from a personal mobile device—for communicating protected health information
C) HIPAA compliance is not maintained if all the information is de-identified before it is transmitted
D) The transmission of a verbal order requires real-time, synchronous clarification and confirmation of the order as it is given by the ordering practitioner
The correct response is Option D.
In collaboration with the Centers for Medicare & Medicaid Services (CMS), The Joint Commission developed the following recommendations:
All health care organizations should have policies prohibiting the use of unsecured text messaging—that is, short message service (SMS) text messaging from a personal mobile device—for communicating protected health information. Organizations are expected to incorporate limitations on the use of unsecured text messaging in their policies protecting the privacy of health information. This policy should be routinely discussed during orientation of all practitioners and staff working in the facility.
Computerized provider order entry (CPOE) should be the preferred method for submitting orders as it allows providers to directly enter orders into the electronic health record (EHR). CPOE helps ensure accuracy and allows the provider to view and respond to clinical decision support (CDS) recommendations and alerts.
In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable and it should allow for a real-time, synchronous clarification and confirmation of the order as it is given by the ordering practitioner.
HIPAA compliance can also be maintained by deidentifying information before it is transmitted. Under the Safe Harbor Method, health information is no longer linked to an individual when 18 types of patient identifiers have been removed.
A 68-year-old woman presents with multiple injuries sustained during a motor vehicle collision that require reconstructive surgery. She will require a stay in a skilled nursing facility following her initial hospitalization. Which of the following parts of Medicare covers this service?
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
The correct response is Option A.
Medicare Part A covers services and supplies considered medically necessary to treat a disease. These services include inpatient hospital care, skilled nursing facility care, and hospice environments. In addition, when appropriate, home health services are covered by Part A.
Medicare Part B covers medically necessary services and preventative care services. Physician services, durable medical equipment, and mental health services are included in Part B coverage.
Medicare Part C is also known as Medicare Advantage. Part C allows for a Medicare-eligible individual to select an approved private health insurance plan. Medicare Part D offers prescription drug coverage to original Medicare. Part D can be added to a Medicare Advantage Plan if prescription drug coverage is not included.
A study is conducted to evaluate the association between diabetes and postoperative infection in patients undergoing implant-based breast reconstruction with acellular dermal matrix. Which of the following statistical tests is most appropriate to supply the data for this study?
A) Analysis of variance (ANOVA)
B) Linear regression analysis
C) Pearson’s chi-squared test
D) Unpaired T test
E) Wilcoxon rank-sum test
The correct response is Option C.
Selecting an appropriate statistical test is critical for accurate data analysis. Determining the optimal method for a given data set must take into account several factors including the limitations and distributional properties of the variables under study.
Statistical variables may be defined as either categorical or numerical. Categorical variables typically represent qualitative observations (eg, postoperative infection, diabetes, obesity) while numerical variables refer to quantitative observations (eg, body mass index, HgbA1c). Additionally, it is important to distinguish between independent (predictive) and dependent (predicted) variables. These variables can also be categorical or numerical. Dependent variables are typically the measured endpoints of the study (eg, postoperative infections – categorical versus operative times – numerical) while independent variables are hypothesized to have an influence over the measured endpoints (eg, diabetes/obesity – categorical versus HgbA1c / BMI – numerical).
Studies, such as this one examining only categorical variables (diabetes and postoperative infection), are best analyzed using Pearson’s chi-squared test. In contrast, a study evaluating only numerical variables is best analyzed using regression analysis.
The unpaired T test and analysis of variance (ANOVA) are best used as statistical tests to analyze independent numerical and dependent categorical data. The tables shown help to provide a general outline for statistical test selection based on the different types of statistical variables being studied including categorical or numerical variables, independent or dependent variables, number of groups being studied, and whether the variables are normally distributed or not.
These statistical tests make assumptions of the parameters of the population distribution and are considered parametric tests. Non-parametric tests, including the Wilcoxon rank-sum and Kruskal-Wallis tests, are used when the data does not meet the assumptions required for parametric tests.
n a randomized, blinded, placebo controlled trial, 84% of patients in the migraine surgery vs. 58% of patients in the sham surgery group had greater than 50% reduction in migraine symptoms (p < 0.05). Which of the following is indicated by a p value of <0.05?
