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					                          Medical Science 801, 806, & 807



Patient, Doctor, and Society:
COMBINED OBJECTIVES
                   Fall 2005 – Spring 2007
                                      last updated 7/23/2008




                                       Christopher B. Kolar
                                        cbkolar@wisc.edu


 This study guide has been created in the course of my studies at the University of Wisconsin
 School of Medicine and Public Health. It is intended as an exam review of the required learning
 objectives. It references a variety of course materials, including lecture, Power Point, assigned
 readings, and sometimes outside sources. While I have attempted to make it as thorough, specific,
 and accurate as possible, I cannot guarantee this, so use it at your own risk. If you have any
 questions or comments, or have found an error within the text, please feel free to contact me.




                                                               COLOR KEY:
                                                               • red:    diseases
                                                               • blue:   medications
                                                               • orange: enzymes and compounds
                                                               • pink:   microorganisms


                                                               FORMAT KEY:
                                                               • margins: 1”
                                                               • tab stops: 0.25”
                                                               • font:      Times New Roman
                                                               • size:      10
                                                                             Patient, Doctor, & Society 2: NOTES (page 2 of 117)




Approach to Adolescents
overview
- definitions
   - adolescence
      - beginning:       appearance of secondary sex characteristics
      - termination:     cessation of somatic growth
   - American Academy of Pediatrics (AAP):            up to age 21
   - Society for Adolescent Medicine (SAM):           up to age 25
- needs
   - personal:      initiative, transportation, money, time away from school
   - practitioner: additional time (above what physicians generally offer)
                    person who can be trusted
adolescent development
- developmental tasks
   - emancipation:       leave the family of origin
   - skills:             acquire economic independence
   - maturity:           sexual self concept
                         realistic, positive self image
- physical maturity: Tanner ratings
   - function:      describe and track progress of physical maturity in an individual
   - variation:     ethnic groups
                    individual differences – not everyone achieves adult hair, genital size

  TABLE: Tanner Stages for Male Development
   stage genitals                         pubic hair                       milestones
   1     preadolescent penis and testes   absent
   2     increased size                   scant, straight                  growth spurt begins
   3     increased size                   sparse, dark, initial            sperm production
                                          curl
   4     increased size                   thick, covers pubic              adult height achieved
                                          region
   5     adult appearance and size        spreads to medial
                                          thigh, umbilicus

  TABLE: Tanner Stages for Female Development
   stage breasts                          pubic hair                       milestones
   1     no development                   absent
   2     breast bud                       sparse, straight                 growth spurt begins
   3     enlarged, with minimal contour   darker, initial curl
   4     secondary mound                  coarse, curly                    menarche
   5     mature breast contour            adult triangle, down
                                          medial thighs

- cognitive development
   - early (less than 14 years old)
      - concrete thinking, literal interpretation
      - limited ability to anticipate, project self into future
      - difficulty separating feelings from reality
      - self centered
   - middle (15-17)
      - improved language skills
      - understanding of metaphor, double entendre
      - rise in spiritual interest
                                                                             Patient, Doctor, & Society 2: NOTES (page 3 of 117)



  - late (older than 17 years)
     - formal operational thought and abstract thinking
     - ability to compromise, set limits
     - understanding of empathy

- implications
   - cognitive development does not always match physical development
   - abstract thinking may be difficult for some adolescents
   - assume adolescent is thinking in concrete fashion, and needs clear, specific questions

inherent challenges in seeing adolescents
- history
   - sources of history
      - parent
      - adolescent
   - possible interview styles
      - interview both together
      - interview each alone
      - interview adolescent alone
      - interview both together and then adolescent alone
- chief complaint: may be different for both parent and adolescent
- legality: parent responsible until 18
- confidentiality
   - important for adolescent seeking independence from parental units
      - Wisconsin: sexual confidentiality after 14 years old
      - adolescents more likely to seek health care if assured confidentiality
   - breaking confidentiality
      - emergency
      - emancipated minor (marriage, parenthood, military separation, etc.)
      - specific conditions
         - pregnancy
         - STDs
         - contraception
         - substance abuse
         - mental illness
      - mature minor rule

history taking
- focus
   - problem visit:          shorter, more focused
   - health supervision:     more thorough
   - general:                psychosocial issues
- general methods
   - be aware of the possibility of a hidden agenda when eliciting a chief complaint
      - especially important with sensitive issues
      - non-compliance (“This was my mom’s idea”): “Sorry, I understand, can I talk to you anyway?”
   - become familiar with the patient as a person
   - be especially non-judgmental
   - assure confidentiality
   - begin open-ended, but be more specific if need be
   - don’t make assumptions about family

- sensitive issues
   - important issues to ask about: HEADSS
      - home
      - education, employment
                                                                               Patient, Doctor, & Society 2: NOTES (page 4 of 117)



     - activities
     - drugs
     - sex
     - suicide/depression
  - sex
     - normalization: “I ask everyone these questions”
     - important topics
        - dating and intimacy
        - sexual contact or intercourse
     - avoid vague questions
        - “Are you sexually active?”
        - “Have you had sex?”
  - drugs
     - normalization: “Some of my patients your age have been doing drugs. Have you…?”
     - important topics
        - use by friends (often easier to approach first)
        - use by parents
        - personal use (“Have you ever tried…?” tends to be fairly non-threatening)
     - alcohol screening: CAGE
        - cut down:      ever feel the need?
        - annoyed:       ever been annoyed by criticism over your use?
        - guilty:        ever felt guilty about drug or alcohol use?
        - eye-opener: ever needed one? ever had a hangover?
  - depression
     - normalization: “It is vary common in adolescents to feel…”
     - important topics
        - diversion
        - stress management
        - depression
        - suicide
     - specific questions
        - what do you do when you are stressed?
        - do you get down or depressed very often?
        - do you see your self more depressed than your friends?
        - how depressed do you get? Enough to kill yourself? If so, how would you do it?

physical examination
- importance of privacy
   - ensure door is locked
   - maintain curtain between door, patient
   - shut window shades
   - adequate garments to preserve modesty
   - assume modest until told otherwise
   - explain what is being done, why it is being done, and that it is normal
- presence of parent
   - boys: tend to kick parents out around 12
   - girls: tend to kick parents out later
- private exams
   - girls:   breast exam embarrassing
              teach self breast exams after 16
   - boys:    palpate, check for hernias at all ages
              teach self testicular exams by 16
   - general: inform the patient what is being taught to the opposite sex

assessment and plan
- emphasis on normalcy
                                                                          Patient, Doctor, & Society 2: NOTES (page 5 of 117)



   - adolescents do not want to be different than their peers
   - point out normal variants
      - gynecomastia
      - asymmetric breasts
      - body hair
      - varicocoele
- sensitive issues
   - rehearse prior to dealing with an issue in clinic
   - encourage sharing with parents
   - discuss withholding information without lying
- long agenda: find a reason to bring them back




Approach to Older Adults
demographics
- prevalence
   - 2005:          1 in 8 Americans over the age of 65
   - 2030:          1 in 5 Americans over the age of 65
- costs: older patients are 13% of the population, but account for:
   - 50% of all inpatient days
   - 38% of all health care costs
- life expectancy at age 65
   - females:       19 additional years
   - males:         14 additional years
- poverty: affects 1 in 5 of the elderly population

general principles
- two groups of elderly patients
   - relatively healthy
      - age:         generally 65-80
      - needs:       not much different than late middle age adults
   - frail
      - age:         generally over 75
      - needs:       special monitoring, services
- elderly patients
   - typical 65 year old
      - localization:    98% live in the community
      - medication:      2-3 medications
      - cognition:       3% have cognitive impairment
   - typical 85 year old
      - localization:    60% live in the community
      - medication:      5-6 medications
      - cognition:       35% have cognitive impairment
   - heterogeneity: exists even among those of similar chronological age
- decline in body systems
   - historical: generally attributed to “normal aging”
   - current: etiology considered as rule of thirds
      - 1/3 disease
      - 1/3 disuse
      - 1/3 normal aging
- presentation
   - typical signs and symptoms for disease, illness may be delayed or absent
                                                                             Patient, Doctor, & Society 2: NOTES (page 6 of 117)



  - severe, acute illnesses in older individuals are frequently vague and non-specific
     - frequent descriptors
        - “I don’t feel right”
        - “I lost my zip”
        - “I lost my taste for meat”
     - typical altered presentations of illness in older adults
        - depression:                  without sadness
        - infectious disease:          without fever
        - myocardial infarction:       without chest pain
        - pulmonary edema:             without shortness of breath
        - surgical abdomen:            silent
  - any abrupt change in functional status should be regarded as a potential sign of illness
     - confusion
     - falling
     - incontinence
     - self neglect
     - fatigue
     - anorexia
  - polypharmacy: indiscriminate giving of multiple concurrent medications
     - polypharmacy should always be considered
     - stopping a medicine frequently more helpful than adding another

comprehensive geriatric evaluation
- components
   - social
   - mental
   - functional
   - physical

the interview and social history
- important characteristics
   - ask how the patient wishes to be addressed
   - be aware of sensory impairments
   - talk to the patient first, then the family or caregiver
   - consider a comprehensive history and physical at several visits, especially for older, frail adults
- medication history
   - essential part of any geriatric evaluation
   - paper bag test: request that the patient bring all medications or old bottles in
- social assessment
   - support system:            availability and health of caregivers
   - emergency:                 availability of emergency help
   - services:                  needed or received (meals on wheels, home health aid, etc.)
   - transportation:            status of transportation needs
- review of systems (ROS)
   - should be comprehensive, targeting “hidden illnesses”
   - important points
      - depression
      - incontinence
      - falling
      - hearing loss
      - dental problems
      - poor nutrition
      - sexual dysfunction

assessing mental status
- suggestions of decline
                                                                            Patient, Doctor, & Society 2: NOTES (page 7 of 117)



   - reduction in activities
   - self neglect
   - increased accidents
- important characteristics of mental assessment
   - cognitive impairment can be masked more easily than decline in social skills
   - objective measurement needed with any suspicion of functional decline
   - normalization of the examination can help reduce embarrassment of asking about mental status
- methods
   - Folstein Mini-Mental Status Exam (MMSE): 50-70% sensitive when followed over time
      - orientation:     (5) year, date, day, month, season
      - location:        (5) state, county, city, building, floor
      - registration:    (3) repeat three objects
      - attention:       (5) serial 7 subtraction from 100, or spelling of “world” backwards
      - recall:          (3) repeat the three previous objects
      - language:        (2) identification:      identify two objects (e.g. pencil, watch)
                         (1) repetition:          repeat the following: “No ifs, ands, or buts”
                         (3) command:             follow a 3 step command
                         (1) reading:             CLOSE YOUR EYES
                         (1) writing:             write a sentence (must have subject, verb)
                         (1) copying:             copy a design (two embedded pentagons)
   - animal fluency test
      - method:          name as many animals as possible in under a minute
      - sensitivity:     <12 animals is nearly 100% sensitive for significant cognitive impairment
   - clock test: draw a clock at a given time

  TABLE: Delirium vs. Dementia
                    delirium                            dementia
   etiology         physical illness                    cognitive deficit
   onset            abrupt, precise                     gradual
   symptoms
   - consciousness  clouded                             normal
   - disorientation early onset                         late onset
   - attention      short                               normal
   - agitation      frequent                            infrequent
   urgency          medical emergency                   quality of life issues


functional assessment
- importance
   - optimal function: overriding objective of good geriatric care
   - helps in prioritizing management of multiple problems
- methods
   - Activities of Daily Living (ALDLs)
      - definition: essential self-care skills of everyday living
      - skills:     bathing
                    continence
                    dressing
                    feeding
                    toileting
                    transferring
   - Instrumental Activities of Daily Living (IADLs)
      - definition: complex activities needed for independent living
      - skills:     food preparation
                    shopping
                    housework
                                                                            Patient, Doctor, & Society 2: NOTES (page 8 of 117)



                  money management
                  medication management
                  transportation management

  - memory device:         ALDLs: BCDFTT
                           IADLs: FSHMMT

physical exam
- areas of emphasis
   - weight:               global marker for nutrition
   - height:               indicator of osteoporosis
   - vision:               visual acuity
   - audition:             auditory acuity, check for cerumen
   - oral exam:            dentures should be removed
   - lower extremities:    signs of vascular disease
                           - arterial insufficiency: extremities are cool, without hair or pulses
                           - venous disease: extremities are swollen, have a brownish hue near ankles
  - range of motion:       focus on hips
  - muscular strength:     focus on getting up out of a chair
  - gait:                  hip fractures a frequent cause of loss of independence

other issues
- advanced directives:     end of life planning, essential even with a healthy older adult
- driving status:          would you feel comfortable driving with the patient?
- elder abuse, neglect
- hospitalization:         avoid as much as possible due to iatrogenic issues, rapid functional decline




Approach to Children
overview
- pediatrics: study of the health of infants, children, and adolescents
- periods of growth
   - infancy:                0 to 1.25 years
   - early childhood:        1.25 to 4 years
   - middle childhood:       5 to 10 years
   - adolescence:            11 to 19 years
- well child checkup (health supervision visit): regular, periodic visits with a primary care providers
   - evaluate developmental changes
   - identify and monitor medical, psychosocial risks
   - provide families with information on the promotion of healthy habits
   - provide families with information on the prevention of injury and illness
- differences that distinguish children from adults
   - spectrum of diseases
   - ongoing physical, physiological, psychological maturation
   - unique response to stress, illness
   - complete history involves:
      - communication with both child and caretaker
      - added emphasis of non-verbal cues

general approach to the pediatric history
the problem visit
- observe first, and address the most pressing issue
                                                                             Patient, Doctor, & Society 2: NOTES (page 9 of 117)



- obtain the history in chronological order
- address the chief complaint, but look further

the well child visit
- allow family and child to voice their concerns
   - “What are your questions today?”
   - “Do you have any concerns about your child’s health?”

- developmental history
   - factors
      - gross motor skills
      - fine motor skills
      - social skills
      - verbal skills
      - school performance
   - tools
      - observation and body language
      - Denver Developmental Screening Tool: pediatric chart that gives “normal” values
- growth history
   - factors
      - height and weight
      - head circumference
      - trend in growth over time
   - tools
      - pediatric growth charts
      - different trends for different populations (boys, girls, Down, Turner, premature babies, etc.)
- medical history
   - immunizations
   - medications
   - allergies
   - interval history (how the child has been since the last visit)
      - illnesses
      - hospitalizations
      - surgeries
- dietary history
   - dietary history varies with age
      - infants:               discussion of breastfeeding vs. formula
      - 5-6 months:            introduce solid food
      - 12 months:             transition to whole cow’s milk
      - toddler, older child: typical daily meal intake
   - avoid allergy foods early on
      - strawberries
      - peanut butter
   - technique
      - important, especially in light of obesity epidemic
      - difficult to get a good dietary history in children without being specific
- sleep hygiene
   - questions
      - “Where is the child sleeping?”
      - “What is the bedtime routine?”
      - do not make assumptions
   - infant sleep recommendations
      - back only
      - firm surface
      - no pillows or toys in the sleeping area
      - light covering only (64-65°); avoid overheating
                                                                        Patient, Doctor, & Society 2: NOTES (page 10 of 117)



      - NEVER allow sleep on a couch
- toilet habits
   - importance: significant, difficult part of training a child
   - issues
      - constipation: can occur in childhood
      - toilet training
      - bed wetting
- family and home environment
   - avoid assumptions about the home environment
   - questions
      - “Who lives in the home?”
      - “Who regularly takes care of the child?”
      - “Any other social issues?”

general approach to the pediatric exam
- partnership with parents
   - improper physician roles
      - dictator
      - servant
   - families are different: be open-minded and willing to learn from patients
      - “What works for you?”
      - “May I offer some other suggestions?”
- address the patient
   - children can hear you
   - even infants respond to tone of voice
   - parents appreciate your caring manner
- observation
   - address immediate concerns of comfort with children
   - observe interaction and developmental skills as you talk or play
- modesty
   - be respectful of patient’s modesty
   - never assume a child won’t mind being examined – aware of “private parts” as early as 1 year old
- staging of exam
   - importance
      - elements of exam are same as in an adult
      - proceeding in the same order may not be a good idea
   - perform history or physical first
      - generally better to obtain history first
      - at times, it may be easiest to do the exam first
         - acute illness
         - infant is crying, cold, or hungry
         - toddler having a tantrum because he wants to play in the play room
   - improving success
      - approach with a gentle touch first
      - perform the least invasive steps first (ascultation of the heart beat is popular)
      - perform the most uncomfortable part of the exam last (ears, throat, etc.)

age-based approach
approaching the infant
- history: entirely from the caretaker’s perspective
   - make no assumptions about the person accompanying the child
   - know all of the caretakers involved
- non-verbal communication
   - observe infant’s non-verbal cues
      - poor eye contact:         fear
      - crying with movement: pain
                                                                           Patient, Doctor, & Society 2: NOTES (page 11 of 117)



   - comforting sensory experience
      - soft tones and gentle handling
      - consider examining infant in parent’s lap
      - allow infant to keep comfort items during exam
- separation anxiety
   - timing: children from 9 to 15 months of age
   - techniques
      - approach the child gradually:     form a rapport with a parent or sibling first
      - gain their trust:                 play with them (peak-a-boo, toys, etc.)
      - use transitional objects:         demonstrate exam on a doll, don’t remove pacifier until necessary
      - use parent’s lap:                 stress is lower
      - utilize demonstration:            show via parent, sibling that medical tools are not painful

approaching the toddler
- initial approach
   - introduce yourself, but approach slowly
   - allow time and space to “warm up” before beginning the exam
   - offer a toy or book to use while talking to the caretaker
- general techniques
   - engage in conversation:               children at this age may know their age and name
   - don’t ask permission:                 toddlers know the word “no” and will use it
   - give explanations:                    offer explanations before you do it
- techniques emphasizing their individuality
   - give power in decision-making:        “Would you like to sit on the table or on the chair by Dad?”
   - allow them to climb on table:         observation of motor skills
   - praise for talent

approaching the pre-school and school age child
- characteristics
   - preschool child
      - increased development of logical thinking
      - decreased egocentricity
      - increasing curiosity about the world around them
      - development of self esteem and gender identity
   - school age child
      - even greater logical, coherent thinking
      - more advanced social skills
- techniques
   - do not talk down to them
   - make eye contact
   - elicit information from the child
   - if apprehensive, give them some control
   - explain everything as concretely as possible
   - involve the child in the plan
   - rehearse the plan with the child




Alzheimer’s Disease
- normal aging of the brain
   - increased retrieval time (can be mistaken for memory impairment)
   - decreased ability to register, retain new information
   - decreased attention, concentration
                                                                           Patient, Doctor, & Society 2: NOTES (page 12 of 117)




TABLE: Normal Aging vs. Dementia
                        normal aging                      dementia
 memory impairment      minimal                           significant
 progression            minimal                           significant
 functional consequence none                              significant

dementia
- symptoms:      loss of intellectual function of sufficient severity to interfere with a person’s daily functioning
                 - must be a decline from a previous level of intellectual ability
                 - simple forgetfulness is not sufficient for diagnosis of dementia
- prevalence:    11% of population over 65
                 +2% for every year of life after age 75
- etiology:      Alzheimer’s disease (AD):         65%
                 AD and vascular causes:           10%
                 Lewy body:                        7%
                 AD and Lewy body:                 5%
                 vascular:                         5%
                 other:                            8%        (multiple sclerosis, injury, Parkinson’s, etc.)

Alzheimer’s disease
- symptoms:     confusion
                forgetfulness
                dementia
                mental emptiness
- prevalence:   affected people
                - United States: 4 million        (projected: 14 million in 2050)
                - Wisconsin:       110,000        (projected: 170,000 in 2030)
                proportions
                - 40% of persons turning 65 in 2000 will survive to age 85
                - 30-50% of persons reaching 85 will have Alzheimer’s disease
                - 53% of persons reaching 95 will have symptoms of Alzheimer’s disease
                - 90% of cases are sporadic, late onset
- etiology:     degeneration of the brain
                - low brain weight (generalized loss of white matter)
                - enlarged ventricles (hydrocephalus ex vacuo)
                - neuronal cell loss
- genetics:     β-amyloid precursor protein (APP):         chromosome 21
                familial early onset: presenillin 1        chromosome 14
                                        presenillin 2      chromosome 1
                familial late onset:    apolipoprotein E chromosome 19
- histology:    hippocampal plaques
                extracellular senile plaques
                intracellular neurofibrillary tangles
                amyloid angiopathy
                degeneration of the nucleus basalis of Meynert (ACh input to hippocampus, temporal cortex)
- risk factors: old age
                Down syndrome
                family history of dementia
                APOE ε4 genotype
                - APOE: apolipoprotein E gene present on chromosome 19
                - E4: associated with 40-50% chance of developing Alzheimer’s
                - E2: protective, reduced risk (mechanism unknown)
- influences:   estrogen
                vitamin E
                                                                          Patient, Doctor, & Society 2: NOTES (page 13 of 117)



                  statins
                  folic acid
                  anti-hypertensives
                  selegiline
                  NSAIDs
                  homocysteine
                  ginkgo biloba
                  cholinesterase inhibitors
- treatment:      goals of therapy
                  - improve function
                  - improve cognition
                  - slow disease progression
                  - improve quality of life of patient and caregiver
                  medication: increased levels of ACh
                  - cholinesterase inhibitors: inhibit breakdown of acetylcholine
                  - examples:        Tacrine
                                     Donepezil
                                     Galantamine
                                     Rivastigmine
                  caregivers
                  - 81% female
                  - 51% in the same residence
                  - 30% are sole caregivers
                  - 34% believe they will not be able to continue for much longer




Examination of the Eye
- components of the eye exam
   - visual acuity
   - visual fields
   - check pupil
   - motility
   - volcano sign
   - slit lamp examination
   - dilation
   - examination of the retina and fundus

checking visual acuity
- characteristics: monocular
                   no squinting:    want to tell if there is a problem with refraction
                   no cheating:     change the chart or change the order
                   correction:      permit lenses, as purpose is only to see if the system is working normally
                   distance:        optical infinity
                                    - 20’: optical infinity
                                    - 14”: average reading distance; can be substituted in a rapid clinical setting
- documentation: conventions
                 - VA:          visual acuity
                 - OD:          oculus dexter      (right eye)
                 - OS:          oculus sinister (left eye)
                 recording
                 - last line read with any modifiers from the next or previous line
                 - example: 20/40-1           (last full line read was 20/40, and one was missed)
                                                                         Patient, Doctor, & Society 2: NOTES (page 14 of 117)