A) The observed difference is likely due to sampling variation (accept null hypothesis)
B) The observed difference is likely due to sampling variation (reject null hypothesis)
C) The observed difference is not likely due to sampling variation (accept null hypothesis)
D) The observed difference is not likely due to sampling variation (reject null hypothesis)
E) Cannot make a determination regarding the null hypothesis
The correct response is Option D.
The p value is defined as the probability of getting a difference at least as large as that observed if the null hypothesis is true. The larger the p value, the more likely the observed difference is due to sampling error (and therefore one accepts the null hypothesis of no difference). The smaller the p value, the more likely the observed difference is not due to sampling error (and therefore one rejects the null hypothesis of no difference).
In patients who suffer from moderate to severe migraine headaches from a single or predominant trigger site, 84% of patients that underwent surgical decompression of that trigger point experienced reduction in migraine symptoms by more than 50%, compared to 58% of those who underwent sham surgery.
Which of the following forms of communication is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?
A) E-mailing the confidential information using an encrypted patient portal server
B) Leaving protected information on the patient’s voicemail
C) Placing a sealed folder with patient records under the attending physician’s office door
D) Texting medical information to a password protected smart phone
E) Transferring the patient records via a non-encrypted flash drive
The correct response is Option A.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is United States legislation that provides data privacy and security provisions for safeguarding medical information. Unauthorized release of any confidential or identifying information, which can be linked to an individual patient, is considered a violation of the law, with penalties ranging from fines to incarceration. The secure, private transmission of Protected Health Information (PHI) is allowed between two treating health-care professionals, provided that the communication is confidential and not at significant risk of breach or theft. Transmission of PHI via social media, e-mail, and other electronic methods must be done through a combination of safeguards that involves encryption. Although the legal understanding of how to communicate PHI continues to evolve, these devices must meet institutional requirements for security.
A 37-year-old woman comes to the office for evaluation for cosmetic rhinoplasty. The patient repeatedly reports to the surgeon that she “is ugly” and “can’t stand” her nose. Physical examination shows no abnormalities consistent with her concerns. Medical history includes five visits to different plastic surgeons in the past 4 months and each surgeon has declined to perform surgery. The surgeon refuses to perform the surgery and refers the patient to a health psychologist. The surgeon’s decision is a demonstration of which of the following principles?
A) Beneficence
B) Iniquity
C) Justice
D) Maleficence
E) Noxiousness
The correct response is Option A.
In refusing to operate on a patient with body dysmorphic disorder and instead referring the patient to a health psychologist, the surgeon is practicing the ethical principle of beneficence—the doing of good. In cases of medical ethics, the terms maleficence, iniquity, and noxiousness are all associated with doing harm. In this scenario, the surgeon is clearly not doing harm. Justice, the ethical principle requiring doctors to ensure that medical care is available to all, is not applicable to this scenario.
Which of the following items are required for the surgeon to perform along with the nurse and anesthesiologist on the World Health Organization Surgical Safety Checklist before the induction of anesthesia?
A) Confirmation of instrument, sponge, and needle counts
B) Confirmation of patient identity, surgical site, procedure, and consent
C) Discussion of specimen labeling
D) Discussion of whether essential imaging needs to be displayed
E) Discussion of whether there were any equipment problems during case
The correct response is Option B.
Confirmation of patient identity, surgical site, procedure, and consent is the only item out of the above answer choices that is required before the induction of anesthesia. The discussion of imaging display occurs after anesthesia induction and before skin incision. Confirmation of instrument, sponge, and needle counts; specimen labeling; and equipment problems are not appropriate before induction of anesthesia, and are performed before the patient leaves the operating room.
Which of the following is a Type I error?
A) Accepting the alternate hypothesis when it is actually true
B) Accepting the null hypothesis when it is actually false
C) Accepting the null hypothesis when it is actually true
D) Rejecting the alternate hypothesis when it is actually true
E) Rejecting the null hypothesis when it is actually true
The correct response is Option E.
A Type 1 error is the error of rejecting the null hypothesis when it is actually true. A Type 2 error is the error of not rejecting the null hypothesis when it is actually false. All the other answers are not correct.
After successfully completing training at an accredited United States or Canadian training institution, the maximum amount of time a surgeon is allowed to advertise as board eligible while seeking initial certification with the American Board of Plastic Surgery (ABPS) is which of the following?
A) 1 year
B) 3 years
C) 8 years
D) 10 years
E) There is no limit
The correct response is Option C.
The American Board of Medical Specialties (ABMS) has held an effective official Board Eligibility Policy since 2012. The policy recognizes physicians’ need to advertise with the term “Board Eligible” during their preparatory time for initial board certification, but closes off the potential for abuse through the use of the term indefinitely. This period of time generally varies between ABMS Member Boards as 3 to 7 years following successful completion of accredited training, plus any additional practice time as required by the Member Board for admissibility to their certifying examination. The American Board of Plastic Surgery (ABPS) is one of approximately 24 Member Boards of the ABMS. For the ABPS, the time period is restricted to a maximum of 8 years (7 years plus an additional 1 year allowance to meet the necessary practice requirement to successfully complete both written and oral examinations in plastic surgery).
Exceptions are considered in instances of military deployment, acute illness, or other individual circumstances according to review by the Member Board.
Once certified, diplomates of the ABPS must complete professionalism requirements, self assessment activities, practice improvement activities, and an examination every 10 years as required by the Maintenance of Certification Program in order to maintain their certification status.
A surgeon is approached by a charitable organization requesting support for a silent auction fund-raiser. Which of the following services can be donated according to the American Society of Plastic Surgeons (ASPS) code of ethics?
A) Abdominoplasty
B) Augmentation mammaplasty
C) Botulinum toxin A for forehead rejuvenation
D) Rhytidectomy
E) Single-site liposuction
The correct response is Option C.
The American Society of Plastic Surgeons (ASPS) has guidelines and policies governing ethical behavior of plastic surgeons. Participation in charitable events is permitted, but must be done in a manner that does not provide implicit understanding of a performance of a procedure for which the patient has not been medically evaluated. Furthermore, an implied or real financial incentive to have a procedure is considered unethical. Botulinum toxin A for forehead rejuvenation is most appropriate. All other options are specific in regards to treatment, for which the patient has ostensibly purchased through the silent auction, but may not be a candidate. Offering free implants also implies that an augmentation mammaplasty is to be done, which is implicitly offering the procedure. No procedures requiring an incision are allowed.
A recent research manuscript is reviewed at a plastic surgery journal club. The article is a case-control study examining the outcomes following peripheral nerve decompression. Which of the following is the level of evidence that this study provides?
A) Level I
B) Level II
C) Level III
D) Level IV
E) Level V
The correct response is Option C.
Level I data are defined as high-quality prospective cohort studies with adequate power or systematic review of these studies. Level II evidence represents lesser quality prospective cohorts, retrospective cohort studies, untreated control from an RCT, or systematic review of these studies. Level III evidence is correct and represents case control studies or systematic review of these studies. Level IV evidence is case series studies. Level V evidence is expert opinion, case report, or clinical example; or evidence based on physiology, bench research, or “first principles.”
As of January 1, 2018, surgeons enrolled in Centers for Medicare & Medicaid Services (CMS) Electronic Health Record (EHR) Meaningful Use incentive programs are subject to which of the following payments?
A) No payments, enrollment is mandatory
B) 1% Penalty adjustments below existing Medicare/Medicaid reimbursements
C) Tax credits commensurate with level of participation
D) 1 To 3% positive adjustments above existing Medicare/Medicaid reimbursements
E) Up to $44,000 to offset EHR initiation costs
The correct response is Option B.
The concept of “meaningful use” of electronic health records was introduced by the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act was one of many measures enacted by the American Reinvestment and Recovery Act of 2009 to modernize the United States’ infrastructure. The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) subsequently published a series of specific rules for health care providers under Electronic Health Record (EHR) Incentive Programs to support the concept of meaningful utilization of electronic health records espoused by HITECH. Both Medicare and Medicaid have related but independent criteria for demonstrating meaningful use through their respective EHR Incentive Programs.
In general, “meaningful use” is defined by the use of certified EHR technology in a meaningful manner (eg, electronic prescribing); ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and that in using certified EHR technology, the provider must submit to the Secretary of Health & Human Services (HHS) information on quality of care and other measures.