                               20/20+1       (last full line read was 20/20, and one from next line was attained)

confrontational visual fields
- position:      mirror image eye covered
                 experimental eyes lined up precisely
- principle:     if tester can see it, patient should see it too
- method:        tester holds up several fingers in a visual quadrant, patient responds as to how many
                 - location: midway between the patient and tester
                                - too close to the patient: underestimation of visual field
                                - too close to the tester: overestimation of visual field
                 - range:       1, 2, or 5 (do not show 3 or 4, as these are hard to distinguish)
                 all four quadrants are tested
- documentation: drawn as the patient sees it

checking pupils
- importance:    early documentation to protect liability
- method:        examination setup
                 - dim room lights
                 - patient focused on a distant point (constriction goes along with accommodation)
                 - bright, small light source
                 part 1: contractility
                 - light on right eye, off right eye
                 - light on left eye, off left eye
                 part 2: optic nerve function
                 - focus on right eye: light on right eye, then to left eye
                 - focus on left eye:      light on left eye, then to right eye
- documentation: pupil size for each eye in dim light, bright light
                 - example: OD:            52
                                                     (no APD)
                                 OS:       55
                 - meaning: left eye at 5 mm, even in bright light, but no afferent defect by swinging test

checking motility
- method:        patient instructed to hold still and move only eyes
                 target shown to patient at comfortable distance in front of bridge of nose (half arm’s length)
                 target moved in H pattern
- scale:         0: normal
                 -4: no movement
                 +4: excessive, maximal movement
- documentation: each of eight cardinal locations, written as the physician sees it
- clinical:      motility disturbances
                 - lack of abduction: lateral rectus                     (CN VI)
                 - lack of adduction: medial rectus                      (CN III)
                 - lack of elevation:    may involve superior rectus (CN III)
                                         may involve inferior oblique (CN III)
                 - lack of depression: may involve inferior rectus       (CN III)
                                         may involve superior oblique (CN IV)
                 - lack of intortion:    superior oblique                (CN IV)
                 - lack of extortion:    inferior oblique                (CN III)
                 strabismus: ocular misalignment
                 - types:       esotropia: cross-eyed (more common in childhood)
                                exotropia: wall-eyed (more common in adulthood)
                                esophoria: cross-eyed under certain circumstances (e.g. tired)
                                exophoria: wall-eyed under certain circumstances (e.g. tired)
                 - etiology: weak or damaged muscles
                                simple misalignment
                                                                          Patient, Doctor, & Society 2: NOTES (page 15 of 117)



                                - unequal input from CN nuclei
                                - usually idiopathic, may result from maldevelopment of proper input balance

checking volcano sign
- anatomy:      ciliary body: produces aqueous humor in a pressure-independent manner
                trabecular meshwork: removes aqueous humor
- function:     determine if patient is at high risk for acute angle closure (covering arse)
                - certain conditions, such as cataract, cause a bulging cataract and reduced trabecular angle
                - contraction of dilating muscles can obstruct meshwork, increasing intraocular pressure
- method:       shine light on side of head, in plane of iris
                - flat (negative):      evenly lit
                - bowed (positive): nasal side of iris in shadow
- clinical:     acute angle closure glaucoma: caused by dilating an eye with reduced angle (that’s bad)

slit lamp exam
- setup:       fixed-focus slit light microscope
               - slit able to pivot
               - axis of pivot precisely the same as the focal point of the scope
- function:    allows ability to take optical cross-section
               allows measurement of depth and thickness
               removes reflections from cornea from the angle of view
- order:       lids and lashes
               conjunctival surface
               cornea
               anterior chamber (cornea to iris)
               iris
               posterior chamber (iris to lens)
               lens
- clinical:    conjunctivitis
               - symptoms: ↑ tearing:        viral:         watery
                                             bacterial:     mucopurulent pus
                               redness:      dilation of normal conjunctival vessels in reaction to infection
                               swelling:     chemosis
               - etiology      infectious: contagious, similar to any other infection
                               - bacterial: exudate (pus)
                               - viral:      no exudate
                               allergic: no purulence, possible chemosis, hallmark of itching
               - diagnosis: made from the door
               subconjunctival hemorrhage
               - incidence: frequently seen
               - pathology: rupture of conjunctival capillary
                               - small amount of blood (drop) spread over a large surface area
                               - wide area, white background gives dramatic appearance
                               tends to be focal
               - etiology: systemic hypertension
                               fragile vessels (steroid use, age)
                               coughing, sneezing, eye rubbing
                               idiopathic
               - urgency: none: looks dramatic, but is fairly minor

dilation
- method:         sympathetic agonists
                  - phenylephrine
                  - neosynephrine (2.5%)
                  parasympathetic antagonists
                  - tropicamide (1%)
                                                                        Patient, Doctor, & Society 2: NOTES (page 16 of 117)



                 - atropine
                 - homatropine
                 - scopolamine
                 - cyclopentolate
- function:      allows better examination of the inside of the eye
                 may wish to re-examine lens with slit lamp
                 - can examine more peripheral portions of the lens
                 - can check for cataract

examination of the retina and fundus
- methods:      direct opthalmoscope
                - advantages:       fast, mobile, portable
                - disadvantages: monocular, no depth perception, can only slightly alter magnification
                indirect opthalmoscope
                - characteristics: binocular telescope: uses prisms to get two independent images through pupil
                                    images are doubly inverted (upside down and backwards)
                - advantages:       greater view of retinal periphery
- indicators:   optic disc exam
                - swelling:               papilledema
                - cupping:                glaucoma (cup:disc ratio >5 may suggest damage)
                - pallor:                 nerve or orbital tumor
                retinal exam
                - vascular caliber:       systemic hypertension
                - hemorrhage:             hypertension, diabetes mellitus
                - cotton wool spots: retinal ischemia, diabetes mellitus
                - tears:                  retinal detachments
- clinical:     papilledema
                - symptoms:         swollen optic nerve head
                                    obscured disc margins
                                    fluffy white swelling of nerve layer fiber
                                    hemorrhages of nerves at disc
                - etiology:         increased intracranial pressure (ICP)
                                    - hydrostatic pressure on optic nerve exceeds axoplasmic force
                                    - axoplasm becomes obstructed at lamina cribosa, causing axonal swelling
                glaucoma
                - symptoms:         increased (cup : disc) ratio:     damaged optic nerve, retinal ganglion cells
                                    decreased peripheral vision: loss of function of retinal ganglion cells
                - etiology:         loss of ganglion cells by apoptosis
                                    - precise triggers not yet known
                                    - increased eye pressure biggest risk factor, but not always present
                - clinical:         cup to disc ratio
                                    - 0.3: borders approximately in thirds
                                    - 0.5: distance from center: cup is half of disc (borderline high)
                                    - 0.8: small rim
                hypertensive retinopathy
                - symptoms:         changes similar to normal aging
                                    - copper wiring: arterial muscular thickening
                                    - silver wiring: arterial edge thickening
                                    - AV nicking:       imprinting of vein into retina with hardening arteries
                                    hard to distinguish, difficult to attribute to single process or disease
                - etiology:         systemic retinopathy
                diabetic retinopathy
                - prevalence:       16 million US citizens with diabetes mellitus
                                    - after 20 years: 100% of type I diabetics have retinopathy
                                    - after 20 years: 60% of type II diabetics have retinopathy
                - symptoms:         dot, blot, and flame hemorrhages
                                                                            Patient, Doctor, & Society 2: NOTES (page 17 of 117)



                                     - microaneurysms
                                     - intraretinal hemorrhages
                                     cotton wool spots
                                     hard exudates
                                     focal ischemia
                                     growth of new blood vessels
                  - etiology:        intimal proliferation
                                     occlusion of vessel limuna
                                     necrosis of vessel wall
                                     - microaneurism
                                     - leakage of water, protein, fat (precipitation, causing hard exudate)
                                     - rupture and hemorrhage
                                     rupture/occlusion of vessel
                                     - downstream ischemia
                                     - axoplasmic flow stops in nerve fiber layer
                                     - cotton wool spot: focal swelling of axons
                                     prolonged ischemia
                                     - release of VEGF
                                     - growth of new vessels into vitreous




Cultural Issues Across the Lifespan
- culture: a shared system of beliefs, values, and/or learned patterns of behavior
   - shapes how we explain, value our world
   - lens through which we give the world meaning
- numerous components of culture
   - occupation
   - socioeconomic status
   - age/life stage
   - gender
   - ethnicity
- clinical encounter
   - cultures
      - patient
      - physician
      - “health care”
   - cultural gap
      - patient-physician
      - patient-health care

age as a cultural issue
- age/life stages
   - childhood
   - adolescence
   - young adulthood
   - mid-adulthood
   - older adulthood/elder
- age or life stage as a cultural issue
   - people of different ages have different beliefs, values, and patterns of behavior
   - age shapes how we explain and value our world
- ethnic variations in life stages and transitions
   - birth
                                                                         Patient, Doctor, & Society 2: NOTES (page 18 of 117)



  - puberty
  - productivity (i.e. financial, social/partnering)
  - reflectivity
  - death




Substance Abuse
consequences of substance abuse
- categories of substance abuse
   - abstinence:       not using at all
   - non-problematic: using occasionally, but not suffering for it
   - at risk:          using in a risky manner, suffering occasional consequences
   - abusive:          suffering repeated negative consequences
   - dependence:       loss of control, preoccupation, compulsivity, and may or may not have physical dependence

TABLE: Consequences of Substance Abuse
                           use                 consequences           repetition            compulsiveness
  abstinence               --                  --                     --                    --
  non-problematic          +                   --                     --                    --
  at-risk                  +                   +/-                    --                    --
  abuse                    +                   +                      +                     --
  dependence               +                   ++                     +                     +
- color coding is courtesy of our Glorious Leader, colorfully fighting terrorism since 2001


epidemiology and demographics
- substance use disorders
   - prevalence of substance use disorders (SUDs)
      - 9.4% of Americans over age 12 have alcohol or drug abuse or dependence
      - twice as high in males
      - peaks between 18 and 25
      - >1% prevalence in youngest and elderly
      - across ethnic groups: 9.3 to 14.1%
      - across urban to rural communities: 6.5 to 10.1%
   - breakdown
      - alcohol only:         67.7%
      - drugs only:           17.7%
      - both:                 14.6%
- demographics of alcohol abuse
   - gender:        males > females
   - age:           adolescents > young adults > middle aged
   - education:     college graduates < all other education levels
   - ethnicity:     whites and Hispanics > blacks
   - income:        annual income < $20,000 > all others
   - location:      major metropolitan areas = other urban suburban areas = rural
- alcohol use in America
   - more common use than any other drug
   - high quantities: each over 14 American in 1989 drank 2.43 gallons of ethanol
      - equivalent to 576 12 oz. beers
      - 10% of drinkers accounted for 50% of the consumption
   - responsible for 5% of all US deaths
      - 100,000 deaths per year, including 18,000 traffic fatalities
                                                                          Patient, Doctor, & Society 2: NOTES (page 19 of 117)



      - third leading cause of preventable death (behind smoking, diet/exercise)
      - other drug abuse deaths: 1% (20,000) per year
- alcohol use in Wisconsin: national rankings
   - abstinence:                                    50th (rate: 30.1%)
   - moderate drinking       (≥30 per month):       1st
   - chronic drinking        (≥60 per month):       5th
   - binge drinking          (≥5 in a row):         near the top in general population
                                                    UW Madison among top 5% of US colleges
                                                    1st among women of reproductive age
   - drinking and driving:                          near the top

etiology
evidence for genetic factors
- twin studies
   - 74% concordance of alcoholism between monozygotic twins
   - 32% concordance of alcoholism between dizygotic twins
- genetic strain of rats can be bred that:
   - seeks higher doses
   - develops pharmacologic dependence more rapidly and more permanently
   - contains less serotonin and dopamine in reward regions
- alcoholic humans can, on average, be differentiated by:
   - distribution of certain blood group factors
   - distribution of certain leukocyte agents
   - increased EEG sensitivity to alcohol in non-drinking sons of alcoholics
evidence for psychological factors
- personality
   - no known premorbid addictive personality
   - antisocial personality disorder people are at higher risk
- psychiatric disorders
   - primary substance abuse can lead to secondary psychiatric disorders
   - primary psychiatric disorders can lead to secondary substance abuse
- stress
   - can be a precipitant, but not considered a direct cause
   - stress often results from biomedical and social consequences of alcohol and other drug problems
evidence for social factors
- alcohol in the family: “families with alcoholism” transmit alcoholism less often than “alcoholic families”
   - families with alcoholism: rituals and roles intact
   - alcoholic families:           rituals and roles altered by alcoholism
- more prevalent in individuals of lower socioeconomic status
   - hopelessness
   - boredom
   - gang economies
   - availability
- cultural factors
   - play a role in facilitating and preventing expression of substance disorders
   - cultural assimilation in the US gradually neutralizing the effect
neuroadaptation
- neuroadaptation: process by which neural systems become acclimated to certain stimuli
- acute opiate use in rats
   - effect:         decreased cell excitability, transcription of certain segments of DNA
   - mechanism: ↓ adenylate cyclase  ↓ cAMP  ↓ PKA  ↓ phosphoproteins
- chronic opiate use in rats
   - effect:         increased cell excitability and maintenance of new steady state of gene expression
   - mechanism: prolonged upregulation of cAMP activity (persists long after cessation of use)

the disease model
                                                                           Patient, Doctor, & Society 2: NOTES (page 20 of 117)



- the psychological progression to dependence
   - I:   learning the mood swing
          - substance users feel euphoric with minimal use
          - increase from, return to normal
   - II: seeking the mood swing
          - users increase use, seeking and attaining more euphoria
          - increase from, return to normal (higher peak)
   - III: paying costs
          - users seek and attain euphoria at the expense of negative consequences and emotional pain
          - increase from normal, fall below normal; return to normal between use
   - IV: relief use
          - baseline state declines, euphoria is unachievable, and users seek relief from pain
          - increase from pain to attain normal, fall back to pain between use

  TABLE: The Moral and Disease Model of Substance Abuse
                            moral model               disease model
   alcohol and drugs are…   evil                      psychoactive substances
   substance use is…        evil                      risky
   substance users are…     evil                      at risk
   substance abuse is…      evil                      preventable
   addicts are…             EEEEEEVIL!                treatable


screening
- standard drinks (12 g ethanol)
   - beer              12 oz
   - shot of spirits   1.5 oz
   - glass of wine     5 oz
   - wine cooler       12 oz
   - glass of liqueur 4 oz

  TABLE: At Risk Drinking
                      per week                   per occasion
   men                > 14 drinks                > 4 drinks
   women              > 7 (11) drinks            > 3 drinks
   elders             > 7 drinks                 > 1 drink

- screening model
   - screen
   - if positive, perform a brief assessment
      - abstinence or low-risk use:        prevention message
      - at-risk use or abuse:              brief intervention, motivational interviewing if necessary
      - dependence:                        refer to treatment, brief intervention/motivational interviewing if necessary
   - follow up
- choosing a screening method
   - number of items
   - method of administration
   - substances covered
   - accuracy by age group, gender, pregnancy status, cultural group
- screening methods
   - alcohol use disorders identification test (AUDIT)
      - method:      10 multiple choice questions
      - value:       sensitivity: 51-97%
                     specificity: 78-96%
   - CAGE
                                                                              Patient, Doctor, & Society 2: NOTES (page 21 of 117)



    - method:     4 questions (1 yes is a positive)
                  - cut down:         ever felt the need?
                  - annoyed:          ever felt annoyed by others criticizing your drinking?
                  - guilty:           ever felt guilty about your drinking?
                  - eye-opener:       ever had a drink first thing in the morning, or to help get over a hangover?
     - value:     sensitivity: 43-94%
                  specificity: 78-96%
  - two item conjoint screen (TICS)
     - method:    2 questions (1 yes is a positive)
                  - “In the past year, have you ever felt that you ought to cut down on your drinking or drug use?”
                  - “In the past year, have you ever drank or used drugs more than you meant to?”
     - value:     sensitivity, specificity:     80%
  - single alcohol screen question
     - method:    1 question (positive response: within the last 3 months)
                  - males:       “When is the last time you had more than 5 drinks?”
                  - females: “When is the last time you had more than 4 drinks?”
     - value:     sensitivity, specificity:     86%
  - other tests
     - CRAFT:          used for adolescents
     - S-MAST-G:       used for geriatric patients
     - TWEAK:          used for pregnant women; covers alcohol only

- establishing quantity and frequency
   - “How many days a week do you drink some alcohol?”
   - “How much do you typically drink when you do drink?”
   - “What’s the most you’ve had to drink at one time in the past 3 months?”
- other questions to consider
   - “Have you ever tried or experimented with…”
      - marijuana
      - cocaine
      - shooting up
      - inhalants
      - pills
      - any other drugs
   - days per week, usual quantity, maximum
   - “Have you ever gotten any help for an alcohol or drug problem?
- for sensitive situations
   - ask first about friends’ substance use
   - ask first about past substance use
   - make normalizing statements before asking questions
- consider non-verbal cues as a positive screen
   - eye contact
   - fluidity, tone of speech
   - posture
   - movements
   - affect

assessment
- function
   - establishes with certainty an individual’s substance-related diagnosis
   - establishes if patients are:
      - at risk:     using in a risky manner
      - abusive:     suffering repeated negative consequences
      - dependent: losing control of use
- brief assessment: method
   - consequences and repetition
                                                                          Patient, Doctor, & Society 2: NOTES (page 22 of 117)



      - psychological
      - family
      - friends
      - biomedical
      - work and school
      - legal
      - financial
      - religious/spiritual
   - control
      - loss of control
      - physical dependence
   - use and frequency
- interviews of patients by skilled assessors are the most accurate source of information
   - family members report less use and consequences than abusers
   - only 25% of problem drinkers have suggestive tests (elevated GGT, MCV)

brief interventions
- components: FERNSS
   - feedback
   - education
   - recommendation
   - negotiation
   - secure agreement
   - set follow-up
- time: as little as 2 ten minute sessions
- cost: can save $1000 in the long run
- one year follow up:
   - decreased self-reported drinking
   - decreased absenteeism at work
   - decreased hospital days
   - decreased ER visits
   - decreased liver inflammation

effectiveness of treatment
- treatment for substance use disorders
   - should be considered similar to other disorders
      - hypertension
      - diabetes
      - asthma
   - evidence on treatment
      - SUDs: chronic relapsing and remitting conditions
      - abstinence is not the sole criterion for evaluating effectiveness
         - less substance use
         - better function
         - improved quality and duration of life
   - pharmacotherapies
      - aversive agents
         - disulfiram (Antabuse)
         - RCTs at one year show no difference in outcome; may be useful for impulsive drinkers
      - anti-craving agents
         - naltrexone (Revia)
         - acamprosate (Campral)
         - leads to decreased desire to drink, fewer and less severe relapses
- alcohol treatment
   - numerous studies show improvements with treatment
   - several studies show better outcomes with particular types of treatment
                                                                            Patient, Doctor, & Society 2: NOTES (page 23 of 117)



   - patients may need to try several over the course of a lifetime
- drug treatment
   - methadone: has yielded the most positive results for those seeking it
   - therapeutic community clients demonstrate better behavior during/after treatment
   - chemical dependency programs have not yet been carefully evaluated for treatment of drug problems
- treatment for criminal factors
   - five year treatment follow-up
      - 21% decrease in drug use
      - 14% decrease in alcohol use
      - 23-38% decrease in particular categories of crime
   - felony recidivism
      - national rate:                                   63%
      - those receiving substance abuse treatment:       35%
   - drug courts
      - purpose:         divert non-violent offenders from prison to treatment
      - effectiveness: save public $5000 per offender
   - crime prevention: treatment is 15X more effective than incarceration
   - every $1 spent on treatment leads to public savings of $7
   - needs
      - inmates in need of treatment:      75 to 80%
      - inmates receiving treatment:       15%




Physician Impairment and Recovery
physician impairment
- physician impairment (AMA)
   - inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness
   - includes alcoholism, drug dependence
- unprofessional conduct (Wisconsin Administrative Code)
   - any practice or conduct which tends to constitute a danger to the health, welfare, or safety of the patient or public
   - practicing, attempting to practice under any license when unable to do so with reasonable skill and safety

- common etiologies for impairment
   - alcohol and drug disorders
   - other addictions or compulsive behaviors
   - psychiatric disorders
      - depression
      - psychosis
   - other health problems
      - dementia
      - medication side effects
   - personality disorders
   - disruptive behaviors
- consequences of impairment
   - legal
      - malpractice
      - non-professional
   - medical
      - harm to patients
      - harm to physician and family
   - disciplinary
      - suspension or loss of hospital privileges
                                                                            Patient, Doctor, & Society 2: NOTES (page 24 of 117)



    - license revocation by state board
    - National Physician Databank entry


demographics
- physicians and substance abuse
   - overall prevalence of substance abuse similar to the general population
   - favor certain drugs due to enhanced access
      - benzodiazepines
      - weak opioids
      - intravenous substances

  TABLE: Substance Abuse in the General Population
   age            men              women
    18-29         23.5%            10.1%
    30-44         14.3%            4.1%
    45-64         7.2%             1.7%
    65+           2.8%             0.4%
   all ages       13.4%            4.4%

- predisposing factors for physician impairment
   - premedical years:       competition, social isolation, achievement orientation, fear of failure
   - medical school:         further social isolation, excessive work load, repression of feelings,
                                  intellectualization of emotions, neglect of personal needs
                                  depression (30% of all medical students)
   - training:               extraordinary length, rigidity, and intensity
   - resistance to help:     fear of consequences, tendency to self-diagnose and self treat,
                                  increased rationalization and denial (due to intelligence)
   - self treatment
   - family of origin
- epidemiology
   - medical students
      - use begins prior to medical school
      - types of drugs same as general population
      - alcohol use and dependence are variable
      - drug use and dependence are reduced
   - residents
      - rates of dependence: 10-14%
      - alcohol, drug use typically begins prior to residency
      - benzodiazepine, opioid use begins during residency
         - self-treatment
         - self-prescribed
   - physicians
      - prevalence of dependence: 8-14% (60,000 to 75,000 affected MDs in the U.S.)
      - use, misuse of benzodiazepine, opioids up to 5X greater
- epidemiology by specialty
   - higher risk
      - anesthesiologists
      - psychiatrists
      - rural family physicians
      - emergency medicine
   - lower risk
      - OB-GYN
      - pathology
      - radiology
                                                                        Patient, Doctor, & Society 2: NOTES (page 25 of 117)



      - pediatrics
- reasons for use
   - recreational:                 seen more in medical students
   - performance enhancement:      seen more in emergency medicine
   - self-medication:              seen more in residents, attendings


detection of impairing conditions
symptoms
- substance abuse: continued use of a psychoactive substance despite repeated negative consequences
- substance dependence: substance abuse with neuroadaptation
   - cravings
   - compulsivity in use
   - preoccupation with obtaining the substance
   - physical dependence (tolerance or withdrawal)
   - loss of control of substance use
- depression
   - persistently depressed or anxious mood
   - increased or decreased sleep
   - increased or decreased appetite and weight
   - difficulty concentrating
   - decreased energy
   - sense of helplessness and hopelessness
   - anhedonia
   - social withdrawal
- general impairment
   - changes in work habits, hours, personality, reliability, patience, amiability
   - change in energy level: loss of energy or agitation
   - decreased frustration tolerance, mood swings
   - decreased energy level
   - change in appearance: grooming, hygiene, dress, tired eyes, weight loss
   - increase in error rate, poor charting
   - increased complaints about work, martyrdom
   - increased mistrust of and dissatisfaction with others
   - concern or complaints expressed by other staff and patients
   - odors of alcohol
barriers to identification and treatment
- symptoms appear last in the workplace
- denial and rationalization by the impaired physician, resistance to help
   - “I can take care of myself”
   - “Knowledge is protective”
   - fear of consequences
- limited training in alcohol and drug problems
- denial by others (“conspiracy of silence”)
   - reputation
   - financial implications
   - fear and intimidation
   - professional pride
reporting
- reasons
   - ethical obligation
   - legal obligation (varies from state to state)
      - reporting mandates
      - slander protection
   - civil liability
- impaired physician advocacy programs
                                                                           Patient, Doctor, & Society 2: NOTES (page 26 of 117)



  - goals:        protect the public
                  help impaired physicians get help and stay in practice
  - structure:    created to encourage reporting
                  - administered by the State Medical Society, licensure board, or independent organization
                  - relationship with the state licensure board
                  - parallel programs in hospitals and medical schools
- options
   - medical school:   AIMS Committee
                       Dean
  - residency:         faculty
                       Employee Assistance Program (EAP)
                       hospital-based committee
  - practice:          JCAHO-mandated hospital committees
                       State Impaired Physicians Program
                       - protect the public
                       - promote rehabilitation and, if safe, return to work
                       state licensure board (often punitive)


treatment
- treatment programs
   - tailored for health care professionals
   - heavy focus on health professional self-help group
- recovery rates
   - success:       64-100% (usually 80-90%)
                    compares quite favorably with the general population
   - reasons:       can afford intensive programs and lengthy follow-up
                    monitoring program
                    higher stakes
                    intelligence: hindrance due to enhancement of rationalization and denial
- factors for success
   - duration of aftercare
   - physician’s health program involvement
   - family involvement
   - 12-step involvement
   - witnessed urine screen
   - contingency contract




Ethics: A Case-Based Approach
introduction to ethics
- ethical dilemmas occur everywhere
   - pediatrics:   12 yo male with recurrent Hodgkin’s lymphoma refuses radiation therapy
   - internist:    89 yo female with dementia and end-stage renal disease (ESRD), daughter requests dialysis
   - surgery:      45 yo male with ruptured spleen, refuses blood transfusions as a Jehovah’s witness
   - OB/Gyn:       25 yo female at 30 weeks gestation with ESRD will not come to the hospital for monitoring
   - family:       23 yo male with growth on neck, excision required, informed consent needed
   - anesthesia: 85 yo male with DNR request, requires colectomy
   - radiology:    75 yo male with abdominal pain, surgeon views something differently
   - pathology: asked to harvest stem cells from an aborted fetus
- characteristics of ethical decision-making
   - can be more difficult than the medical decision, and is frequently poorly taught
                                                                          Patient, Doctor, & Society 2: NOTES (page 27 of 117)



  - can conflict with the “best” medical therapy
  - needs to be practiced, not simply discussed, in order to be done correctly

four box approach to ethics
- four box model
   - medical indications
   - patient preferences
   - quality of life
   - contextual features

- medical indications
   - determine diagnostic and therapeutic interventions
   - verify medical facts of the patient’s case
   - understand the possible benefits
   - determine the goals of treatment
   - determine how harm can be avoided
- patient preferences
   - determine the patient’s goals and values
      - “Go big or go home” – enjoy what you have
      - live as long as possible
   - aid the patient’s understanding of the options
   - determine if the patient has the capacity to make a decision
   - determine the role that surrogates play in patient care
- quality of life
   - determine what the patient views as quality of life
      - freedom from pain
      - maintenance of cognitive abilities
      - independence in care
      - fully supportive care on a ventilator
      - ability to play 18 holes of golf
   - differing views by:
      - patient
      - culture
      - age
- contextual features
   - role of interested parties
   - physician confidentiality
   - institutions
   - financial arrangements
   - social arrangements
   - psychological ramifications
   - legal repercussions
   - religious impact
   - scientific inquiry (research, teaching)

  TABLE: Four Box Approach to Ethics
     medical indications            patient preferences

   • medical facts                   • patient goals and values
   • goals of treatment              • patient understanding
   • options to avoid harm
           quality of life                contextual features

   • freedom from pain               • institutions
   • independence                    • legal repercussions
                                                                           Patient, Doctor, & Society 2: NOTES (page 28 of 117)




guiding ethical principles
- guiding ethical principles
   - autonomy
   - non-malfeasance
   - beneficence
   - fairness (justice)

- autonomy
   - definition:    right to choose treatment or refuse therapy
   - importance: informed adult patient of sound mind is fully able to decide their own therapy
   - protecting autonomy
      - consent forms
      - do not resuscitate (DNR) orders
      - advance medical advice (AMA) forms
- non-malfeasance
   - definition:    primum non nocere (first do no harm)
   - importance: painful, risky, or burdensome therapy
- beneficence
   - definition:    duty to assist patients
   - importance: fundamental goal of physicians is to benefit the patient
                    - patient-centered: class of medicine that respects patient autonomy above all else
                    - paternalism: class of medicine that practices beneficence over autonomy
- fairness
   - definition:    justice
   - importance: situations of limited resources
                    - emergency medicine: not allowed to turn away patients
                    - intensive care: allocated on first-come basis
                    - organ transplants: allocated on recommendations of council


ethics in clinical practice
- age-based ethics
   - adults:          patient-centered (autonomy over beneficence)
   - children:        paternalistic    (beneficence over autonomy)
- decision-making capacity
   - decision-making capacity: ability of a patient to be able to make a decision regarding his or her health care
   - different than legally-competent: specific to the decision at hand
      - my child can decide between Cheerio’s and Golden Grams
      - my child cannot decide whether or not to have breakfast
   - requirements
      - understanding of relevant information
      - understanding of consequences of decision made
      - able to communicate a choice
   - determining decisional capacity
      - simple benefits of mental status
      - evaluation by psychiatry
      - dependent on risk-benefit analysis
         - high risk / low benefit:    higher degree of capacity to consent to treatment
         - high benefit / low risk:    higher degree of capacity to refuse treatment
- making decisions in absence of decision-making capacity
   - people
      - durable power of attorney for health care (DPHC)
      - appointed surrogate decision maker
                                                                         Patient, Doctor, & Society 2: NOTES (page 29 of 117)



   - methods
      - advanced directives:          specifically defined directives regarding health care
      - living will:                  general statement of desires for health care
      - surrogate judgment:           based on the patient’s stated preferences
      - substituted judgment:         based on knowledge of patient’s values or goals
      - best interests of the patient
   - hierarchy of surrogate decision-makers: based on state law
      - spouse
      - parent
      - child
- exceptions
   - implied consent:                 may be presumed when immediate action necessary to preserve patient’s life
   - statutory authority to treat:    involuntary commitment, determined by psychiatrist
   - parental authority:              exceeds child’s capacity to make decision
   - child welfare:                   exceeds parent’s capacity to make decision, in an abuse situation


ethical issues faced by medical students
- ethical issues
   - education and patient care
   - being a “team player”
   - challenging the medical routine
   - witnessing unethical actions

- education and patient care
   - patient consent to student participation
   - need for student to learn skills
   - need for proper patient care
   - chance of success vs. patient discomfort
   - importance of student evaluations
- being a team player
   - ill-defined role of the student
   - limited knowledge of the case for the student
   - low place for student in medical hierarchy
- challenging the medical routine
   - “loose cannon”
      - students that try to buck the hierarchy or do things they are unprepared for
      - may be used in a negative and controlling manner by upper levels of the hierarchy
   - feeling of medical ignorance
   - improved insight into several issues that MD and hospital personnel may not
      - students have more time to spend with patients
      - students may be better informed about the patient personally and socially
- witnessing unethical actions
   - feelings of powerlessness
   - feelings of coercion




Ethics: Conflicts of Interest
- importance
   - human interactions have moral content
   - medical care involved human encounters
   - professional behavior needs ethical foundations to:
                                                                           Patient, Doctor, & Society 2: NOTES (page 30 of 117)



    - explain and give reasons for the practice
    - justify acts to the community
    - construct standards

definitions
- morality: norms about right and wrong
  - function:     concepts sufficiently shared to form a stable set of beliefs
                  - common morality, sometimes expressed as values
                  - able to be generalized to understanding, but are also specific enough to have meaning
  - origins:      both secular and non-secular sources
  - classes:      individual
                  community-specific
                  professional

- ethics: the study of morality
   - function:      understanding and explaining the moral life that one “ought” to live
   - classes:       normative
                    - function: how should we act, behave, or decide
                    - structure: prescriptive guidelines, rules, recommendations
                    non-normative
                    - function: definitions of terms and the factual bases for the normative decisions
                    - structure: “facts” about ethics

- applied ethics: application of theories, principles, or other systematic ways of thinking about ethical problems
   - origin:       “accepted” practice of study, dependent on the problem to be solved
   - goals:        identify and simplify the problem
                   provide ethical boundaries for discussion
                   bring greater clarity to the problem, aiding others in helping to solve it
                   resolve a specific problem

thinking about medical ethics
- topics in medical ethics
   - confidentiality
   - conflict of interest
   - truth telling
   - keeping promises
   - informed consent
   - end of life care
   - gifts
   - bedside rationing
   - incentives to increase or decrease services
   - disclosing mistakes
   - impaired colleagues
- philosophical bases
   - consequential:          outcomes determine the approach
   - deontological:          rules determine the approach
   - virtue-based:           virtuous character will do the right thing
   - ethic of care:          caring relationship must be maintained
   - case-based:             paradigmatic cases to answer future cases
- guidelines
   - respect for autonomy
   - beneficence
   - non-malfeasance
   - justice
- domains of medical ethics
   - clinical ethics:        decision-making at the bedside
                                                                            Patient, Doctor, & Society 2: NOTES (page 31 of 117)



  - policy ethics:          guidelines, policy, standards, regulations, procedures
  - research ethics:        human, animal, molecular

conflicts of interest
- overview
   - occurs when a person entrusted with the interests of a client, dependent, or the public violates that trust
   - found in all professions and public service
   - people tend to believe they are acting with integrity, even when not
- importance in medicine
   - harms patients one at a time:          physician favors him or herself or a third party
   - harms medical practice standards: patients at risk of harm
                                            erodes professional self-esteem
   - harms trust in physicians:             political consequences: loss of autonomy
                                            erodes patient cooperation in care
- definitions
   - patient outcome worse due to subordination of patient’s best interests
   - medical decision-making compromised even though patient not harmed
   - perceived, without harm or potential harm
   - competing vs. conflicting interests
- physician income
   - cost and prices
      - resource-based relative value scale (RBRVS)
      - market-based: buyer-beware
   - reimbursement systems
      - fee for service
      - managed care: prospective payment
   - miscellaneous
      - evaluation and management, counseling, procedures
      - fee splitting
      - referral to owned services
- strategies to manage conflict
   - reaffirm that patient interests are paramount
   - disclose conflicts of interest
      - requires justification
      - patients can take account
   - take precautions to protect patients
      - informed consent
      - institutional review boards (IRBs)
   - prohibit certain actions and situations
      - continuing medical education (CME) controlled by drug companies
      - much of medical practice is related to pharmacologists




Ethics: Truth Telling in Medicine
review: consideration of ethics
- framework
   - medical facts
   - patient preferences
   - quality of life
   - contextual features
- guiding ethical principles
   - autonomy
                                                                            Patient, Doctor, & Society 2: NOTES (page 32 of 117)



   - beneficence
   - non-malfeasance
   - fairness
history of truth telling
- attitudes in history
   - Hippocrates, 406 BC: conceal most things and always appear cheerful and serene
   - Percival, 1849:          conceal information if consequences of knowledge deemed likely to prove harmful
   - Oken, 1961:              don’t tell:   88% of physicians do not tell cancer patients of diagnosis
   - Novack, 1979:            do tell:      98% of physicians do tell cancer patients of diagnosis
- recent history
   - 1960s: avoid disclosure of poor diagnosis whenever possible
   - 1970s: disclose diagnosis no matter what
   - current: disclose as much as the patient wants to know, when the patient wants to know it
non-truth in medicine
- deception and concealment
   - deception
      - lying:                     falsehood
      - misleading:                placebo, euphemism, non-verbal response
   - concealment
      - withholding:               non-disclosure, timing
      - selective disclosure:      omission, emphasis
- classification
   - lying:                   statement that speaker knows or believes is false, and is intended to mislead the listener
                              - despite abnormal values, physician tells a patient that tests are normal
                              - despite knowing, physician indicates “I don’t know”
   - deception:               statement and actions intended to mislead the listener, whether or not literally true
                              - physician uses “growth” as a euphemism for cancer
                              - physician uses technical jargon, misleading statistics, and omits qualifying information
   - misrepresentation:       unintentional, intentional statements and actions which may or may not be literally true
                              - physician fails to check the patient’s understanding
                              - may result from inexperience, poor interpersonal skills, or lack of diligence
   - non-disclosure:          failure to provide information about the diagnosis
                              - physician does not disclose diagnosis unless specifically asked
conflicts in truth-telling
deception of the patient
- in favor of deception and concealment
   - patient may lose hope
   - patient may refuse of beneficial treatment
   - patient is or may become depressed or suicidal
   - disclosure is not culturally appropriate
   - patient does not want to be told
- opposed to deception and concealment
   - lying and deception are morally wrong
   - most patients want to know their diagnosis and options
   - patients need information for decisions
   - disclosure does more good than harm
   - deception will likely require further deception
   - may be impossible
- resolving dilemmas
   - anticipate problems with disclosure
   - determine what the patient wants
   - elicit the family’s concerns
   - focus on how to tell, as opposed to whether
   - if withholding, plan for future contingencies

- why patients refuse treatment
                                                                          Patient, Doctor, & Society 2: NOTES (page 33 of 117)



   - feel they have not been included in the decision-making process
   - feel they do not have enough information to make a good decision
- defining hope
   - good life:         freedom from disease or illness
                        functional capacity and independence
                        societal and material preferences
   - postpone death: maximum good days
                        maximum possible days
   - good death:        freedom from symptoms and debts
                        in a preferred place
                        supported by favorite persons
                        at peace with creator

  TABLE: Ethnicity and Desire for Information
                             cancer diagnosis           terminal prognosis
   European American         87%                        69%
   African American          89%                        63%
   Mexican American          65%                        48%
   Korean American           47%                        35%


deception of third parties
- in favor of deception
   - insurance coverage
   - disability
   - excused absence from work or school
   - airline reservations
   - adoption agencies
   - vehicle licenses
   - disabled parking permits
- opposed to deception
   - physicians should avoid lying and deception
   - harm of deception outweighs the benefits
- resolving dilemmas
   - consider importance of the benefit
   - exhaust all other alternatives
   - involve patients who request deception

other principles in ethics
- keeping promises
   - do not make promises lightly
   - elicit concerns underlying the request for a promise
   - do not promise outcomes you cannot deliver
   - do not violate ethical guidelines because of an ill-considered promise
- preventive clinical ethics
   - elicit preferences in advance, preferably before any tests or examinations are done
   - envision the question as a “vital sign,” asked of every new patient
- exceptions to the duty to disclose
   - patient waiver:          make sure it is well grounded
   - patient incapacity:      inform a surrogate
   - medical emergency: highly defendable
   - therapeutic privilege: rarely defendable
   - cultural differences: check individual’s preferences
- eliciting the patient’s understanding: Kleinman’s eight questions
   - What do you call the problem?
                                                                         Patient, Doctor, & Society 2: NOTES (page 34 of 117)



   - What do you think has caused the problem?
   - Why do you think it started when it did?
   - What do you think the sickness does? How does it work?
   - How severe is the sickness? Will it have a long or short course?
   - What kind of treatment do you think the patient should receive? What results do you hope for?
   - What are the chief problems the sickness has caused?
   - What do you fear most about the sickness?
- delivering bad news
   - the 7 step model
      - prepare
      - elicit prior knowledge
      - elicit learning preference
      - deliver
      - respond to emotion
      - negotiate goals and priorities
      - make a plan
   - other principles
      - provide a calm setting
      - warn patient that bad news is coming
      - avoid euphemisms and jargon
      - allow patient to react
      - keep first discussion brief
      - elicit patient’s reactions and concerns
      - provide realistic hope
      - show your concern
      - repeat discussion at subsequent visits
      - share uncertainty with patient




Ethics: Confidentiality
- definitions
   - privacy:           material     information concerning medical conditions
   - confidentiality:   contract     obligation to maintain privacy by someone who enters into a relationship
- importance
   - patient trust:     utilitarian
                        - guarantee of privacy
                        - accurate diagnosis and treatment
                        - 25% of adolescents would forego care if their parents were informed
  - virtue:             deontologic
                        - allows self respect
                        - patient speaks freely with the assumption of secrecy
- attitudes
   - Hippocratic Oath (4th century BC): absolute privacy
              “Whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart
              there from, which ought not to be noised abroad, I will keep silence thereon, counting such things to be
              as sacred secrets.”
   - American College of Physicians:       privacy assumed
              “To protect patient confidentiality, information should only be released with the written permission of
              the patient or the patient’s legally authorized representative.”
   - America Medical Association:          privacy with exceptions
              “[A] physician shall safeguard patient confidences within the constraints of the law.”
                                                                           Patient, Doctor, & Society 2: NOTES (page 35 of 117)



legal considerations
- federal privacy regulations
   - 31 pages of small print
   - 336 pages of commentary
- increasing third party management of health care
   - pharmacy benefit programs
   - insurance databanks
   - employers
- computerized record systems: HIPAA
   - HIPAA: Health Insurance Portability and Accountability Act, 1996
   - protected health information (PHI)
      - any information with identifiers
      - can be written, spoken, or electronic
   - objective: establishes regulations for electronic transfers of data
      - safeguarding PHI
      - accessing PHI
      - disclosing PHI
      - fundraising and marketing
      - research

breaching confidentiality
- breach: disclosure to a third party, without patient consent or court order, of PHI
   - learned within the physician-patient relationship
   - shared without consent of the patient
   - applies to oral, written, telephone, fax, or electronic transmission
- acceptable breaches: when the public good outweighs the individual
   - suspected child abuse or elder abuse
   - threats to public health (e.g. sexually transmitted diseases)
   - litigation (after reasonable attempts to notify the patient)
   - law enforcement
      - identification
      - pertinent information for individuals under custody (e.g. diabetic prisoners)
      - blood draws
      - evaluation for emergency detention or detox
- what is not considered a breach
   - implied consent
      - to other health care providers involved in care         (covered with blanket release form)
      - to health plans as needed for a claim                   (covered by previous release form)
   - requires written permission
      - marketing and fundraising
      - research
      - disclosure (of certain things) to law enforcement
- legal landmarks
   - first US law (1828)
      - patients have a right to prevent testimony communicated in the course of treatment
      - privacy provisions of the Constitution
   - Tarasoff v. Board of Regents, 1976
      - information that obviously threatens the public good is not considered privileged information
      - stemmed from a case involving a psychiatrist who withheld a direct threat of harm from one of his patients
      - he threatened “I am going to kill my girlfriend,” and later followed up on it.
   - currently, the state decides many issues, including:
      - HIV and other STD notification
      - genetic counseling
      - mental health
- inadvertent breaches
   - elevator chat
                                                                             Patient, Doctor, & Society 2: NOTES (page 36 of 117)



    - cafeteria or cell phone conversation
    - computer records: forgot to log off, “just checking”

ethics in the consideration of confidentiality
- four groups of people with regards to PMI
   - must know
   - could know
   - should know
   - should not know
- the four box model

    TABLE: Four Box Approach to Ethics
        medical indications          patient preferences

     • medical facts                    • patient goals and values
     • goals of treatment               • patient understanding
     • options to avoid harm
             quality of life                contextual features

     • freedom from pain                • institutions
     • independence                     • legal repercussions


- guiding ethical principles
   - autonomy
   - justice
   - beneficence, non-malfeasance

- overriding themes
   - information should be considered private unless specifically authorized
   - sharing may not require express written consent if directly related to patient care
   - breaches may be acceptable in certain cases
   - when considering intentional deception, read the following sentence:

                    DO NOT LIE!




Formulating an Assessment
•     Become familiar with the process of clinical reasoning and focused history taking.

- deductive method
   - initial cues:             patient appearance, chief complaint
   - early hypotheses:         large differential
   - hypothesis testing:       history, physical exam, and laboratory work
   - case building:            narrowing of the differential
   - working diagnosis:        diagnosis, follow-up and confirmation

- differential diagnosis: VINDICATE
   - V: vascular
                                                                             Patient, Doctor, & Society 2: NOTES (page 37 of 117)



    - I:   infectious / inflammatory
    - N:   neoplastic
    - D:   drug / degenerative
    - I:   idiopathic / iatrogenic
    - C:   congenital
    - A:   autoimmune
    - T:   traumatic
    - E:   endocrine

- diagnostic decision: made when uncertainty about diagnosis is reduced to an acceptable level for the clinician


•     Describe the 3 components of an assessment for an acute and chronic problem.
•     Formulate an assessment based on clinical information.

- assessment of an acute problem
   - statement:              statement of the problem
   - differential diagnosis: list of hypotheses, usually presented from most to least likely
   - clinical reasoning:     rationale for or against each hypothesis using data from history, PE, and labs

               Assessment: Cough of 4 weeks duration. The most likely diagnosis is post nasal drip because of the
               duration and timing with seasonal allergies. Pneumonia is unlikely due to lack of fever and SOB.
               GERD seems unlikely due to lack of association with meals, though association with lying recumbent
               is supportive. This could be the onset of asthma, though would expect more SOB and relationship to
               activity.

- assessment of a chronic problem
   - statement:            statement of the problem
   - status:               well-controlled, poorly controlled, resolved, improving, worsening, persistent, etc.
   - clinical reasoning:   rationale for status statement using data from history, PE, and labs

               Assessment: Diabetes, well controlled with diet and weight loss. There are no symptoms of
               hyperglycemia and blood work confirms good glucose control.


•     Describe the components of a SOAP note. Describe the clinical information included in each section.
•     Translate clinical information from a patient encounter into SOAP format.

- anatomy of a SOAP note
   - Subjective: patient description            (CC, HPI, FH, PP, and relevant ROS)
   - Objective:  physician observation          (physical exam and lab diagnostics)
   - Assessment: diagnosis                      (statement of the problem, DD x / status, and clinical reasoning)
   - Plan:       intended action                (diagnostics, therapeutics, patient education, follow-up)

- subjective section
   - first sentence:    statement of relevant identifying information and PMH
      - format:              “[patient name] is a [age] y/o [gender] with a PMH significant for [relevant information]
                             who presents to the clinic today with a [duration] history of [chief concern].”

      - example:              JH is a 25 y/o female with a PMH significant for asthma,
                              who presents to clinic today with a 3 day history of increasing shortness of breath.

    - 1st paragraph:    HPI

    - 2nd paragraph:    pertinent FH, PP, and relevant ROS
                                                                             Patient, Doctor, & Society 2: NOTES (page 38 of 117)




Head and Neck Exam
The head and neck exam will not be covered for the PDS III final exam.




Office-Based Prevention
•     Describe the 4 types of prevention interventions. Know which type of intervention has the potential for the
      greatest impact in prevention of disease.

- definitions of prevention
   - primary prevention
      - definition:     measures involving asymptomatic individuals to prevent onset of a targeted condition
      - example:        routine immunization for children
   - secondary prevention
      - definition:     measures identifying asymptomatic persons with a disease (early detection)
      - example:        screening mammograms, screening flexible sigmoidoscopy
   - tertiary prevention
      - definition:     measures in symptomatic patients that prevent complications of disease
      - example:        aspirin therapy in patients with history of MI

- levels of prevention
   - root causes:             societal determinants of illness
                              - standard of living
                              - social equality
    - population illness:     public health interventions to reduce illness in populations
                              - water purification
                              - cigarette smoking bans
                              - HIV education
    - individual clinician:   intervention at the level of the physician

- types of prevention interventions
   - screening tests:       use of tests to identify asymptomatic individuals with a disease
   - counseling:            information and advice about personal behaviors (greatest potential impact)
   - immunization:          use of an agent intended to sensitize the immune system and prevent future disease
   - chemoprophylaxis:      drugs and vitamins taken by asymptomatic individuals in order to prevent disease


•     Explain the criteria for a good screening test.

- criteria for a good screening test
   - disease impact:         disease or condition must have a significant effect on the quality and quantity of life
   - treatment:              acceptable methods of treatment must be available
   - early detection:        early detection and treatment must significantly reduce mortality
   - better outcome:         persons who are detected early must have a better outcome than those not detected
                                                                              Patient, Doctor, & Society 2: NOTES (page 39 of 117)



    - accurate:              test must not produce overly large false positives and false negatives
    - feasible:              test must be available, and at a reasonable cost


•     Discuss the barriers to implementation of prevention practices.

- barriers to implementation
   - insufficient time
   - uncertainty and confusion over what to offer to patients
   - cost
   - racial and socioeconomic bias
   - office visits that concentrate only on illness
   - lack of physician training
   - skepticism of physicians about effectiveness of interventions


•     Explain the need for risk factor assessment and prioritization when practicing prevention.

- improving preventative care
   - prioritize efforts
      - risk factor profile
      - patient concern
      - leading cause of death

    - know where to find reliable preventative care guidelines
       - U.S. Preventive Services Task Force
                USPSTF Guide to Clinical Preventive Services, 3rd edition.
                Williams & Wilkins, Baltimore, MD. 2002
       - available online (2nd edition):
                http://odphp.osophs.dhhs.gov/pubs/guidecps/

    - capitalize on missed opportunities (especially with persons who have limited access to care)
       - outpatient illness visits
       - hospitalizations

    - share in decision-making about prevention interventions
       - not all patients understand risk vs. benefit in the same way
       - clinicians should explicitly acknowledge areas of uncertainty


•     List the leading causes of death by age group (from 2002 data).

- leading causes of death by age group
   - birth to 4 years:     1.) injuries (unintentional > motor vehicle)
                           2.) congenital anomalies
                           3.) malignancy
                           4.) homicide

    - ages 5-14 years:       1.)   injuries (motor vehicle > unintentional)
                             2.)   malignancy
                             3.)   homicide
                             [5]   suicide

    - ages 15-24 years:      1.) injuries (motor vehicle >> unintentional)
                             2.) homicide
                             3.) suicide
                                                                              Patient, Doctor, & Society 2: NOTES (page 40 of 117)



                             [9] HIV

    - ages 25-44 years:      1.)   injuries (motor vehicle = unintentional)
                             2.)   malignancy
                             3.)   heart disease
                             4.)   suicide
                             5.)   homicide
                             6.)   HIV

    - ages 45-64 years:      1.)   malignancy
                             2.)   heart disease
                             3.)   injuries (motor vehicle = unintentional)
                             4.)   diabetes
                             5.)   cerebrovascular disease
                             6.)   chronic respiratory disease
                             7.)   chronic liver disease / cirrhosis

    - ages 65 and older:     1.)   heart disease
                             2.)   malignancy
                             3.)   cerebrovascular disease
                             4.)   chronic respiratory disease
                             5.)   Alzheimer’s disease
                             6.)   pneumonia and influenza
                             7.)   diabetes

- source:      Table 7: Death and death rates for the 10 leading causes of death in specified age groups, National
               Vitals Statistics Report, United States, from the National Center for Health Statistics web site
               http://www.cdc.gov/nchs/


•     Recommend prevention interventions for an individual patient based on risk factors, guidelines, and patient
      preference.

See Objective 4, “Explain the need for risk factor assessment and prioritization when practicing prevention.”




Approach to a Patient with a Dermatologic Problem
•     List important history to obtain from a patient with a dermatologic concern.

- patient interview
   - history of present illness
      - duration
      - onset
         - acute vs. chronic
         - prior episodes
      - progressive vs. stable
      - localized symptoms
         - itchy
         - painful
         - burning
                                                                           Patient, Doctor, & Society 2: NOTES (page 41 of 117)



       - systemic symptoms
          - fever
          - chills
          - arthritis
    - family history
    - past medical history
       - medications
          - topical and systemic
          - OTC and prescription
       - allergies
    - social history
       - occupation and exposures
       - travel

- examination
   - general technique
      - good, natural lighting
      - magnifying lens
      - attention to patient modesty and comfort
      - selected areas examined or fully disrobed
   - purposeful close examination of involved areas
      - description of individual lesions
         - color
         - shape
         - scale +/–
         - raised or depressed
      - grouping
      - distribution and symmetry
   - examination of other contributing areas
      - pertinent positive and negative findings
      - areas to examine:
         - skin
         - hair
         - nails
         - mucous membrane


•     Describe the primary lesions included in the lecture handout.

- primary lesion: physical alteration of the skin considered to be caused directly by the disease process

- examples of primary lesions
   - macule:          circumscribed flat discoloration (size < 1 cm)
   - patch:           circumscribed flat discoloration (size > 1 cm)
   - papule:          superficial elevated solid lesion (size < 1 cm)
   - plaque:          superficial elevated solid lesion (size > 1 cm)
   - nodule / tumor: circumscribed depth, implied solid lesion (size > 1 cm)
   - vesicle:         circumscribed collection of free fluid
   - bulla:           circumscribed collection of free fluid (size > 0.5 cm)
   - pustule:         vesicle containing pus
   - wheal:           edematous, transitory plaque secondary to extravasation into the dermis
                                                                          Patient, Doctor, & Society 2: NOTES (page 42 of 117)




- papule contour
   - flat topped         (lichen planus)
   - dome-shaped         (lymphomatoid papulosis)
   - slightly elevated   (panniculitis)
   - acuminate           (acute spongiotic dermatitis)
   - papillated          (intradermal nevus)
   - digitated           (wart-like)
   - umbilicated         (molluscum contagiosum)




•   Describe the secondary lesions included in the lecture handout.

- secondary lesion: resultant effect from external factors (scratching, trauma, infection, or changes from healing)

- examples of secondary lesions
   - scale:           epidermal thickening
   - crust:           dried serum
   - fissure:         crack or split
   - erosion:         loss of epidermis (superficial)
   - ulcer:           loss of epidermis and dermis (deeper)
   - lichenification: thickening (especially epidermis) with skin line accentuation
   - scar:            thickening, fibrous tissue
   - atrophy:         loss of substance (thinning)
   - excoriation:     linear erosion
                                                                          Patient, Doctor, & Society 2: NOTES (page 43 of 117)




•   List and define the key configurations used to describe individual and grouped lesions.

- configuration: shape or morphology of lesions

- examples of configurations
   - margination:     sharp vs. ill-defined
   - circinate:       round, circular
   - arciform:        partial circle
   - annular:         round or circular with central clearing
   - iris / target:   bullseye lesions, annular with central internal activity zone
   - serpiginous:     meandering (serpent-like)
   - gyrate:          connecting arcs
   - linear:          straight
   - zosteriform:     dermatomal
                                                                        Patient, Doctor, & Society 2: NOTES (page 44 of 117)




•   List and define the key distribution patterns used to describe individual and grouped lesions.

- distribution: clinical arrangement of skin lesions

- examples of distributions
   - localized:        grouped into specific areas
   - generalized:      dispersed all over
   - symmetric:        no pattern
   - asymmetric:       pattern lacking randomness
   - discrete:         separate
   - grouped:          clustered
   - confluent:        coalescing smaller into larger
   - cleavage plane: arranged along lines of skin tension




- miscellaneous modifiers
  - verrucous:       wart-like
  - telangiectasia:  conditional dilated capillary blood
  - blanching:       press out
  - eczematoid:      dermatitis
                                                                               Patient, Doctor, & Society 2: NOTES (page 45 of 117)



    - hyperkeratotic:     thick
    - sessile:            attached directly
    - purpura:            condition characterized by extravasated blood in the skin (bruise)
    - pedunculated:       attached via a narrow neck of tissue


•     Describe the dermatologic findings (appearance, distribution, etc.) of the common disorders included in the
      lecture handout.

- acne:                   erythematous papules in a generalized distribution

- viral infections
   - verruca:             thick, “cauliflower” papules in a generalized distribution
   - herpes:              grouped vesicles; resolution may leave a crust

- bacterial infections
   - impetigo:         thick, scaly crusts
   - folliculitis:     pustules

- fungal infections
   - tinea pedis:         erythematous scale localized to the foot
   - tinea corporis:      scale on the body
   - tinea capitis:       scale localized to the scalp

- infestations
   - scabies:             papules, localized to moist areas, with secondary scales due to scratching
   - head lice:           scalp papules, with secondary scales due to scratching (Pediculus humanus var. capitis)
   - crabs:               pubic papules, with secondary scales due to scratching (Phthirus pubis)

- contact dermatitis:     clear filled vesicles or bullae with surrounding edematous skin

- genetic disorders
   - psoriasis:           thick scaly plaques
   - neurofibromatosis:   large, dispersed patches
   - Ehlers-Danlos:       hyperelasticity
   - cutis laxis:         hyperelasticity (X-linked Ehlers-Danlos syndrome)

- nevi:                   macule or patch; may be quite large

- tattoos:                patch

- skin cancers
   - basal cell:          flesh-colored papule with telangiectasis; may ulcerate
   - melanoma:            black nodule




The Cardiac Exam
•     Define the normal range for pulse rate.

- normal heart rate:      60-90 beats/minute
                                                                             Patient, Doctor, & Society 2: NOTES (page 46 of 117)



    - tachycardia:       > 100 beats/minute
    - bradycardia:       < 60 beats/minute


•     Define the postural changes in pulse and blood pressure that make a patient “orthostatic.”

- normal changes in blood pressure from lying to standing
   - heart rate:      increases 5-10 beats/minute
   - systolic BP:     decreases 5 mmHg
   - diastolic BP:    decreases 5 mmHg

- definition of orthostatic changes (lying to standing)
   - heart rate:        increases > 20 beats/minute
   - systolic BP:       decreases > 10 mmHg

    - note that either sign is sufficient for diagnosis (one need not have both changes)


•     Define bruit, murmur, and thrill. Know which arteries should be auscultated for bruits.

- bruits, murmurs, and thrills
   - bruit:           sound over a vessel (“uproar,” noise)
   - murmur:          sound across a valve
   - thrill:          palpable sensation (vibration) over a vessel or valve

- clinician should auscultate for bruits over:
   - carotid arteries
   - abdominal aorta
   - renal arteries
   - iliac arteries
   - femoral arteries


•     Describe the grading scale for pulses.

- pulse grading scale
     0: absent
     1: weak
     2: expected
     3: increased
     4: bounding


•     Describe the location of the second intercostal space and the Angle of Louis (manubriosternal angle).

- auscultatory regions of the heart
   - R 2nd intercostal space:              aortic outflow tract

    - L 2nd intercostal space:             pulmonic outflow tract

    - L 4th intercostal space:             tricuspid valve
                                           right atrium
                                           right ventricle

    - L midclavicular 5th intercostal:     mitral valve
                                           left atrium
                                                                             Patient, Doctor, & Society 2: NOTES (page 47 of 117)



                                           left ventricle
                                           aortic valve

    - axilla:                              mitral valve

    - memory device: APTM

- sternal angle: angle formed by manubrium and body of the sternum (Angle of Louis, manubriosternal joint)
   - palpable clinical landmark
   - marks approximate level of 2nd intercostal space


•     Describe the physiologic cause for S1, S2, S3, and S4. Know which abnormal conditions are associated with
      S3 and S4.

- stethoscope auscultation
   - diaphragm:        useful for hearing high sounds (firm contact on a tunable diaphragm)
   - bell:             useful for hearing low sounds (light contact on a tunable diaphragm)

- heart sounds
   - S1
      - physiology:      closure of the mitral and tricuspid valves
      - auscultation:    best heard at the apex

    - S2
       - physiology:     closure of the aortic and pulmonic valves
       - auscultation:   best heard at the base
       - clinical:       S2 splits during inspiration
                         - RV takes longer to empty
                         - LV takes less time to empty

    - S3
       - physiology:     rapid early filling of the LV
       - pathology:      heart failure
       - auscultation:   best heard at the apex, in the left lateral recumbent position (low sound)
       - clinical:       can be normal in children or those who are exercising

    - S4
       - physiology:     extra late filling of LV
       - pathology:      stiff LV (e.g. secondary to hypertensive hypertrophy)
       - auscultation:   best heard at the apex in the left lateral recumbent position (low sound)


•     Describe the location and characteristics of a normal PMI.

- point of maximal impulse (PMI)
   - definition:     point on the chest where the impulse of the left ventricle is strongest
   - interpretation: normal values
                     - location:        L 5th intercostal space, L midclavicular line (apex)
                     - intensity:       moderate
                     - duration:        brief (lasting less than systole)
                     - onset:           correlates with carotid pulse
                     - size:            < 1 cm
   - clinical:       lateral displacement suggests cardiomegaly
                     other conditions can cause displacement
                     - pleural or pulmonary diseases
                                                                            Patient, Doctor, & Society 2: NOTES (page 48 of 117)



                        - deformities of the chest wall or the thoracic vertebra


•     For the following murmurs, describe whether the murmur is heard in systole or diastole, the typical location
      and radiation.
                   • mitral regurgitation
                   • mitral stenosis
                   • aortic regurgitation
                   • aortic stenosis
                   • tricuspid regurgitation

- definitions
   - radiation: site farthest from the location of greatest intensity
   - pitch: high (diaphragm) or low (bell)

    TABLE: Auscultation of Murmurs
                             timing             location                    pitch                        radiation
     aortic stenosis         systole            base                        high (diaphragm)             carotids, LSB
     aortic regurgitation    diastole           L sternal border            high (diaphragm)             apex, RSB
     mitral stenosis         diastole           apex                        low (bell)                   ---
     mitral regurgitation    systole            apex                        high (diaphragm)             axilla
     tricuspid regurgitation systolic           L lower sternal border      high (diaphragm)             L axilla



•     Describe the grading scheme for murmurs based on a scale from I-VI.

- murmur grading scale
  - grade I:    cardiologists only
  - grade II:   quiet but immediately audible
  - grade III:  loud
  - grade IV:   loud, with faint thrill
  - grade V:    audible with scope partially off chest; easily palpable thrill
  - grade VI:   audible with scope completely off chest; visible thrill


•     Explain the significance of jugular venous pressure (JVP). Know the normal range.

- jugular venous pressure (JVP)
   - function:        indicator of right atrial pressure (an indicator of blood volume)
   - method:          raise or lower exam table until veins are visible at the mid neck
                      measure height above right atrium
                      - measure vertical difference between sternal angle and highest point of pulsation
                      - add 5 cm to approximate distance from sternum to heart
   - interpretation:  low:           < 5 cm
                      normal:        5-7 cm
                      borderline: 7-10 cm
                      high:          > 10 cm


•     Know how to differentiate between the jugular venous and carotid artery pulsation.

    TABLE: Internal Jugular vs. Carotid Artery
                                    jugular               carotid
     pulsations per heart beat        2-3                    1
                                                                           Patient, Doctor, & Society 2: NOTES (page 49 of 117)



     palpable                             no            yes
     variation with respiration         present        absent
     variation with position            present        absent



•     Define hepatojugular reflux (HJR).

- hepatojugular reflux (abdominojugular compression test)
   - function:         indicator of venous congestion and elevated RA pressure
   - method:           have patient breathe normally (false positives can occur if patient is holding breath)
                       apply firm pressure to RUQ, and watch jugular venous pressure (JVP)
                       release compression, and watch JVP
   - interpretation:   normal:       slow increase with pressure, slow decline when removing hand
                       positive:     abrupt elevation with compression, abrupt decline with release


•     Describe the typical signs and symptoms of congestive heart failure (CHF).

- congestive heart failure
   - signs
      - laterally displaced PMI
      - elevated JVP
      - S3
      - positive hepatojugular reflux
      - lower extremity edema

    - symptoms
       - exertional dyspnea
       - wheezing
       - orthopnea
       - paroxysmal nocturnal dyspnea (PND)
       - dyspnea at rest

- grading edema
   • 1+: disappears rapidly
   • 2+: disappears in 10-15 seconds
   • 3+: lasts 1 minute
   • 4+: lasts 2-5 minutes




Approach to a Patient with Palpitations
•     List important history and physical exam maneuvers for patients with palpitations.

- palpitation: awareness of the beating of the heart
   - “pounding”
   - “racing”
   - “skipping / flopping”
   - “fluttering”

- history
   - description of palpitations
                                                                              Patient, Doctor, & Society 2: NOTES (page 50 of 117)



       - occurring during activity or at rest
       - gradual vs. sudden onset / resolution
       - regular vs. irregular
       - intermittent vs. continuous
       - exacerbating, relieving factors
    - other symptoms (indicators of more serious problems)
       - dyspnea
       - chest pain
       - syncope or near syncope
    - associated problems
       - recent acute problems that may cause palpitations
       - past history of similar problem
       - past history of coronary artery / heart valve / pulmonary problems

- physical exam
   - vital signs
      - blood pressure       (supine and standing)
      - pulse:               (apical and peripheral)
   - cardiac exam
      - evaluation for vascular disease
      - evaluation for valvular disease
   - pulmonary exam


•     Based on a patient’s description of the palpitations, list the possible causes.

- no distinct onset/resolution, rapid rate:
   - exertion
   - emotion
   - drug side effect
   - fever
   - dehydration
   - pregnancy
   - stimulants (coffee, tea, tobacco, illicit drugs)

- no distinct onset/resolution, variable rate, not easily identifiable by history:
   - aortic or mitral regurgitation
   - bradycardia
   - anemia
   - hyperthyroidism

- occasional isolated palpitations:
   - premature atrial contractions
   - premature ventricular contractions

- rapid rate, sudden onset, sudden resolution:
   - irregular
      - atrial fibrillation
      - frequent atrial or ventricular contractions
   - regular
      - AV nodal reentrant tachycardia (AVNRT)
      - ventricular tachycardia (usually associated with serious symptoms)


•     List the factors that are more likely to predict an arrhythmia.
                                                                          Patient, Doctor, & Society 2: NOTES (page 51 of 117)



- factors suggestive of arrhythmia as an underlying cause
   - isolated extra beats
   - rapid beats, sudden onset, sudden resolution

- factors contraindicating arrhythmia as an underlying cause
   - undefined symptoms
   - indistinct onset and resolution


•    Identify when ambulatory monitoring and stress testing may be used to diagnose and arrhythmia.

- general diagnostic evaluation
   - with appropriate signs or symptoms:
      - hemoglobin
      - thyroid function tests
   - with risks of electrolyte loss:
      - potassium
      - calcium
   - if arrhythmia is suspected:
      - ECG (low threshold for performing ECG)

- further diagnostic evaluation
   - further testing is needed if:
      - initial evaluation suggests serious arrhythmia
      - patient is at high risk for arrhythmia
      - a further explanation is needed
   - methods
      - ambulatory monitoring
         - short term recorders (Holter)
         - long term recorders (Reveal, Loop, Event)
      - stress testing
      - electrophysiologic evaluation


•    Describe the rhythm associated with AV nodal reentrant tachycardia (AVNRT).

- AV nodal reentrant tachycardia (AVNRT)
  - pathology:        cyclic activation of the AV node
                      - AV node is lobulated, with a compact portion and several atrial extensions
                      - conduction at differing velocities places tissue at risk for reentrant mechanism
  - mechanism:        reentry
                      - premature depolarization causes conduction down slow pathway (fast pathway is refractory)
                      - conduction wave loops around, reaches end of fast pathway (no longer refractory)
                      - wave loops back up into AV node (reentry), causes another depolarization
  - presentation:     young adults:      moderate symptoms (palpitations, light-headedness, shortness of breath)
                      elderly:           more severe symptoms (syncope, angina, pulmonary edema)
  - diagnosis:        ECG: presence of a delta wave (early depolarization prior to R wave)
  - treatment:        β blocker, Ca2+ channel blocker
                      radiofrequency catheter ablation


•    Describe the rhythm associated with atrial fibrillation.

- atrial fibrillation
   - pathology:         rapid irregular atrial activity (350-600 bpm)
                        - less frequent ventricular depolarization as few atrial signals are conducted through AV node
                                                                          Patient, Doctor, & Society 2: NOTES (page 52 of 117)



                       - similar to atrial flutter, but with greater irregularity
    - mechanism:       “wandering” reentrant circuits
                       atrial ectopic focus
    - etiology:        atrial enlargement
                       HTN
                       coronary artery disease
                       alcohol intoxication
                       thyrotoxicosis
                       pulmonary disease
                       cardiothoracic surgery
    - complications:   hypotension and pulmonary congestion (secondary to ventricular tachycardia)
                       stroke (secondary to atrial blood stasis, clot formation, and embolus)
    - diagnosis:       ECG: chaotic atrial activity without organized P waves; irregularity of QRS (ventricular) rate
    - treatment:       pharmacological therapy
                       - slow ventricular rate by increasing AV block (β blockers, Ca2+ channel blockers)
                       - restore sinus rhythm with antiarrhythmic drugs
                       - utilize class IA, IC, or III antiarrhythmic drugs chronically to prevent recurrences
                       cardioversion (pharmacologic or electrical)




The Pulmonary Exam
•     Know the normal respiratory rate.

- normal respiratory rate: 14-20 breaths / minute


•     Define the following:
                   • dyspnea
                   • tachypnea
                   • hyperventilation
                   • Cheyne-Stokes respiration

- abnormal breathing patterns
   - tachypnea:        faster than 20 breaths/minute
   - hyperventilation: faster than 20 breaths/minute, with deep breathing
   - Cheyne-Stokes: varying periods of crescendo-decrescendo breathing, interspersed with apnea


•     Know which areas of the chest correspond to upper, middle, and lower lung fields.

- internal anatomy
   - right lung
      - lobes:         upper, middle, lower lobes
      - fissures:      horizontal: divides upper and middle lobes
                       oblique:     divides middle and lower lobes
    - left lung
       - lobes:        upper, lower
       - fissures:     oblique:     divides upper and lower lobes

- surface projections of the lungs
                                                                                Patient, Doctor, & Society 2: NOTES (page 53 of 117)



    - superior margin:          slightly superior to the clavicles
    - inferior margin:          rib levels 6, 8, 10     (at mid-clavicular, mid-axillary, para-vertebral lines)
    - pleural reflections:      rib levels 8, 10, 12    (at mid-clavicular, mid-axillary, para-vertebral lines)

    - oblique fissures:         5th intercostal space
    - horizontal fissure:       deep to 4th rib (R 4th costochondral junction to R 5th intercostal space)


•     Define tactile fremitus and know in which pathologic states this is increased and decreased.

- tactile fremitus
   - method:                patient says “ninety-nine” in a normal voice
                            physician palpates symmetrical areas of the posterior thorax simultaneously (ball of hand)
    - interpretation:       vibrations should be palpable
                            - increased: suggests consolidation
                            - decreased: suggests COPD / emphysema
                            - absent:     suggests pleural effusion, pneumothorax
    - mechanism:            with consolidation, sound not dispersed as deeply into the lungs, so vibration increases


•     Define egophony and whispered pectoriloquy and know in which pathologic states they are present.

- egophony
   - method:                patient repeatedly says “ee”
                            physician auscultates and compares symmetrical areas of the R and L thorax
    - interpretation:       normal:       muffled “ee” sound
                            positive:     muffled “ay” sound (suggests consolidation)
    - mechanism:            with consolidation, sound not dispersed as deeply into the lungs, so vibration increases

- whispered pectoriloquy
  - method:           patient repeatedly whispers “ninety-nine”
                      physician auscultates and compares symmetrical areas of the R and L thorax
  - interpretation:   normal:       faint sounds
                      positive:     amplified or relative clarity in a certain area (suggests consolidation)
  - mechanism:        with consolidation, sound not dispersed as deeply into the lungs, so vibration increases


•     Discuss the physical findings related to inspection, palpation, percussion, and lung auscultation of patients
      with the following conditions:
                    • emphysema / COPD
                    • large pleural effusion
                    • pneumonia / consolidation
                    • pneumothorax

- pneumothorax
   - inspection:            ↑ volume on involved side
   - palpation:             absent tactile fremitus
   - percussion:            ↑ resonance
   - auscultation:          ↓ breath and vocal sounds
   - radiology:             absence of lung markings, outline of lung on radiolucent field

- large pleural effusion
   - inspection:        ↓ expansion on inspiration
   - palpation:         absent tactile fremitus
   - percussion:        dullness
   - auscultation:      absent breath and vocal sounds in lower part of percussible dullness
                                                                              Patient, Doctor, & Society 2: NOTES (page 54 of 117)



    - radiology:           opacification form the base upward, often with meniscus-shaped upper margin

- pneumonia
   - inspection:           ↓ expansion on inspiration
   - palpation:            ↑ tactile fremitus
   - percussion:           dullness
   - auscultation:         bronchial breath sounds, crackles, egophony, whispered pectoriloquy
   - radiology:            opacification

- emphysema / COPD
   - inspection:   ↑ AP diameter (“barrel-chested”), use of accessory muscles
   - palpation:    ↓ rib cage movement, ↓ tactile fremitus
   - percussion:   ↑ resonance, ↓ diaphragm movement
   - auscultation: ↓ breath sounds, ↓ heart sounds, prolonged expiration, wheezes
   - radiology:    radiolucent lung fields, widened intercostal spaces, narrow and elongated mediastinum




Approach to a Patient with Chest Pain
•     Develop a differential diagnosis for chest pain / discomfort.

- cardiovascular
   - myocardial infarction:             severe, constant, crushing pain, nausea, diaphoresis, dyspnea, radiation
   - angina pectoris:                   pressure, squeezing, tightness
   - myocarditis / pericarditis:        sharp, pleuritic pain, associated with change in position, recent illness
   - aortic dissection / aneurism:      severe, sudden onset, radiation to back, hypotension, syncope

- pulmonary
   - pneumothorax:                      sharp, constant, pleuritic pain, often with dyspnea
   - pulmonary embolus:                 pleuritic pain, dyspnea, symptoms of diaphoresis, “sense of doom”
   - pneumonic process:                 constant, mild to sharp boring pain, dyspnea, fever, sweats, fatigue
      - pneumonia
      - abscess
      - neoplasm

- gastrointestinal
   - reflux esophagitis:                burning pain in chest, acid taste in mouth, often associated w/ meals or laying
   - esophageal spasm:                  sharp pain, intermittent; pain on swallowing

- musculoskeletal
  - costochondritis:                    sharp, constant, pleuritic, reproduced by palpitation
  - rib fracture:                       sharp, pleuritic, tender to touch at site of fracture
  - herpes zoster:                      intense pain, radiates in “band,” unilateral (dermatomal)
  - muscular / ligament strain:         localized pain, worse with inspiration or movement, may be palpable

- psychogenic
   - hyperventilation:                  anxiety, sharp, difficulty in deep breath, numbness / tingling in hands and mouth


•     Elicit a history for acute chest pain and describe the typical history of angina.
                                                                             Patient, Doctor, & Society 2: NOTES (page 55 of 117)



- major characteristics of angina pectoris
  - quality:      vague pressure, squeezing, tightness
  - exertion:     consistent relationship to activity
  - duration:     lasts 30 seconds to a few minutes
  - radiation:    radiation to arms, neck, and jaw
  - associated: nausea, indigestion, sweating, palpitations, dyspnea

- positive (+) and negative (–) signs of angina pectoris: patient description
   - patient descriptions
        (+) “It felt like an anvil / elephant / piano / Liza Minnelli sitting on my chest”
        (+) “It’s not really a pain, more a discomfort”
        (+) “Whenever I walk up a certain hill, I get this pressure or tightness.”
        (–)    “It’s a sharp pain – right here. I can never tell when it’s going to hit me.”
        (–)    “It lasts 1-2 seconds.”

    - other factors
         (+) other known cardiac or vascular disease
         (+) relief of pain with nitroglycerin
         (+) cardiovascular disease risk factors
         (+/-) associated with emotional stress
         (–)    sharp, lasting only seconds (or minutes to hours), even if resting
         (–)    changes with position (increase with lying down suggests pericarditis)
         (–)    increased with deep breath, cough (suggests pleural or pericardial irritation, musculoskeletal)
         (–)    reproduced with chest wall pressure (suggests costochondritis)

- relevant questions
   - “Describe your current chest pain or discomfort to me.”
   - “Does this pain or discomfort limit your activity?”
   - “How long have you been having this discomfort?”
   - “How long does an episode of discomfort last”
   - “What causes the pain / discomfort?”
   - “What else relieves the pain / discomfort?”
   - What else do you notice during the pain / discomfort? Other symptoms?”

- definitions
   - stable angina: reproducible, usually exertional angina reproducible with the same stimulus; predictable
   - unstable angina: new onset, angina at rest, or accelerated angina; unpredictable
   - myocardial infarction: cardiac ischemia that results in significant myocardial cell death
   - acute coronary syndrome (ACS): unstable angina and myocardial infarction (plaque rupture with ischemia)


•     Elicit a and integrate a history of cardiovascular risk factors into a medical interview.

- cardiovascular disease risk factors
   - age
   - gender
   - family history
   - sedentary lifestyle
   - hypertension
   - smoking
   - cholesterol disorders
   - obesity
   - diabetes mellitus

- interview for a risk factor history
   - smoking
                                                                            Patient, Doctor, & Society 2: NOTES (page 56 of 117)



      - “Do you use any form of tobacco? How much, how long?”
      - “Are you exposed to secondhand smoke in your home or workplace?”
      - “Are you interested in stopping the use of tobacco?”

    - family history
       - “Do any of your close relatives (parents, siblings, grandparents, children) have heart disease?”
       - cause and of relatives’ deaths
       - cardiac diseases and symptoms (include age of onset)
       - risk factors for the disease

    - exercise / physical activity
       - “Do you exercise?”
       - “How much and how often?”
       - “Does your work involve physical labor?”
       - “How many years have you been physically active / not active?”

    - diabetes mellitus
       - “Has anyone ever told you that you have high blood sugar or diabetes?”
       - “Are you aware if you have ever had a blood test done to screen for diabetes?”
       - “Is there someone in your family that has DM?”
       - “Have you recently developed excessive thirst or urination?”

    - high blood pressure
       - “Were you ever told that you have high blood pressure?”
       - “Have you ever been on high blood pressure medication?”
       - “Is there any close family member with high blood pressure?”
       - ask about other risk factors: salt intake, NSAIDS, steroids, alcohol, weight loss supplements

    - dyslipidemia
       - “Do you know your blood cholesterol levels?”
       - “When was the last time you had your cholesterol levels checked?”
       - “Is there a close family member who has abnormal cholesterol levels? What kind? Are they being treated?”
       - “Have you ever been on a special diet or medication for your cholesterol?”

    - nutrition/obesity
       - “Have you had any recent weight loss or gain?”
       - “What is your goal weight?”
       - “Are you on a special nutritional plan, program, or diet?
       - “Who cooks and shops for your meals? What percent of meals are eaten outside the home?”
       - “What is a typical 24 hour pattern of food intake?”

    - stress, depression, and behavioral factors
       - “Do you feel that you are under a significant amount of stress? Why?”
       - “Do you ever feel that you are depressed, sad, or lose interest in life activities?”
       - “Do you have difficulty sleeping?
       - “Have you ever received treatment or counseling for depression?”
       - “Do you find it difficult to relax?”
       - “Do you often feel rushed, pressured by time, or angry about those who take too long to do things?”


•     Describe the signs and symptoms of congestive heart failure (CHF).

- congestive heart failure
   - symptoms
      - exertional dyspnea
      - wheezing
                                                                          Patient, Doctor, & Society 2: NOTES (page 57 of 117)



      - orthopnea
      - paroxysmal nocturnal dyspnea (PND)
      - dyspnea at rest

    - signs
       - laterally displaced PMI
       - elevated JVP
       - S3
       - positive hepatojugular reflux
       - lower extremity edema


•     List the signs and symptoms of peripheral arterial insufficiency.

- peripheral arterial insufficiency (claudication)
   - symptoms
      - exercise-induced cramping
      - reduction of pain with cessation of exercise

    - signs
       - femoral bruits
       - diminished peripheral pulses
       - cold or cool feet, pallor
       - poor capillary refill
       - other cardiac risk factors
          - smoking
          - hyperlipidemia
          - diabetes mellitus


•     List cardiovascular disease risk factors and know how to ask about them.

- major risk factors of CHD
  - age:                   male > 45 years old, female > 55 years old
  - family history         male relative <55 years old, female relative < 65 years old
  - hypertension:          systolic BP > 140; diastolic BP > 90
  - diabetes mellitus:     3-5x increased risk of suffering a major CV event
  - tobacco smoking:       increased risk; effects last 1-2 years
  - dyslipidemia:          high total cholesterol:      > 200 mg/dL
                           high TG:                     > 150 mg/dL
                           high LDL-C:                  based on risk factor guidelines
                                                        - no major factors:                             >160 mg/dL
                                                        - 10-20% risk, no known vasc. disease:          >130 mg/dL
                                                        - 20% or more, no known vasc. disease:          >100 mg/dL
                                                        - 20% or more, with known CVD/PVD:              >70 mg/dL
                           reduced HDL levels:          < 40 mg/dL

- contributing factors
   - male gender
   - early menopause
   - family history of CHD (males < 55, females < 65)
   - hs-CRP
   - high triglycerides
   - high homocysteine
   - high lp(a)
   - obesity
                                                                          Patient, Doctor, & Society 2: NOTES (page 58 of 117)



    - glucose intolerance
    - sedentary lifestyle
    - renal failure
    - inflammatory conditions
    - depression
    - emotional stress
    - diagonal ear lobe creases




Evidence-Based Medicine: Therapy
- answering clinical questions
   - consider your past experience
   - ask colleagues
   - go to an online database
   - use a textbook

- when evidence is necessary
  - new therapy or diagnostic test
  - internet or media claims
  - controversial issue

- barriers to EBM
   - quicker to ask a colleague or look at an online database
   - easy to rely on expert opinion
   - many clinical questions lack evidence
   - fear that “evidence” will take the place of patient choice and common sense


•     Describe the steps to EBM.

- steps of EBM
   - define:            define clinical questions that can be answered using evidence-based resources.
   - find:              effectively and efficiently find evidence
   - assess:            assess the meaning and results of your search
   - apply:             apply the answers to patient care
   - communicate:       communicate evidence to patients


•     Formulate a clinical question in PICO format from a patient scenario.

- PICO format
   - P: patient / problem
   - I: intervention
   - C: comparison
   - O: outcome

- example PICO questions
   - P: In women with breast cancer,
   - I: does the use of chemotherapy and surgery
   - C: compared to surgery alone
                                                                            Patient, Doctor, & Society 2: NOTES (page 59 of 117)



    - O:   result in improved survival?

    - P:   In a woman with osteoporosis,
    - I:   does raloxifene
    - C:   compared to no medicine
    - O:   result in reduced vertebral fractures?


•     Recognize types of clinical questions.

- types of clinical questions
   - diagnosis:         How do I diagnose what my patient has?
   - prevention:        How can a certain outcome be prevented?
   - therapy:           Will this treatment make my patient better?
   - prognosis:         What will happen?
   - harm:              Is this harmful to my patient


•     Assess evidence for validity.

- validity questions
   - randomization:      Was the assignment of patients to treatment randomized?
   - follow-up:          Was follow-up sufficiently long and complete?
   - analysis:           Were patients analyzed in the groups to which they were randomized (intention to treat)?
   - blinding:           Were physicians and patients kept “blind” to treatment?
   - treatment:          Were groups treated equally apart from the experimental therapy?
   - equivalence:        Were groups similar at the start of the trial?

- definitions
   - randomized controlled trial: longitudinal, prospective, experimental trials preceded by randomization
   - randomization: random allocation of subjects to control and experimental groups
   - intention to treat: analysis based on originally assigned group, regardless of group at the end


•     Differentiate between unblinded, single, and double blinding in studies.

- types of blinding
   - double-blinded:     both subject and physician are unaware of subject’s group (control or experimental)
   - single-blinded:     subject is unaware of group assignment, but physician is aware
   - unblinded:          both subject and physician are aware of subject’s group


•     Derive and interpret RR, ARR/ABI, RRR/RBI, and NNT.

- absolute risk (AR / incidence)
   - definition:        risk of an event in a given group (incidence)
                                     number of events
   - calculation:       incidence 
                                      number in group

- relative risk (RR)
   - definition:         incidence in one group compared to the other
                                   I
    - calculation:        RR  control         | risk of control therapy relative to experimental therapy
                                I experim ent
                                            al
                                                                                       Patient, Doctor, & Society 2: NOTES (page 60 of 117)



                               I experiment
                        RR 
                                          al
                                                          | risk of experimental therapy relative to control therapy
                                 I control

- absolute risk reduction (ARR)
   - definition:       difference in incidence between control and experimental treatment
   - calculation:       ARR  I control  I experim ent
                                                      al

    - implications:     substantial differences in baseline risk can substantially alter ARR

- relative risk reduction (RRR / efficacy)
   - definition:        reduction in risk of the experimental treatment relative to the control treatment
                                   I control  I experiment
   - calculation:       efficacy 
                                                          al

                                            I control

- number needed to treat (NNT)
   - definition:      number of experimental treatments to prevent a single adverse outcome (relative to control)
   - calculation:              1           1
                      NNT        
                                ARR            I control  I experim ent
                                                                       al

    - implications:     inverse proportion
                        - if ARR is small, NNT is large
                        - even large RR reductions can be quite insignificant if the risk was small to begin with

- definitions
   - relative benefit increase (RBI):             similar to RRR, but calculates probability of a good event
   - absolute benefit increase (ABI):             similar to ARR, but calculates probability of a good event

    - these equations are used when the experimental treatment increases the probability of a good event


•     Describe the limitations of using intermediate end points.

- intermediate end points: use of intermediate outcomes as markers for final outcomes
   - examples
      - coronary artery luminal diameter… as a measure of cardiac events
      - score on a dementia scale…             as a measure of decreased rates of nursing home placement
      - peak flow rates…                       as a measure of rates of ER visits or hospitalizations
   - limitations
      - intermediate end points do not always correlate with final outcomes
      - reliance on too substantial a jump between end point and outcome can lead to poor clinical decision making


•     Interpret confidence intervals and p values. Know when a result is statistically significant.

- P-value
   - definition:        assuming the null hypothesis is true, probability of finding a difference as large or larger
   - interpretation:    small P values suggest a high likelihood that events are not due to chance
   - clinical:          statistical significance:  defined as P ≤ 0.05

- confidence interval
   - definition:      range within which the “true” population value likely is (vs. the experimental results)
   - interpretation:  “For 95% CI, I am 95% confident that the true value is within this range.”
   - clinical:        CI for RR that includes 1:                  not statistically significant
                      CI for RRR, ARR, or ABI that include 0:     not statistically significant

•     Apply therapy evidence to patients.
                                                                             Patient, Doctor, & Society 2: NOTES (page 61 of 117)




- questions regarding application to the patient
   - “How is my patient similar to/different from the study population? Is this significant?”
   - “Is the treatment available and affordable to my patient?”
   - “What is my patient’s potential benefits and harms from the therapy?”
   - “Based on this evidence, what should I recommend?”




Evidence-Based Medicine: Diagnosis
    FIGURE: Clinical Spectrum and Usefulness of Diagnostic Tests

       Don’t test or treat                   Test, then treat based on the results                      Don’t test, TREAT

     0%                      ?                                                                      ?                    100%

    - implications
       - for certain illnesses, testing does not affect clinical situations, and should not be done
       - diagnostic testing (and EBM) is useful only when it will move towards one or the other decision


•     Develop a PICO question from a clinical scenario.

- PICO format
   - P: patient / problem
   - I: intervention
   - C: comparison
   - O: outcome

- example PICO questions
   - P: In women with breast cancer,
   - I: does the use of chemotherapy and surgery
   - C: compared to surgery alone
   - O: result in improved survival?

    - P:   In a woman with osteoporosis,
    - I:   does raloxifene
    - C:   compared to no medicine
    - O:   result in reduced vertebral fractures?


•     Given an article studying a diagnostic test, be able to assess the study’s validity:
                   • identify the study’s reference (or gold) standard
                   • recognize whether a study compares results to a reference standard
                   • determine whether the test was evaluated in an appropriate spectrum of patients
                   • determine whether results of the test influenced the decision to perform the reference standard

- reference standard: diagnostic method to which the experimental method is compared
- gold standard: method recognized as the current standard diagnosis

- steps of EBM
                                                                             Patient, Doctor, & Society 2: NOTES (page 62 of 117)



    - define:            define clinical questions that can be answered using evidence-based resources.
    - find:              effectively and efficiently find evidence
    - assess:            assess the meaning and results of your search
    - apply:             apply the answers to patient care

- assessment
   - validity:           likelihood of the results to be valid
                         - Was there an independent blind comparison to a reference standard?         (obligatory “yes”)
                         - Was the test evaluated in an appropriate spectrum of patients?             (obligatory “yes”)
                         - Was the reference standard applied regardless of the test result?          (recommended)
                         - Was the test validated in an second, independent group of patients?        (optional)

    - importance:        actual results and their applicability to the patient
                         - Can this test distinguish patients with and without the diagnosis?
                         - Do these results make a sufficient distinction to be useful for my patient?


•     Given an article studying a diagnostic test, be able to interpret the results:.
                   • define likelihood ratio, pretest probability, and posttest probability
                   • identify significant or important likelihood ratios


    TABLE: Derivation of Validity-Testing Equations (Sensitivity, Specificity, PPV, and NPV)
                    disease                   non-disease
     test (+)                   a                         b                         a
                                                                            PPV 
                            (true +)                  (false +)                   ab
     test (–)                   c                         d                         d
                                                                            NPV 
                            (false –)                  (true –)                   cd
                                          a                          d                           ac
                         sensitivity               specificity                prevalence 
                                         ac                        bd                        abcd


definitions and quantitation of validity testing
- prevalence
   - definition:     proportion of a given population who has a disease
   - quantitation:                   ac
                     prevalence 
                                          abcd


- pretest and posttest probability
   - pretest probability:   prior to performing a diagnostic test, the probability a patient has a diagnosis
   - posttest probability: subsequent to performing a diagnostic test, the probability a patient has a diagnosis


- sensitivity and specificity
   - sensitivity
      - definition:     probability of a positive test result in patients who have a disease
      - quantitation:                 a
                        sensitivity 
                                          ac
    - specificity
       - definition:     probability of a negative test result in patients who do not have a disease
       - quantitation:                     d
                          specificity 
                                          bd
                                                                             Patient, Doctor, & Society 2: NOTES (page 63 of 117)



- predictive value: the probability that the test result accurately reflects disease status
   - positive predictive value
      - definition:      of the people that test positive, the proportion of those that have the disease
      - quantitation:             a
                         PPV 
                                ab

  - negative predictive value
     - definition:     of the people that test negative, the proportion of those that do not have the disease
     - quantitation:            d
                       NPV 
                                cd


- likelihood ratio: likelihood of a test result in patients with vs. without the disorder
   - positive likelihood ratio (LR+)
      - definition:      likelihood of positive test result in diseased individuals compared to non-diseased individuals
      - quantitation:              sensitivity
                         (LR  ) 
                                 1  specificit y
  - negative likelihood ratio (LR–)
     - definition:     likelihood of negative test result in non-diseased individuals compared to diseased individuals
     - quantitation:            1  sensitivity
                       (LR ) 
                                  specificit y

interpreting validity testing

  TABLE: Effect of Changing Prevalence on Validity Testing
                                      PPV               NPV                  effect on results
   with increasing prevalence…          ↑                 ↓                  positive results more informative
   with decreasing prevalence…          ↓                 ↑                  negative results more informative


  TABLE: Effect of Sensitivity and Specificity on Validity Testing
                                        false tests           LR 1         effect on results
    sensitive, but not specific test   high false +         low LR+        negative result more informative
                                                            low LR –
    specific, but not sensitive test   high false –         high LR+       positive result more informative
                                                           high LR –
  1
    recall that a low value for LR– suggests a better negative predictive value


  TABLE: Effect of Likelihood Ratios on Validity Testing
                                         posttest probability                effect on results
   high LR+ test, (+) result           dramatically increased                positive result more informative
   low LR– test, (–) result            dramatically decreased                negative result more informative


  TABLE: Usefulness of Likelihood Ratios
                          LR+          LR –
   conclusive             > 10         < 0.1
   moderately helpful     5-10        0.1-0.2
   possibly helpful       2-5         0.2-0.5
   not helpful            1-2         0.5-1.0
                                                                              Patient, Doctor, & Society 2: NOTES (page 64 of 117)



•     Given an article studying a diagnostic test, be able to apply the results to the patient:
                   • given a pretest probability, be able to use the likelihood ratio to identify a posttest probability
                   • using the likelihood ratio, decide whether to test further, treat, or do nothing

- use of likelihood ratios: conversion chart
   - structure:         left side:     pretest probability
                        middle:        likelihood ratio (LR+ and LR–)
                        right side: posttest probability
   - method:            using a straightedge, line up pretest probability and the likelihood ratio of the given patient
                        the line will intersect the posttest probability
   - interpretation:    may or may not affect treatment decision based on subjective thresholds


    FIGURE: Clinical Spectrum and Usefulness of Diagnostic Tests

       Don’t test or treat                    Test, then treat based on the results                      Don’t test, TREAT

     0%                      ?                                                                       ?                    100%




SMALL GROUP:
    Musculoskeletal Exam I and II
•     Know the components of a systematic musculoskeletal (MSK) exam

- systematic musculoskeletal exam
   - inspection
   - palpation
   - range of motion
   - strength
   - laxity
   - special maneuvers


•     Understand and be able to perform all elements of the musculoskeletal exam, including:
                  • shoulder exam
                  • elbow exam
                  • wrist / hand exam
                  • spinal exam
                  • hip exam
                  • knee exam
                  • ankle / foot exam

- shoulder exam
   - inspection: shoulder girdle

    - palpation:    sternoclavicular joint
                    acromioclavicular joint
                                                                               Patient, Doctor, & Society 2: NOTES (page 65 of 117)



                   subacromial space
                   biceps groove and tendon

  - ROM:           active range of motion
                   - flexion / extension
                   - abduction / adduction
                   - external / internal rotation

  - strength:      muscles of the rotator cuff
                   - empty can test                      (supraspinatus pathology)
                   - external rotation                   (infraspinatus, teres minor pathology)
                   - internal rotation                   (subscapularis pathology)

  - laxity:        apprehension test                     (forward dislocation)

  - special:       Neer test                             (rotator cuff tear, impingement syndrome)
                   Hawkins test                          (rotator cuff tear, impingement syndrome)

- elbow exam
   - inspection:   elbow
                   - medial epicondyle
                   - lateral epicondyle
                   - olecranon process
                   - lateral / medial joint lines

  - palpation:     medial epicondyle
                   lateral epicondyle
                   olecranon process
                   lateral and medial joint line

  - ROM:           active range of motion
                   flexion / extension
                   pronation / supination

  - strength:      flexion / extension

  - laxity:        -----

  - special:       wrist flexion                         (medial epicondylitis)
                   wrist extension                       (lateral epicondylitis)

- wrist / hand exam
  - inspection: wrist and hand
                  - thenar atrophy
                  - CPC enlargement

  - palpation:     snuffbox                              (scaphoid fracture)
                   wrist
                   MCP, PIP and DIP joints

  - ROM:           active ROM
                   - wrist flexion / extension
                   - ulnar / radial deviation of wrist
                   - fist grip
                   - thumb flexion / extension
                   - thumb abduction / adduction
                                                                             Patient, Doctor, & Society 2: NOTES (page 66 of 117)



                   - thumb opposition

  - strength:      grasp
                   finger abduction
                   thumb abduction
                   wrist flexion / extension
                   ulnar / radial deviation

  - laxity:        -----

  - special:       Tinel (tapping)                        (carpal tunnel syndrome)
                   Phalen (flexion)                       (carpal tunnel syndrome)
                   Finkelstein (stretching)               (DeQuervain’s tenosynitis)

- spinal exam
   - inspection:   alignment
                   - scoliosis, kyphosis, lordosis
                   - leg length

  - palpation:     spinous processes
                   sacroiliac joints
                   paraspinal musculature

  - ROM:           active ROM of neck
                   - flexion / extension
                   - rotation
                   - lateral bending
                   active thoracolumbar ROM
                   - flexion / extension
                   - rotation
                   - lateral bending

  - laxity:        ---

  - special:       Spurling maneuver                      (cervical radiculopathy)
                   straight leg raise                     (lumbosacral radiculopathy)
                   Patrick’s (FABER) test                 (hip or sacroiliac joint pathology)
                   femoral stretch test                   (upper lumbar radiculopathy)

- hip exam
   - inspection:   gait

  - palpation:     trochanteric bursa
                   anterior superior iliac spine (ASIS)

  - ROM:           passive range of motion
                   - flexion
                   - abduction / adduction
                   - external / internal rotation

  - strength:      abduction / adduction
                   flexion / extension

  - laxity:        -----

  - special:       -----
                                                                         Patient, Doctor, & Society 2: NOTES (page 67 of 117)




- knee exam
   - inspection:   knee

    - palpation:   tibial tuberosity
                   patellar tendon and patella
                   medial femoral condyle, joint line, MCL
                   lateral femoral condyle, joint line, LCL
                   fibular head (lateral joint space)

    - ROM:         active range of motion
                   - flexion / extension

    - strength:    flexion / extension

    - laxity:      valgus stress                      (MCL integrity)
                   varus stress                       (LCL integrity)
                   Lachman / anterior drawer          (ACL integrity)

    - special:     McMurray test:                     medial / lateral meniscal tear

- ankle / foot exam
   - inspection: ankle / foot

    - palpation:   lateral ligaments (ATF, CF, PTF)
                   medial ligament (deltoid)
                   anterior ankle joint
                   lateral / medial malleolus
                   proximal 5th metatarsal head
                   navicular bone
                   Achilles tendon
                   plantar fascia insertion site      (medial calcaneal tuberosity)
                   MTP joints

    - ROM:         active ROM
                   - plantar flexion / dorsiflexion
                   - inversion / eversion

    - laxity:      drawer test                        (anterior talofibular ligament)

    - special:     squeeze test                       (Achilles tendon rupture)


•     Know differential diagnoses for shoulder pain and anterior knee pain

- DDx: shoulder pain
  - cervical spondylosis
  - bursitis
  - tendinitis
  - osteoarthritis
  - rheumatoid arthritis
  - trauma
  - frozen shoulder
  - pneumothorax
                                                                       Patient, Doctor, & Society 2: NOTES (page 68 of 117)



    - gout
    - nerve damage
    - tumor

- DDx: anterior knee pain
  - osteoarthritis
  - bursitis
  - rheumatoid arthritis
  - gout
  - nerve damage
  - tendinitis
  - lumbar (intervertebral) disk disorders
  - endocarditis
  - Lyme disease




SMALL GROUP:
    Cardiopulmonary Exam I
•     Demonstrate proper draping technique for the chest exam.

- proper draping technique
   - manipulate the gown to leave breasts covered
   - manipulate the blanket to leave legs covered
   - don’t leave ‘em nekkid


•     Find the Angle of Louis (manubriosternal junction) and know which rib articulates at this point. Know how
      to count intercostal spaces.

- sternal angle (Angle of Louis, manubriosternal joint): angle formed by manubrium and body of the sternum
   - palpable clinical landmark
   - denotes approximate level of 2nd costal cartilage

- counting intercostal spaces
   - method:      correspond to the above rib
   - example:     2nd space is between the 2nd and 3rd rib


•     Know the components of a systematic cardiopulmonary exam

- systematic musculoskeletal exam
   - inspection
   - palpation
   - percussion
   - auscultation
   - advanced testing


•     Understand and be able to perform all elements of the cardiopulmonary exam, including:
                                                                            Patient, Doctor, & Society 2: NOTES (page 69 of 117)



                     • vital signs
                     • pulmonary exam
                     • neck exam
                     • cardiac exam
                     • vascular exam

- vital signs
   - pulse rate
   - blood pressure
   - respiratory rate

- pulmonary exam
   - posterior thorax
      - inspection:         expansion, symmetry, chest wall deformity
      - palpation:          symmetry
      - percussion:         resonance
      - auscultation:       presence, quality, intensity, abnormalities (rales, rhonchi, pleural friction rubs)

  - anterior thorax
     - inspection:          asymmetry, masses, respiratory effort
     - auscultation:        presence, quality, intensity, abnormalities (rales, rhonchi, pleural friction rubs)

  - advanced testing:
     - tactile fremitus:    can suggest lung pathology
     - egophony:            suggests consolidation
     - pectoriloquy:        suggests consolidation

- neck exam
   - inspection:            identify jugular venous pulse
   - testing:               estimate jugular venous pressure (JVP)
                            test for hepatojugular reflux
  - palpation:              carotid arteries
  - auscultation:           carotid arteries (bruits)

- cardiac exam
   - inspection:            precordium (visible movement)
   - palpation:             point of maximal impulse (PMI)
   - auscultation:          major auscultatory areas
                            - identify S1 and S2
                            - know which valve is best heard at each auscultatory area
                            - describe the I-VI murmur grading scheme

- vascular exam
  - palpation:              aorta
  - auscultation:           aorta (bruits)
                            renal arteries (bruits)
  - palpation:              peripheral pulses
                            - brachial
                            - radial
                            - femoral (also auscultate for bruits)
                            - popliteal
                            - posterior tibial
                            - dorsalis pedis
                                                                       Patient, Doctor, & Society 2: NOTES (page 70 of 117)




Promoting Commitment to Healthy Behaviors
                                                                                                     January 9th, 2007

    TABLE: Importance of Addressing Unhealthy Behaviors
      cause of death                    incidence
      tobacco use                        400,000
      diet and exercise                  300,000
      alcohol use                        100,000
      firearms use                        35,000
      sexual practices                    30,000
      motor vehicle crashes               25,000
      other drug use                      20,000
      TOTAL                              910,000
    - data is from 1990

- the importance of addressing unhealthy behaviors in medical practice
   - in 1990, there were 2.1 million deaths in the United States
   - including nonadherence to medication, as well as deaths above, ~50% of deaths are due to unhealthy behaviors


•    Recall concepts on stages of change and motivational interviewing from the PDS-1 Tobacco Intervention
     Basic Skill (TIBS).
•    Apply these concepts for patients engaging in a wide variety of unhealthy behaviors.

stages of readiness to change
- pre-contemplation
   - definition:      not considering change
   - goal:            move to contemplation; consider change
   - barriers:        lack of knowledge of risks or consequences
                      lack of self- efficacy
                      contentment

- contemplation
   - definition:      ambivalent about change
   - goal:            move to determination; promote commitment to change
   - barriers:        lack of knowledge of risks / consequences
                      lack of self efficacy
                      contentment
                      indecisiveness

- determination / preparation
   - definition:      firmly committed to change within one month
   - goals:           design a plan for change and move to action
   - barriers:        loss of commitment
                      knowledge of options for change
                      making decisions about plans for change

- action
   - definition:      engaged in change
   - goals:           optimize plans, maintain changes
   - barriers:        failure and disillusionment
                                                                           Patient, Doctor, & Society 2: NOTES (page 71 of 117)



                      overconfidence

- maintenance
  - definition:       continuing change which is well-learned, but with risk of relapse
  - goals:            stable, new lifestyle, with attainment of original goals
  - barriers:         risk of relapse through:
                      - major stress
                      - major loss
                      - failure to identify or satisfy the initial reasons for change

- relapse
   - definition:      resumption of undesired behavior
   - goals:           identify relapse
                      reframe as opportunity to learn
                      restage
  - clinical:         remember that relapse is a normal, expected stage of behavior change

- termination
   - definition:      firmly entrenched in new lifestyle, with very low risk of relapse
   - goals:           maintain termination
   - clinical:        only 15% of nicotine or alcohol-dependent patients reach termination

  BOX: Important Principles of Readiness to Change
    • listen past “should” and get more information on what a patient actually wants to do
    • change need not imply complete absence of behavior



principles of motivational interviewing
- advice:             give advice only when patient will be receptive
                      target advice to stage of change

- barriers:           decrease the barriers to change
                      - bolster self-efficacy
                      - address logistical barriers

- choice:             remember that it is the patient’s choice on whether to change, and how to do it

- ↓ desirability:     help individuals:
                      - decrease their perceptions of the desirability of the behavior
                      - identify other behaviors to replace the positives

- empathy:            show understanding and compassion towards patients
                      - difficulty of changing behaviors
                      - pain of engaging in behaviors they would like to change

- feedback:           ensure that patients are aware of:
                      - risks of the unhealthy behavior
                      - consequences relevant to the patient

- goals:              in light of their goals for the future, help individuals weigh:
                      - pros and cons of their behavior
                      - pros and cons of changing their behavior

- helping:            without assuming responsibility, extend yourself and show you care
                                                                            Patient, Doctor, & Society 2: NOTES (page 72 of 117)




    BOX: Principles of Motivational Interviewing
     • advice:           give advice when patient will be receptive
     • barriers:         decrease the barriers to change
     • choice:           remember that it is the patient’s choice
     • ↓ desirability:   decrease desirability and identify replacement behaviors
     • empathy:          show understanding and compassion towards patients
     • feedback:         ensure that patients are aware of risks and consequences
     • goals:            help individuals weigh pros and cons of behaviors
     • helping:          without assuming responsibility, show you care



process of motivational interviewing
- motivational interviewing
  - ask:               ask about the negative behavior
                       - ask / determine the type, quantity, and history
                       - determine stage or readiness to change

    - assess:            assess commitment and barriers
                         - assess for self-efficacy
                         - examine pros and cons
                         - offer information
                         - assess for relevant goals
                         - explore for more commitment

    - assist:            assist patients committed to change
                         - reinforce commitment to change
                         - help develop or refine a plan
                         - arrange for follow-up

    BOX: Motivational Interviewing Flow Chart
     • ask:        ask about the negative behavior
     • assess:     assess commitment and barriers
     • assist:     assist patients committed to change




•     Apply additional motivational skills in promoting commitment to change unhealthy behaviors, including:
              • open-ended questions
              • summarization
              • reflective statements
              • educating about risks and consequences
              • affirmations
              • eliciting self-motivational statements
              • developing discrepancy
              • heightening discomfort
              • assessing and addressing barriers to change

- open-ended questions
   - concept:        open-ended questions are those that:
                     - call for descriptive answers
                     - encourage patients to say what is important to them
                     - elicit contextual information
                                                                            Patient, Doctor, & Society 2: NOTES (page 73 of 117)



  - importance:        the importance of open-ended questions is that they are better able to:
                       - uncover patient priorities and values
                       - avoid socially-desirable responses
  - examples:          comparison of closed and open questions
                       - closed:     “Would you like to quit smoking?”
                       - open:       “How do you feel about your smoking?”

- summarizations
   - concept:          summarizes the most important aspects of what the patient said
   - importance:       the importance of summarizing statements is that they:
                       - convey that you have listened and that you care
                       - allow a check for accuracy
                       - may aid in transitioning to another topic
  - examples:          summarizing statements include:
                       - “What you’ve said is important.”
                       - “I value what you say.”
                       - “Here are the salient points.”
                       - “Did I hear you correctly?”

- reflective statements
   - concept:           mirror what the patient just said with slightly different words
                        - do not add any meaning, interpretation, or label
                        - do not question, agree, or disagree

                        reflective listening                              not reflective listening
                        • “I hear you.”                                   • directing         • disagreeing
                        • “I’m accepting, not judging you.”               • warning           • labeling
                        • “This is important.”                            • advising          • interpreting
                        • “Please tell me more.”                          • persuading        • reassuring
                                                                          • moralizing        • questioning
                                                                          • agreeing          • withdrawing


  - importance:        the importance of reflective statements is that they are:
                       - convey understanding, interest, and empathy
                       - cover up expressions of physician emotions that might otherwise
  - examples:          drug abuse
                       - statement:      “My girlfriend gets really angry when I get stoned and pass out.”
                       - reflection:     “She gets mad when you do that.”
                       alcoholism
                       - statement:      “I’m not a pleasant drunk; I’ve really beaten people up badly.”
                       - reflection:     “You’ve hurt people when you’ve gotten drunk.”

- educating about risks and consequences
   - concept:          in educating about risks and consequences:
                       - remember that patients often have key information already
                       - avoid lectures
                       - start with open-ended question about what patients already know
                       - emphasize risks and consequences that are relevant to the patient
                       - if appropriate, offer one or two new pieces of information
                       - assess for relevance of new information
   - importance:       fundamental to patient understanding of the need to change
   - clinical:         for patients with large needs for knowledge:
                       - ask if they would like to hear more now or later
                       - schedule another visit if patient would be more receptive
                       - provide written information appropriate for age, gender, culture, and literacy
                                                                          Patient, Doctor, & Society 2: NOTES (page 74 of 117)



                       - link patients with other resources

- affirmations
   - concept:          the purposes of affirmations are to:
                       - support the patient
                       - convey respect and understanding
                       - encourage more progress
                       - help clients / patients reveal less positive aspects of themselves
    - importance:      reassurance in continuing to change behaviors
    - examples:        “I can understand how it would be difficult to give up drinking now.”
                       “You’ve accomplished a lot in a short time.”

- eliciting self-motivational statements
   - concept:            motivation is difficult
                         - physicians often have insufficient information to know how to motivate the individual
                         - this issue can be avoided by having the patient self-motivate
   - importance:         fundamental to motivation and perception of the ability to change
   - examples:           problem recognition
                         - “How has [behavior] made problems for you?”
                         - “How do you think you’ve been hurt by [behavior]?”
                         concern
                         - “What worries do you have about your [behavior]?”
                         - “What are you afraid might happen if your [behavior] continues like it is?”
                         intention to change
                         - “What might be some advantages of changing your [behavior]?”
                         - “What might be better for you if you changed your [behavior]?”
                         - “On a scale of 0-10, how important is change? …Why didn’t you say [2-3 less]?”
                         optimism
                         - “What difficult goals have you attained in the past? …How can this be applied?”
                         - “What might work for you if you decided to change your [behavior]?”
                         - “On a scale of 0-10, how confident are you? …Why didn’t you say [2-3 less]?”

- developing discrepancy
   - concept:         ask patient whether behavior helps or hinders attaining their goals
   - importance:      forces the patient to understand where current behaviors are potentially harmful
   - examples:        “Running a marathon may be difficult while smoking 5 packs a day…”
                      “You probably won’t finish medical school if you continue to smoke all that crack…”

- heightening discomfort
   - concept:         draw patients out about:
                      - the pain of engaging in behavior that interferes with their goals
                      - the pain of being “stuck” with indecision about changing
   - importance:
   - examples:        “…and hasn’t it been so difficult to have your kids see that, day after day?”
                      “…and wouldn’t you be so proud if you would be able to buy your girlfriend that ring with all
                      the money you’re saving?”


•     Discuss strategies for integrating behavioral counseling into busy medical practices.

- barriers to behavioral medicine services delivery
   - training, knowledge, and skills
   - attitudes and beliefs (physician role, stereotyping, pessimism)
   - lack of systems
   - reimbursement
   - time
                                                                            Patient, Doctor, & Society 2: NOTES (page 75 of 117)




- integrating behavioral counseling into busy practices
   - homework:         list and prioritize pros and cons of the behavior
                       list previous accomplishments and related strengths
                       list goals, and how the behavior helps or hinders each goal
   - handouts:         distribute handouts on common consequences of behaviors, and ways of change
   - staff:            utilize on-site behavioral medicine staff


•    Identify barriers to change for patients not committed to change:
              • knowledge of risk and consequences
              • lack of self efficacy
              • contentment with current behavior

barriers to change
- knowledge
   - barrier:          lack of knowledge of relevant risks or consequences of behavior
   - strategies:       assess current knowledge
                       add new information that is likely to be relevant, based on age, gender, culture, goals, values

- self-efficacy
   - barrier:          lack of self-efficacy in changing the behavior
   - strategies:       assess for previous, partial successes in changing behavior
                       assess for previous successes in other realms
                       help the patient identify how previous strengths can be applied
                       for low self-esteem, assess and treat for depression, trauma, and/or family dysfunction

- contentment
   - barrier:          lack of a sense that changing behavior is important
   - strategies:       help the patient identify important life goals
                       help the patient assess how the behavior might help or hinder them in attaining these goals




Working with Interpreters
                                                                                                        January 17th, 2007

- demographics
   - in the United States:
      - 1 in 9 is foreign born
      - 46.9 million (17.9%) speak a language other than English at home
      - 35.3 million are Latino, a growth of 58% from 1990 to 2000
   - in Dane county
      - Latino:       14,386 (3.4% of total, 150.5% increase since 1990)
      - Asian:        14,868 (3.5% of total, 71.6% increase since 1990)

legal requirements for interpreters
- Title VI of the Civil Rights Act, 1964
   - requirement:        “No person in the U.S. shall, on the basis of race, color, or national origin be excluded from
                         participation in, be denied the benefits of, or be subjected to discrimination under any
                         program or activity receiving Federal financial assistance.”
                                                                            Patient, Doctor, & Society 2: NOTES (page 76 of 117)



                       “An LEP individual is a person who is unable to speak, read, write or understand the English
                       language at a level that permits him or her to interact effectively with health and social
                       agencies and providers.”

    - implication:     with regards to limited English proficiency (LEP) individuals, Title VI prohibits:
                       - denial of services or opportunity to participate
                       - delay in delivery of services
                       - less effective services

- Americans with Disabilities Act (ADA), 1990
   - requirement:    prohibits discrimination on the basis of disability
   - implication:    deaf and hard of hearing patients have the right to a qualified sign language interpreter


•     Recognize the impact of language on the clinical interpretations and patient outcomes.
•     Recognize issues that may arise when there are language barriers.

- challenges faced by new immigrants
   - socioeconomic barriers
   - lack of exposure to preventative health care
   - lack of understanding of U.S. health care system
   - lack of health care coverage
   - language barriers

- limited English speakers report:
   - less likelihood of receiving preventive services
   - fewer physician visits
   - poorer experiences in the ED, including more problems with care, less satisfaction and less willingness to return
   - more difficulties understanding medication instructions


•     Understand the role of the medical interpreter.

- characteristics of a qualified interpreters
   - fluent in two languages
   - trained as an interpreter
      - understands and adheres to the Interpreter’s Code of Ethics
      - able to accurately transfer information between 2 languages (does not add, edit, or omit)
      - familiar with medical concepts and terminology
      - familiar with Western biomedical culture and LEP patient’s culture
   - not a friend, family member, or child

- clues of a bad interpreter
   - responds to physician question without talking to the patient
   - response seems insufficient or excessive relative to the length of the patient’s speech


•     Learn strategies on how to effectively communicate through an interpreter.

- use qualified interpreters

- have a brief pre-interview meeting with the interpreter

- speak directly to the patient, not the interpreter

- speak at an even pace, in relatively short segments
                                                                          Patient, Doctor, & Society 2: NOTES (page 77 of 117)



  - speak in normal voice                         (not louder or slower)
  - speak for a short time                        (one longer sentence, or 3-4 short ones)
  - avoid complicated sentence structures
  - do not change thoughts in mid-sentence

- do not hold the interpreter responsible for what the patient does or does not say

- avoid jargon or technical terms
   - avoid idioms, technical words, and cultural references
   - be aware that many expressed concepts have no linguistic equivalent in other languages
   - know that the patient may have to use explanatory phrases

- do not say anything you do not want the patient to hear (expect that everything will be interpreted)

- avoid patronizing the patient

- encourage the interpreter to alert you to potential cultural misunderstandings

- be patient




Ethics: Informed Consent
                                                                                                      January 23rd, 2007

approach to ethics
- four box approach to ethics
   - medical indications
   - patient preferences
   - quality of life
   - contextual features

        medical indications              patient preferences

   • medical facts                  • patient goals and values
   • goals of treatment             • patient understanding
   • options to avoid harm
           quality of life               contextual features

   • freedom from pain              • institutions
   • independence                   • legal repercussions



- guiding ethical principles
   - autonomy
      - definition:     right to choose treatment or refuse therapy
      - importance:     informed adult patient of sound mind is fully able to decide their own therapy
      - clinical:       protecting autonomy
                        - consent forms
                        - do not resuscitate (DNR) orders
                                                                             Patient, Doctor, & Society 2: NOTES (page 78 of 117)



                        - advance medical advice (AMA) forms

    - non-malfeasance
       - definition:  primum non nocere (first do no harm)
       - importance:  painful, risky, or burdensome therapy

    - beneficence
       - definition:    duty to assist patients
       - importance:    fundamental goal of physicians is to benefit the patient
                        - patient-centered: class of medicine that respects patient autonomy above all else
                        - paternalism: class of medicine that practices beneficence over autonomy
    - fairness
       - definition:    justice
       - importance:    situations of limited resources
                        - emergency medicine:       not allowed to turn away patients
                        - intensive care:           allocated on first-come basis
                        - organ transplants:        allocated on recommendations of council

    BOX: Guiding Ethical Principles
     • autonomy:              right to choose treatment or refuse therapy
     • non-malfeasance:       first do no harm
     • beneficence:           duty to assist patients
     • fairness:              justice




•     Understand the basic principles of the informed consent process.

- standards for informed consent
   - full disclosure
      - definition:    full disclosure of all risks and benefits
      - example:       “These are all possible risks, benefits, and probabilities…”
      - clinical:      not easy, practical, or desirable (may unreasonably increase fear of procedure)

    - standard practice
       - definition:    what a reasonable, prudent physician would tell a patient
       - example:       “Most of my colleagues would tell you that…”
       - clinical:      utilized for many years, but no longer standard practice

    - objective standard (reasonable patient standard)
       - definition:    what a reasonable patient would want to know about a procedure
       - example:       “Most patients would want to know that…”
       - clinical:      current practice in Wisconsin and most other states

    - subjective standard
       - definition:    information provided tailored specifically to a particular patient’s need (ideal)
       - example:       “For you in particular, it is important to know that…”
       - clinical:      current practice in some states, but difficult to measure

    BOX: Standards of Informed Consent
     • standard practice:         what a reasonable, prudent physician would tell a patient
     • objective standard:        what a reasonable patient would want to know about a procedure
     • subjective standard:       information provided tailored specifically to a particular patient’s need
                                                                              Patient, Doctor, & Society 2: NOTES (page 79 of 117)




- informed consent
   - decision:           “The willing acceptance of a medical intervention by a patient after adequate disclosure by
                         the physician of the nature of the intervention, its risks and benefits, and also its alternatives
                         with their risks and benefits.”
    - characteristics:   informed consent should include the following:
                         - current medical condition and likely course if no treatment is provided
                         - interventions that might aid prognosis, including risks, benefits, probabilities, uncertainties
                         - alternatives
                         - recommendations for therapy based on physician’s best medical judgment


•     Understand the historical precedents for informed consent and the legal requirements for informed consent
      in Wisconsin.

- historic precedents for informed consent
   - Schloendorff v. Society of New York Hospital, 1914
      - issue:          patient received a uterine fibroid removal that she did not consent to
      - decision:       “Every human being of adult years and sound mind has a right to determine what shall be
                        done with his own body and a surgeon who performs an operation without his patient’s
                        consent commits an assault for which he is liable in damage.” –Justice Cardozo
      - interpretation: patient must consent to medical care

    - Nathanson v. Kline, 1960
      - issue:          patient was not informed of possible surgical risks
      - decision:       “…the duty to disclose is limited to those disclosures which a reasonable medical practitioner
                        would make under the same or similar circumstances”
                        “…each man is considered to be master of his own body, and he may, if he be of sound mind,
                        prohibit the performance of life-saving surgery or other medical treatment.”
      - interpretation: patient must be informed of risks, and may decline medical treatment if of sound mind

    - Canterbury v. Spence, 1972
      - issue:          patient was not informed of possible risks of laminectomy
      - decision:       “It is the prerogative of the patient, not the physician to determine for himself the direction in
                        which his interests seem to lie…what a prudent person in the patient's position would have
                        decided if suitably informed of all perils bearing significance.”
      - interpretation: reinforced the objective standard (reasonable patient standard) of informed consent

- legal requirements for informed consent in Wisconsin
   - Wisconsin utilizes the objective standard, meaning what a reasonable patient would want to know
   - this can be overridden in cases where patients may not be able to legally consent (minors, cognitive disabilities)


•     Recognize the pitfalls in communicating risks and benefits to patients.

- problems with informed consent
   - information:         medical information is often statistical
                          - good at predicting a population average outcome
                          - poor at predicting an outcome for a given patient

    - communication:         medical information can be slanted
                             - statistics may be phrased in terms of survival vs. mortality
                             - other data (e.g. comorbidities) may be more important than simply survival

    - understanding:         patient understanding can be limited
                                                                                Patient, Doctor, & Society 2: NOTES (page 80 of 117)



                                - statistical numbers are often relative, and difficult to define as high or low
                                - consent may not always imply understanding
                                in general, humans are poor at risk evaluation
                                - 2x as many Americans commit suicide as are murdered
                                - 10x as many Americans die falling out of bed as from lightning strike

    - desperation / anxiety: patient may make poor or uncharacteristic decisions in the context of fear / anxiety

    - time / urgency:           obligations differ in different situations
                                - emergent
                                - elective
                                - medically unnecessary

    - clinical uncertainty:     medical information is often incomplete
                                - procedures may be apparently equivocal
                                - some patients may prefer certainty of outcome over improved survival

    - practitioner bias:        recommendations for therapy often depend on skills of practitioner
                                - surgeons recommend surgery, internal medicine physicians recommend medicine
                                - practice may differ based on physician viewing of data

    - patient preferences:      patients differ in personal preference
                                - length of live vs. quality of life
                                - large risks for large benefits
                                - inability to tolerate certain comorbidities or changes in body image / function


    BOX: Problems and Pitfalls with Informed Consent
     • information:                medical information is often statistical
     • communication:              medical information can be slanted
     • understanding:              patient understanding can be limited
     • desperation / anxiety:      patient may make uncharacteristic decisions in the context of fear / anxiety
     • time / urgency:             obligations differ in different situations
     • clinical uncertainty:       medical information is often incomplete
     • practitioner bias:          recommendations for therapy often depend on skills of practitioner
     • patient preferences:        patients differ in personal preference




Recognizing and Responding to Sexual Assault
                                                                                                            February 7th, 2007

•     Define sexual violence and recognize its prevalence within society.

- sexual assault: sexual contact without consent
   - sexual contact: any contact with an intimate body part
   - consent:          words or overt actions that indicate a freely-given agreement to have sexual contact
                       consent is legally unable to be given by:
                       - minors
                                                                           Patient, Doctor, & Society 2: NOTES (page 81 of 117)



                        - severely disabled
                        - unconscious
                        - intoxicated

    - classification:   sexual assault is classified by degrees
                        - 4th degree: grabbing arse
                        - 1st degree: sexual intercourse without consent

- general points regarding sexual assault
   - 90% of rape is committed by someone the victim knows
   - women raped by someone they know experience a similar degree of trauma than to those raped by a stranger
   - level of false reporting is no different than other violent crimes
   - men can be and are sexually assaulted
   - some societies have extremely low incidence of rape
   - motives for rape are complex and varied
   - 1 in 4 women and 1 in 8 boys will be victims of sexual assault by the age of 18


•     Understand the impact of sexual violence on the victim / survivor of sexual assault.

- feelings after sexual assault
   - shock / disorganization
   - denial
   - depression / guilt
   - fear / anxiety
   - anger
   - re-acceptance of self

- coping strategies
   - alcohol and drug use
   - self-harm behaviors (e.g. cutting)
   - over- and under eating
   - promiscuity
   - isolation
   - overly controlling / rigid behaviors
   - extreme passivity


•     Describe the appropriate questions to ask patients who may have experienced or may be experiencing sexual
      violence.

- importance of asking about sexual assault
   - 1 in 4 women in the U.S. have been the victim of an attempted or completed sexual assault
   - 95% of sexual assault survivors do not initially go to a registered clinical counselor (RCC) or psychotherapist
   - survivors may have physical and psychological effects of sexual violence, and these effects may be long-lasting
   - survivors of rape are 13 times more likely to commit suicide than non-crime victims

- barriers to asking
   - myths about sexual violence
   - lack of information and training about sexual violence
   - provider’s own traumatic experiences
   - belief that this is a “private” matter
   - discomfort with patient expressing emotion
   - discomfort with feeling helpless and not being able to “fix” the patient

screening for sexual assault
                                                                         Patient, Doctor, & Society 2: NOTES (page 82 of 117)



- SAVE screening for sexual assault
   - screen
      - method:      screen all patients for sexual assault
                     - ensure a safe environment, with privacy and clothes on
                     - normalize the experience
      - examples:     “Violence is such a big problem for many people, and it impacts health in so many ways…”
                     “Sexual assault is such a big problem…”

  - ask
     - method:        ask questions in a nonjudgmental way
     - examples:      “Have you ever been touched sexually against your will or without your consent?”
                      “Have you ever been forced or pressured to have sex?”
                      “What happens if you say no to having sex?”

  - validate
     - method:        validate the patient
                      - do not blame or shame the abused person
                      - be nonjudgmental and supportive
    - examples:       “I’m so sorry this happened to you.”
                      “This is not your fault.”
                      “There is help available.”

  - evaluate
     - method:        evaluate, educate, and refer
                      obtain more information in order to offer the best resources
    - examples:       acute assault:         SANE program, Rape Crisis Center
                      nonacute assault:      ask the patient what he / she needs
                                             - “How are you dealing with this?”
                                             - “How can I help? What do you need?”

  BOX: SAVE Screening for Sexual Assault
   • screen:         screen all patients for sexual assault
   • ask:            ask questions in a nonjudgmental way
   • validate:       validate the patient
   • evaluate:       evaluate, educate, and refer



- for a patient who says no:
   - maintain an open door policy
   - ask again


victimization across the lifespan
- children
   - epidemiology:    1 in 7 victims of sexual assault is under the age of 6
                      females comprise 82% of all juvenile victims
                      1 in 4 victims of sexual assault under the age of 12 are boys
                      regarding relationship to the offender (1999 data):
                      - 47% related
                      - 49% acquaintances
                      - 4% strangers
   - process:         reassure the parent / caretaker
                      defer forensic interviewing to those who are specifically trained
                      if you must question the child:
                                                                         Patient, Doctor, & Society 2: NOTES (page 83 of 117)



                      - you are not responsible for investigation / determination of crime
                      - NO leading or suggestive questions (most important for children < 10 years old)
                      - W questions are usually okay (who, what, when, where), but not why or how
                      - avoid using the word “hurt”
                      if information is provided by the child:
                      - define the child’s vocabulary
                      - document if statements are spontaneous or in response to questions
                      - document exactly what the child was asked, and the child’s verbatim response
                      - document what was happening when the disclosure was made
  - examples:         “Has anyone ever touched you in a way / place that made you feel uncomfortable”
  - clinical:         mandated reporting
                      - must report all cases of suspected child abuse and neglect
                      - understood as reasonable cause to suspect, not definitive proof

  BOX: Leading Questions
   Leading questions are those that:

     • contain the answer
     • contain a choice of answers
     • contain the name of the suspect before the child identifies the person
     • contains the interviewer’s assumptions
     • explains or offers explicit details of the alleged offense



- adolescents
   - epidemiology:    33% of sexual assaults occur when victims are between the ages of 12-17
                      rate of victimization by an intimate partner is greatest between ages of 16-24
                      1 in 5 HS females experience physical and/or sexual abuse at the hands of a dating partner
  - process:          define sexual assault for the adolescent
                      separate from caregivers who may be abusers
                      ask in successive visits
  - examples:         questions should be specific and direct
                      - “Are you ever frightened by your boyfriend’s temper?”
                      - “Has your boyfriend ever hurt you or threatened to hurt you?”
                      - “Has your boyfriend ever forced you to have sex when you didn’t want to?”

  BOX: Exceptions to Mandated Reporting
   In order to allow children to obtain confidential “health care services,”
     WI Statute 48.981 (2m) permits exceptions to mandatory reporting in
     the following circumstances:

     • family planning services
     • pregnancy testing
     • obstetrical health care or screening
     • diagnosis and treatment for an STI


     These exceptions are not applicable in the following circumstances:

     • sexual contact with a caregiver
     • mental illness or deficiency
     • age / immaturity (incapable of understanding)
     • physical inability to communicate unwillingness
                                                                         Patient, Doctor, & Society 2: NOTES (page 84 of 117)




      • reasonable doubt as to voluntary participation



- spouse
   - epidemiology:    28% of rape victims are raped by intimate partners (husbands, boyfriends)
                      rape occurs in 33-46% of women who are physically abused
                      relative to non-rape abuse, wife rape is associated with:
                      - more severe battering
                      - increased risk of homicide
  - process:          battered women must be specifically asked about sexual abuse
                      goal is to help victims regain control of their lives
                      - respect the right not to disclose or to refuse intervention
                      - patient’s decision should be documented in medical record

  BOX: Policy on Reporting Domestic Violence
   The WI State Medical Society policy on physician reporting of domestic
     violence specifies that intervention must occur, with or without patient
     consent, in the following cases:

      • child abuse or neglect
      • questions regarding the patient’s medical competency
      • gunshot wounds or life-threatening injuries
      • high risk for life-threatening or serious injury



- elderly
   - epidemiology:    2-7% of women who are raped are “older”
                      - incidence is believed to be more frequent and extremely underreported
                      - 30% of people age 65 or older report their sexual assault to law enforcement
  - barriers:         barriers to self-reporting in the elderly include:
                      - lack of education about sexual violence and how to report it
                      - unawareness or poor understanding of marital abuse laws
                      - difficulty in discussing sex or sexual abuse (generational beliefs)
                      - fear of reprisal, loss of personal care, or other services
                      - physical incapacity to report
  - process:          anticipate hesitancy in discussing sexual issues
                      explain that a “foggy memory” is normal
                      avoid showing surprise or disgust
                      reassure the victim that the perpetrator is at fault

- drug-facilitated sexual assault (DFSA)
   - epidemiology:     difficult to define due to:
                       - feelings of guilt or self blame
                       - confusion and uncertainty
                       - no memory of assault circumstances
   - methods:          date rape drugs
                       alcohol
   - process:          do not minimize the trauma
                       - patients often told that they are “lucky” they cannot remember
                       - in many ways, this can be even more traumatic

- males
  - epidemiology:     5% of rape victims are male
                                                                          Patient, Doctor, & Society 2: NOTES (page 85 of 117)



                       underreporting is common
                       - more likely to have had multiple assailants, as well as for weapons to have been involved
                       - more likely to blame themselves for not being able to fend off attackers
                       - fewer options for support
    - process:         provide an explanatory and normalizing introduction
                       anticipate an immediate “no” response
                       - respond with “open door” policy
                       - ask again at each visit
                       do not assume sex of a perpetrator
                       reduce shame (in stress, erection can be a normal physiological response)
    - clinical:        National Organization on Male Sexual Victimization: www.nomsv.org

- same sex relationships
   - epidemiology:     similar problems with abuse and sexual abuse in same-sex relationships
   - barriers:         primary barrier to reporting is the fear of being outed
   - clinical:         resources are limited
                       - Madison:        WCASA, RCC, Outreach
                       - Milwaukee:      Counseling Center, LGBT Center

- developmental disabilities
   - epidemiology:    90% of people with DD will experience sexual abuse / assault
                      50% of women with DD who have been assaulted report having been assaulted > 10 times
                      reporting is less likely to be believed or investigated
   - barriers:        barriers to reporting include:
                      - lack of appropriate sexual education
                      - dependence on perpetrator
   - process:         be patient
                      ascertain the level of understanding the patient has and how he/she communicates
                      quiet environment, free of distractions
                      non-offending caretaker may assist (be careful)
                      avoid leading questions, avoid yes / no questions
                      be repetitious


•     Describe an appropriate response to patients who disclose being a victim / survivor of sexual violence.

- compassionate responses to sexual assault disclosures
   - listen
      - importance:  unless in forensics, role of the physician is not to ask probing questions or collect evidence
      - example:     “Please take your time. I’d like to hear how you are feeling about this.”

    - believe
       - importance:   unless of immediate concern, role of the physician is not to figure out inconsistencies
       - example:      “I’m so sorry this happened to you. It takes a lot of courage to talk about this.”

    - validate
       - importance:   normalize the patient’s reactions (e.g. shame, guilt, sadness, confusion)
       - example:      “Many people feel ___ after a sexual assault. Your responses are quite normal.”

    - empower
       - importance:   resist the impulse to give advice, and offer the patient resources
       - example:      “You survived a painful experience. It takes a lot of courage to talk about this.”
                       “You deserve to have some support. Here are some options…”

- phrases to avoid
   - “Are you sure about this?”
                                                                           Patient, Doctor, & Society 2: NOTES (page 86 of 117)



    - “How drunk/high were you?”
    - “I can’t believe it happened that way.”
    - “I know how you must feel.”
    - “What were you wearing?”
    - “What happened? Oh, that sounds horrible.”
    - ‘Let this be a lesson to you.”
    - “What do you expect from that kind of person?”
    - “Why were you in that area?”
    - “Why didn’t you fight back?”
    - “Why didn’t you come in sooner?”
    - “You MUST report this to the police.”
    - “You are lucky you can’t remember what happened.”


•     Identify available community resources available to help victims / survivors

- Rape Crisis Center
  - function:        numerous services regarding support and counseling regarding rape
                     - individual counseling
                     - crisis line
                     - support groups
                     - medical and legal advocacy / accompaniments
  - contact:         Main Office:           (608) 251-5126
                     Campus Office:         (608) 265-6389
                     24 hour Crisis Line: (680) 251-RAPE
                     web site:              danecountyrcc.org

- Sexual Assault Nurse Examiner (SANE)
   - function:        nursing subspecialty educated in dealing with rape
   - contact:         Meriter Hospital SANE program
                      - number:    (608) 267-5916
                      - hours:     M-F 9:00 a.m. to 5:00 p.m.

- Wisconsin Coalition Against Sexual Assault (WCASA)
  - function:         local hotline for resources regarding rape
  - contact:          (608) 257-1516

- Rape and Incest National Network (RAINN)
  - function:         national hotline for resources regarding rape
  - contact:          (800) 656-HOPE




Principles of Health Insurance
                                                                                                      February 14th, 2007

- importance of understanding health care insurance
   - many individuals who influence the cost / availability of health services do not share medical ethics / values
   - effective physician participation in policy requires a thorough understanding of how the system functions
   - it is easier to achieve happiness and piece of mind if you understand the system in which you work
                                                                            Patient, Doctor, & Society 2: NOTES (page 87 of 117)



•     Have a sense of how health care in the United States is financed: who pays for it, and how the money is
      spent.

- health care financing
   - costs:             $1.9 trillion
                        - accounts for 17-18% of GDP
                        - this proportion is increasing, and may reach 25% by 2020
   - financing:         health care is financed by:
                        - government
                        - private insurance
                        - individuals




                FIGURE: International Spending on Health Care (% of GDP)


- the uninsured
   - epidemiology:      41.7 million persons of all ages (14%) uninsured in 2005
                        - 52.4 million uninsured during part of the previous year
                        - 8.6% of children under age 18 uninsured
                        60% have incomes above the poverty level
    - risk factors:     higher rates of uninsured seen in:
                        - adults
                        - unskilled laborers
                        - service workers
                        - limited term employees (LTEs)
                        - part time workers
                        - illegal workers
    - financing:         “cost shifting” to paying customers
    - clinical:         the uninsured population
                        - higher rates of preventable and untreated illnesses, hospitalizations
                        - pay more for their health care
                        - have poorer outcomes


•     Understand the basics of health care insurance, including private insurance, Medicare, and Medicaid.

Medicare
- Medicare
                                                                           Patient, Doctor, & Society 2: NOTES (page 88 of 117)



  - origin:            Social Security Act of 1965 (Lyndon Johnson)
  - function:          health insurance for elderly (> 65 years old), some disabled people, ESKD patients
  - structure:         federal fee for service plan
                       - Medicare pays any provider that “accepts” Medicare assignment
                       - providers accepting payments from Medicare patients are subject to Medicare regulations
  - enrollment:        40 million (enrollment is not automatic once reaching eligible age

- components of medicare
   - Medicare part A
     - function:     hospital insurance
     - costs:        deductible of $952
     - corollaries:  no premium if you paid taxes while working; some may be able to purchase coverage

  - Medicare part B
    - function:        outpatient services (physician care, laboratory testing)
    - costs:           monthly premium of $88.50, co-pay of 20%, deductible of $124
    - corollaries:     failure to sign up after eligibility increases cost 10% for each year deferred

  - Medicare Part D
    - function:     drug insurance
    - costs:        monthly premium of $35, deductible of $265
                    20% co-pay for costs up to $2400
                    - no coverage (“donut hole”) for costs $2250-$3600
                    - $2 per prescription after $3850
    - corollaries:  failure to sign up after eligibility increases cost 1% for each month deferred

Medicaid
- Medicaid
  - origin:            Social Security Act of 1965
  - function:          health insurance for persons of limited economic means
                       - relative caretaker of a deprived child
                       - pregnant
                       - under age 19
                       - over age 65           (with asset documentation)
                       - blind or disabled     (with asset documentation)
  - structure:         state-administered programs covering basic medical needs
  - importance:        only government program that will pay for long-term nursing care

private health insurance
- definitions
   - risk aversion: the degree to which a certain outcome is preferred to a risky alternative
   - moral hazard: the tendency to use services you do not pay for
   - underwriting: the practice of evaluating individuals or groups to determine whether or not insurance is offered
   - adverse selection: more all-inclusive plans will gain more sick patients and have higher rates

- insurance vs. health insurance
   - property / disability / life insurance
      - amount purchased is dictated by value
      - purchaser hopes never to use benefit (few transactions)
      - usually purchased by individuals
   - health insurance
      - purchased for benefits likely to be used (many transactions)
      - usually purchased by employers

- business model
   - premium covers medical expenses in the coming year
                                                                             Patient, Doctor, & Society 2: NOTES (page 89 of 117)



      - insurer pools premiums and spreads risks among many customers
      - sum of premiums exceeds losses, or insurer recoups losses in the next year

                                   estimated losses
                      +     administrative expenses
                      +       reserve requirements
                      +                       profit
                      =              total premium

    - prices fluctuate from year to year to recuperate losses, and insurance companies never lose
    - premium is set by underwriting
       - small groups: careful underwriting, less coverage of preexisting conditions
       - large groups: all-inclusive

- types of health insurance
   - indemnity insurance
      - structure:      fee-for-service
      - price:          high price
      - management: low management of care

    - preferred provider organization (PPO)
       - structure:     partial fee-for-service
                        - insurer covers visits to certain providers; other visits receive less or no coverage
                        - tends to lead to consolidation by physicians
       - price:         intermediate price
       - management: intermediate management

    - health maintenance organization (HMO)
       - structure:    managed care
                       - insurer covers only visits to providers within the HMO
                       - visits outside these providers are not covered
       - price:        low price
       - management: high management

    - health savings accounts / high deductible health plans
       - origin:        Medicare Prescription Drug, Improvement, and Modernization Act (2003)
       - structure:     catastrophic coverage
                        - money is paid into a tax-free health savings account
                        - withdrawal permitted for medical expenses only, unless tax + penalty is paid
       - costs:         $2850 per individual, or $5650 per family
       - advantages:    can be used for most things health-related
       - limitations:   high deductible
                        benefits primarily to the young and healthy (who already benefit in our system)


•     List reasons why health care costs have increased.

- increasing health care costs
   - spending:         44x increase in annual health care spending
                       - 1960: $26.7 billion      ($143 per person)
                       - 2004: $1.9 trillion      ($6,280 per person)
   - wages:            5x increase in minimum wage
                       - 1960: $1.00 / hour
                       - 2004: $5.15 / hour

- reasons for increasing health care costs
                                                                            Patient, Doctor, & Society 2: NOTES (page 90 of 117)



    - aging population
    - new medical technologies

•     Describe how employers and governments have reacted to increasing health care costs.

- employer response to rising costs
   - reduced employment / wages
   - increased proportion of health care costs paid by employee
   - shifting of jobs to areas where profit margins are higher


•     Know how fee-for-service, discounted care, and capitation work as methods for payment.

- definitions
   - fee-for-service (FFS): payment of fees as they are charged by providers
   - discounted FFS: discounts arranged by agreement or imposed upon providers
   - capitation: fee rendered on a per-patient basis in exchange for all care rendered to that patient under a contract




HIV Counseling
                                                                                                       February 21st, 2007

- HIV success stories in the U.S.
  - lower mortality rates
  - lower rates of complications
  - lower rates of HIV transmission to newborns
  - lower rates of HIV from needle stick injury to health care workers

- epidemiology of AIDS in the U.S.
   - 40,000 new cases per year
   - half of all new infections in people < 25
   - women account for half of all new infections (not a “gay male” disease)
      - 85% of women with HIV are of child-bearing age
      - heterosexual transmission is the leading risk factor among women

    TABLE: Risk Factors and Transmission Rates
      risk factor                     rate 1
      shared needles                  0.67-10%
      receptive anal                  0.8-5%
      occupational needle stick       0.3%
      receptive vaginal               < 0.1-1%
      insertional anal                < 0.1-1%
      insertional vaginal             0.01-5.6% 2
      receptive oral                  ?
    1
      per contact transmission rate
    2
      as this was a metaanalysis, this was probably an outlier value


- risk groups
   - men who have sex with men
                                                                            Patient, Doctor, & Society 2: NOTES (page 91 of 117)



      - lack of continuity of care (more frequent use of ED)
      - sexual history often missed or incomplete in urgent care settings

    - young women
       - biologically more vulnerable (5-8x)
       - unlikely to be able to negotiate safer sex with an older partner
       - feelings of invincibility
       - more worried about pregnancy than STI or HIV


•     List two reasons why physicians should generally provide HIV testing.

- benefits of HIV diagnosis
   - prolonged patient life / improved quality of life
   - reduced HIV transmission
      - HIV+ people who know their status reduce high risk sex by 50%
      - lower viral loads from antivirals reduce transmission

HIV screening
  - purpose:             reduce the rate of transmission and increase personal awareness
                         - 45% of U.S. adults have been voluntarily tested as of 2001
                         - only 65-75% of HIV-infected patients have been identified
                         - HIV testing is accurate
                         - 40% of patients were diagnosed with AIDS within one year of HIV testing
    - practice:          HIV screening is currently limited to:
                         - military personnel / recruits
                         - federal and most state inmates
                         - people attempting to immigrate to the U.S.
                         - blood donors
                         - pregnant women (theoretical)

    TABLE: Proportion of HIV Testing in Various Locations
      setting                                   proportion
      anonymous testing sites                     < 1%
      military                                    < 1%
      STI clinics                                 < 1%
      incarceration settings                        3%
      blood / tissue donation locale                5%
      hospitals and ED 1                           30%
      clinical offices 1                           55%
    1
      65% of positive HIV tests are obtained in hospitals and clinic settings



•     Identify two barriers to HIV testing for patients in the U.S.

- barriers to HIV testing
   - patient issues (probably minor)
      - lack of knowledge about HIV/AIDS and new treatments
      - fear of knowing they have the disease
      - HIV-related stigma and discrimination
      - financial reasons (not necessarily testing)
         - follow-up health care
         - medications
         - possible job loss
                                                                            Patient, Doctor, & Society 2: NOTES (page 92 of 117)



      - cultural attitudes
      - feelings of invincibility
      - mistrust of health care providers
      - drug use
      - mental illness

    - provider issues
       - complacency
       - difficulty discussing high-risk behaviors
       - skepticism regarding patient risk
       - fear of offending patient
       - confidentiality issues
       - time pressures
       - prioritization of other health problems


•     List two requirements of pre- and posttest HIV counseling.

- current screening recommendations
   - source:           The CDC HIV Testing Recommendations for Adults and Adolescents, 2006
   - guidelines:       all patients ages 13-64 years should receive routine HIV screening, in all health care settings
                       - HIV screening should be voluntary
                       - HIV screening should be opt-out
                       - separate written consent for HIV testing is not recommended
                       - prevention counseling should not be required
                       - high risk patients should be screened at least annually
   - clinical:         note that CDC guidelines do not supersede state law

    BOX: High Risk Patients
     Annual repeat screening is recommended for high risk patients, which includes:

       • injection-drug users (IDU)
       • sex partners of IDU
       • persons who exchange sex for money or drugs
       • sex partners of HIV-infected
       • men who have sex with men (MSM)
       • multiple sexual partners (in individual or partner)




•     List two ways in which HIV testing can facilitate prevention.

- prevention effect from diagnosis
   - behavioral:       diagnosed patients reduce high risk sex by 50%
   - treatment:        antivirals lower viral load, reducing transmission


•     Identify controversies in HIV testing.

- controversies in HIV testing
   - stigma and discrimination of HIV diagnosis
   - access to care with a positive diagnosis
   - possible sacrifice of counseling under newer guidelines
   - legal issues regarding opt-out testing and informed consent
                                                                          Patient, Doctor, & Society 2: NOTES (page 93 of 117)




•     Demonstrate communication techniques pertinent to HIV testing.

- ACTS approach to HIV counseling and testing
  - assess
     - method:      explain that it is standard practice to discuss HIV with all patients
                    - explain benefits
                    - describe HIV transmission: sex / needles / perinatal
                    review risk screen or explain that HIV testing is advisable if:
                    - you have ever had sex
                    - you have ever used IV drugs

      - examples:     “I talk about HIV testing with all my patients…”
                      “HIV screening is something that I recommend to everyone who has ever had sex…”
                      “It is important for every person to understand his/her status including if they have HIV…”
                      “If you test HIV-negative, you can learn ways to stay healthy.”
                      “If you test HIV-positive, you can get good medical care and counseling.”
                      “In most screening programs, the vast majority of patients will test negative…”

    - consent
       - method:      review DOH consent form
                      - meaning of positive and negative results
                      - confidential vs. anonymous testing
                      - names reporting
                      - partner notification
                      - domestic violence screening

      - examples:     “A negative result means that there is no current evidence that you are infected with HIV, but
                      it may not show a very recent infection.”

                      “A positive result means that you are infected with HIV and you can infect others… If you
                      are HIV-positive, you will need more tests and a check-up to learn more about your health
                      and to see if you need to start any medicines.”

                      “Confidential Testing requires your name, and the test will be part of your medical record so it
                      can be used in your medical care. All information about HIV is confidential, which means
                      that your test results can only be given to people with your written approval…”

    - test
       - method:      describe / provide HIV test
                      make plan to deliver results, or have patient wait for rapid results

      - examples:     “For this test we will draw some blood from your arm / do a finger prick.”

                      “Results are usually available in two to seven days. Let’s make an appointment for you to
                      return for your results, or you can call to get your results.”

                      RAPID: “We are using a rapid test today. Your results will be ready in 30 minutes. If you test
                      negative, your results are final today. However, if your results on this test are preliminary
                      positive, you will need to take a second test to make sure you are actually infected…”

    - support
       - method:      give results and allow time to process
                      - negative: clarify need to retest (window period), and discuss true prevention
                      - positive: provide support, review reporting / partner notification
                                                                           Patient, Doctor, & Society 2: NOTES (page 94 of 117)




      - examples:      “Thank you for coming back (calling or waiting) for your HIV test results. Your HIV test
                       came back negative, which means you do not currently have antibodies to HIV and there is no
                       sign you are infected.”

                       “If you have had unprotected sex (or shared needles) with anyone in the past three months, we
                       recommend that you stay safe and repeat this test in three months. This is called the window
                       period.”

                       “Even though this test is negative, you can get HIV in the future if you do not protect yourself
                       during sex by using condoms and discussing HIV risks with your partner(s).”

    BOX: ACTS Approach to HIV Screening
     • assess:        explain that it is standard practice to discuss HIV with all patients
                      review risk screen or explain that HIV testing is advisable if:

     • consent:       review DOH consent form and obtain consent

     • test:          describe / provide HIV test
                      make plan to deliver results, or have patient wait for rapid results

     • support:       give results and allow time to process
                      - negative: clarify need to retest (window period), and discuss true prevention
                      - positive: provide support, review reporting / partner notification




HIV Case Conference
                                                                                                      February 28th, 2007

- epidemiology of HIV and AIDS
   - global:         total incidence of 60 million infected, with > 30 million currently living
   - United States:  demographic trends
                     - increasing HIV in people of color, heterosexuals, and women
                     - high seroprevalence in young, gay men in large cities (2-12%)
                     - 30% of young, gay, black males infected
                     - impressive declines in perinatal transmission of HIV in the United States

•     List three means by which social, cultural, and media messages affect sexual attitudes, behaviors, and the
      evolution of the HIV and AIDS epidemic.

- media and cultural influences
  - sources:           alcohol and other advertising
                       television and movies
                       print and visual media

    - effects:         promotion of:
                       - risky sexual behaviors
                       - sexual assault
                                                                          Patient, Doctor, & Society 2: NOTES (page 95 of 117)



                         - poor or manipulative communication
                         - abusive relationships




               FIGURE: How to Throw an Orgy
               What are you going to do with all that junk, all that junk inside your trunk?
               I’m going to get you drunk, get you love drunk off my hump. My hump. My lovely lady lumps.


•     List two reasons why sexually active teenage girls are at greater risk of acquiring HIV infection than males.

- effect of gender on HIV acquisition
   - epidemiology:     females > males
   - reasons:          biological susceptibility
                       cultural susceptibility
                       - age discrepancy in relationships
                       - power imbalance with male partners
                       - high prevalence of STI / HIV in partners
                       - high rates of substance use / abuse, multiple partners, and unprotected sex

- sexual violations on campus
   - method:           survey of 1000 UW Madison women (April 1995)
                       “against your will” sexual violations, including:
                       - kissed on lips
                       - touched on breasts or genitals over the clothes
                       - touched on breasts or genitals under the clothes
                       - forced to touch someone else’s genitals
                       - experienced attempted intercourse
                       - forced to perform or receive oral sex
                       - forced into sexual intercourse
   - results:          at least one sexual violation:                     47% of seniors
                       at least one forced intercourse / forced oral sex: 12% of seniors
                       at least one violation during the academic year: 27% of undergraduates
                       93% experienced negative consequences
                       alcohol involved 69% - 74%

    BOX: Increased Susceptibility to STIs in Females
     • biological susceptibility:        5-8x more susceptible due to mucosal differences
     • cultural susceptibility:          age discrepancy in relationships
                                         power imbalance with male partners
                                         high prevalence of STI / HIV in partners
                                                                          Patient, Doctor, & Society 2: NOTES (page 96 of 117)




                                        high rates of substance use / abuse, multiple partners, and unprotected sex




•     Describe three techniques physicians can use to facilitate better communication with patients about sexual
      issues.

- communicating with patients about sexuality (CAGELAC)
   - confidentiality:     confidentiality should be reassured
   - acknowledge:         acknowledge difficulty of the topic
   - generalize:          generalize the importance to all patients
   - eye contact:         eye contact should be interactive and appropriate
   - language:            language should be gender-neutral and clear
   - avoid assumptions:   avoid making assumptions about marital status and sexual orientation
   - congruence:          search for correspondence between verbal and non-verbal messages

- specific questions
   - general:               “How would you describe your relationship?”
                            “What sort of person is your partner?”
                            “What were some of your earliest feelings about sex? Masturbation? Relationships?”
                            “Do you have any questions or concerns about sex you’d like to discuss today?”

    - adolescents:          “Many girls / boys your age have questions about sex / sexual feelings. How about you?”
                            “Do you have any questions about your body? Sex? Masturbation? Birth control?”
                            “Do you have sexual feelings or attraction for girls, boys, both, neither?”
                            “Are your friends or kids at school having sex?”
                            “Can you talk with your parents about sex?”

    - behavioral:           “Do you have vaginal, anal, or oral sex?”
                            “Do you use condoms? (0%, 50%, 75%, 100%)
                            “Has anyone ever hurt you physically or forced you to have sex?”
                            “Have you ever, even once, used any IV drug, or had sex with someone who did?”

    BOX: Facilitating Better Communication About Sexual Issues
     • consider patient perceptions of behavioral norms (“everybody’s doing it”)
     • use the CAGELAC mnemonic for better communication
     • explore individual and patient attitudes




•     Define the stage of change for a given patient, based on the patient’s willingness to use condoms to protect
      against STDs.

- pre-contemplation
   - definition:       not considering change
   - goal:             move to contemplation / consider change
   - barriers:         lack of knowledge of risks or consequences
                       lack of self- efficacy
                       contentment
    - clinical:        sample dialogue
                       - clinician: Do you use condoms when you have sex?
                       - patient:     No.
                       - clinician: Why not?
                                                                        Patient, Doctor, & Society 2: NOTES (page 97 of 117)



                     - patient:     I don’t know. They don’t feel good.
                     - clinician:   I have many patients who have gotten HIV or other STIs or had unintended
                                    pregnancy from unprotected sex. It is really important to protect yourself.
                                    Here’s something to read about condoms. Let’s talk more about condoms and
                                    protection at your next visit.

- contemplation
   - definition:     ambivalent about change
   - goal:           move to determination / promote commitment to change
   - barriers:       lack of knowledge of risks / consequences
                     lack of self efficacy
                     contentment
                     indecisiveness
  - clinical:        sample dialogue
                     - clinician: What do you know about condoms?
                     - patient:     Well, they can prevent pregnancy, HIV, and other stuff.
                     - clinician: What do you think about using condoms the next time you have sex?
                     - patient:     Yeah, well, maybe.
                     - clinician: What would make it easier for you to use condoms?

- determination / preparation
   - definition:      firmly committed to change within one month
   - goals:           design a plan for change and move to action
   - barriers:        loss of commitment
                      knowledge of options for change
                      making decisions about plans for change
   - clinical:        sample dialogue
                      - clinician: Now that you know how to use condoms the right way, what do you need to do
                                    so you’re ready to use them the next time you have sex?
                      - patient:    I’m going to take some of those free condoms and lubricants from the waiting
                                    room, and I’ll keep them with me. But how am I going to tell my boyfriend he’s
                                    got to wear one?
                      - clinician: What do you think would happen if you brought the condoms out or insisted he
                                    wear one? What would you say to him?

- action
   - definition:     engaged in change
   - goals:          optimize plans, maintain changes
   - barriers:       failure and disillusionment
                     overconfidence
  - clinical:        sample dialogue
                     - clinician: So, how are you doing using condoms?
                     - patient:    We did it! I can’t believe it wasn’t so hard; I mean it was okay.
                     - clinician: That’s great! Do you need more condoms? How’s your relationship going?

- maintenance
  - definition:      continuing change which is well-learned, but with risk of relapse
  - goals:           stable, new lifestyle, with attainment of original goals
  - barriers:        risk of relapse through stress, loss, or failure to satisfy the initial reasons for change
  - clinical:        sample dialogue
                     - clinician: I’m really proud of you! It’s great that you’re using condoms when you’re
                                   having sex. What are you going to do to make sure that you keep using them?
                     - patient:    Well, I haven’t gotten high recently, so it’s been pretty easy to remember to use
                                   the condoms, but when I’m partying it’s going to be a lot harder to take a time-
                                   out from the moment, you know what I mean?
                                                                           Patient, Doctor, & Society 2: NOTES (page 98 of 117)



                       - clinician:   What’s going on when you feel like you need to party? What other ways could
                                      you deal with those issues? What other choices do you have?

- relapse
   - definition:       resumption of undesired behavior
   - goals:            identify relapse
                       reframe as opportunity to learn
                       restage
    - clinical:        remember that relapse is a normal, expected stage of behavior change

- termination
   - definition:       firmly entrenched in new lifestyle, with very low risk of relapse
   - goals:            maintain termination
   - clinical:         only 15% of nicotine or alcohol-dependent patients reach termination

    BOX: Motivational Interviewing and the Stages of Change
     • pre-contemplation:   not considering change
     • contemplation:       ambivalent about change
     • determination:       firmly committed to change within one month
     • action:              engaged in change
     • maintenance:         continuing change which is well-learned, but with risk of relapse
     • relapse:             resumption of undesired behavior
     • termination:         firmly entrenched in new lifestyle, with very low risk of relapse




•     List two actions you can take as a physician to help your teenage patients reduce the risk of acquiring HIV
      infection.

- clinical interviewing about alcohol
   - function:          interviewing college students about alcohol and alcoholism
   - method:            modified CAGE and MAST for college students (CAG-FIT)
                        - C:     Ever felt the need to cut down on your drinking?
                        - A:     Ever been annoyed at criticism of your drinking?
                        - G:     Ever feel guilty about your drinking?
                        - F:     Any family or friends with problems with alcohol?
                        - I:     Any history of injuries or illness due to drinking?
                        - T:     Gotten into trouble at school / work due to drinking?
   - clinical:          30-50% of all hospital admissions related to alcohol or drug-related disease

reducing the risk of HIV infection
- behavioral counseling
   - method:          motivational interviewing
                      - individualized, supportive, non-punitive, interactive
                      - goal-directed, with specific plans or behavioral prescription
                      - repeated, reviewed, and reinforced
   - epidemiology:    behavioral counseling for reduction of HIV transmission is evidence-based
                      - most evidence supports risk reduction strategies (vs. abstinence-only)
                      - abstinence-only education is insufficient, and may ultimately be harmful
   - barriers:        commonly reported physician barriers include:
                      - lack of training, knowledge, skills, confidence
                      - fear of “Yes” response (avoid asking about it)
                      - misperceptions of patients’ risks
                      - lack of tools to assess patients’ risks
                                                                              Patient, Doctor, & Society 2: NOTES (page 99 of 117)



                           - constraints of time and resources
                           - harm-elimination v. harm-reduction
    - examples:            “On a 1-10 scale…”
                           - …how important is it for you to reduce your risk / maintain safer behavior
                           - …how confident are you that you can reduce this risk behavior / maintain safe ones
                           “Why not 2-3 points lower?”

- risk elimination strategies
   - method:            abstinence education
   - epidemiology:      abstinence-only counseling is insufficient
                        - abstinence-only programs have been shown to be generally less effective than risk reduction
                        - abstinence should always be promoted as the only “safe” choice


    BOX: Reducing Risk of Acquiring HIV
     • risk reduction:        reduced risk of transmission through safer sexual practices
                              - includes behavioral counseling free condoms, needle exchange, etc.
                              - evidence favors risk reduction (vs. abstinence only) in reducing transmission rates

     • risk elimination:      eliminated risk of transmission through abstinence-only strategies
                              - less favorable evidence (vs. risk reduction) in reducing transmission rates
                              - abstinence should always be promoted as the only “safe” choice

     Please note that these are my categories for interpreting the lecture objective.




Public Health Law and Ethics:
      Balancing Physician Responsibilities to Patients
      and Public Health
                                                                                                         February 21st, 2007

•     Understand the legal basis for public health laws (e.g., surveillance, quarantine, vaccination).

- types of public health law
   - constitutional:    most powers granted to the state (10th Amendment)
   - legislative:       enactment of laws and provision of funding
   - administrative:    regulations and rules
   - judicial:          common law (interpreted in courts)

- states rights theory of police powers
   - U.S. Constitution, 10th Amendment
     - language:        The powers not delegated to the United States by the Constitution, nor prohibited by it to the
                        States, are reserved for the States respectively, or to the people.
     - interpretation: states have broad powers regarding welfare, safety, health, morality, etc.
                        - includes police powers, such as licensing, inspection, zoning, safety, and law enforcement
                        - basis of many state regulatory statutes, including those on public health
                                                                           Patient, Doctor, & Society 2: NOTES (page 100 of 117)




    - public health in the state Wisconsin
       - statute:         Wisconsin Public Health statutes section 250.04: powers and duties of the department
       - provisions:      general supervision throughout the state of the health of citizens
                          - may (upon due notice) enter upon and inspect private property
                          - may execute what is reasonable and necessary for the prevention of disease
                          - may investigate the cause and circumstances of any special or unusual disease
                          - may inspect any public building
                          - may do any act necessary for the investigation


•     Define public health ethics. How does this differ from medical or bioethics?

- public health ethics
   - definition:       ethical conflicts between the clinical perspective and the population perspective
                       - clinical:        promotes the best interests and autonomy of the individual
                       - population:      promotes the best interests of the population as a whole
   - clinical:         in most cases, autonomy defers to the public good


•     Consider how one balances the individual rights of a patient versus the benefit to society.

clinical cases
- case 1: No Child Left Unbelted
   - clinical case:    Timmy, age 4, is in the pediatric intensive care unit with severe brain trauma incurred
                       following a car crash. His mother was driving and he was in the back seat, without a seat belt
                       and without an appropriate car seat as required by Wisconsin law.

    - issues:           •   Should the mother be reported for child neglect?
                        •   Should she be prosecuted for criminal neglect?
                        •   What are the potential public health benefits of legal proceedings?

- case 2: Drafting Children to Prevent Others
   - clinical case:    Rubella is a mild disease with little health consequences other than the risk to fetuses. The
                       immunization of children was proposed primarily to prevent them from being vectors