While maximum EHR benefits through the Medicare Incentive Program initially totaled up to $44,000 if specific criteria were met over 5 consecutive years, participants must have begun meeting incentive program criteria by 2014, and the last year these incentive payments were paid was 2016.
Participation for both Medicare and Medicaid EHR Incentive Programs is currently completely “voluntary.” However, since 2015, failure to participate in the incentive programs including attestation to your meaningful use of certified EHR technology on a yearly basis has resulted in a penalty in the form of negative adjustments to Medicare/Medicaid reimbursement rates of at least 1% from CMS. On its own, EHR Meaningful Use “incentive program” has transformed into a euphemism for a de facto penalty program.
A 20-year-old woman comes to the office with her parents because of her significant concern with the appearance of a scar on her forehead of 1 year’s duration. Physical examination shows a well-healed scar that blends in nicely with the surrounding skin and is difficult to see at conversation distance. The patient’s parents do not see the need for any intervention since they also find the scar difficult to see. Which of the following must be present to confirm a diagnosis of body dysmorphic disorder in this patient?
A) History of treatment for an eating disorder
B) Occasional social anxiety
C) Preoccupation with obvious flaws in her appearance
D) Prior rhinoplasty
E) Repetitive behavior related to her appearance concerns
The correct response is Option E.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-V) the following criteria define the diagnosis of body dysmorphic disorder (BDD):
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
The preoccupation causes clinically significant distress and impairment in daily function.
An eating disorder may be seen with body dysmorphia, but is not pivotal to its diagnosis.
A diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance has been added since the DSM-IV-TR, consistent with data indicating the prevalence and importance of this symptom.
Prior history of cosmetic surgery (rhinoplasty in this case) is not part of the diagnostic criteria for body dysmorphic disorder.
A 50-year-old man recently enrolled in a new health insurance plan under the Affordable Care Act. Which of the following benefits is NOT offered as a basic service to this patient?
A) Dental care
B) Mental health and substance use treatments
C) Prescription drugs
D) Preventative services
E) Rehabilitation services
The correct response is Option A.
The Affordable Care Act (ACA) signed into law in 2010 began enrollment in 2013. One of the most fundamental components of the ACA was that any new health insurance plan must offer ten “Essential Health Benefits.” These include: 1) outpatient care; 2) emergency room visits; 3) hospitalization; 4) maternity and newborn care; 5) mental health and substance use treatments; 6) prescription drugs; 7) rehabilitation and rehabilitative services and devices; 8) laboratory tests; 9) preventative services and chronic disease care; and 10) pediatric services including dental and vision. Because the individual in the vignette is 50 years old, his new plan will not cover basic dental services.
A 72-year-old man with type 2 diabetes mellitus is evaluated because of a 2-month history of a plantar heel ulcer. Routine standard therapies have been unsuccessful. Administration of a new topical growth factor ointment indicated for refractory diabetic foot ulcers is planned. The best literature supporting the use of this product for this patient describes a single non-blinded, prospective, randomized controlled trial with low patient numbers and poor long-term follow-up. Which of the following is the level of evidence associated with the therapeutic use of this product?
A) Level I
B) Level II
C) Level III
D) Level IV
E) Level V
The correct response is Option B.
The practice of evidence-based medicine involves the interpretation of the best available evidence in order to make informed clinical decisions regarding the care and treatment of patients. Because the quality of studies published in the literature is of varying quality, a hierarchical grading system often described as the levels of evidence has been employed by multiple different specialties.
Typically, randomized controlled trials (RCTs) are considered the highest level of evidence. However, RCTs cannot be used to answer all types of clinical questions. For example, clinical questions regarding the prognosis of a given condition without any treatment cannot be answered with an RCT. In addition, all RCTs are not of the same quality. Systematic reviews or meta-analysis of similar RCTs can increase the power of the studies. In contrast, RCTs that are not blinded, have poor methods of randomization, lack exclusion criteria, or that have low numbers and are underpowered are considered to be a lower level of evidence. The RCT in this question is non-blinded and underpowered with poor follow up and, therefore, a level II.
The ASPS has published the following evidence rating scale:
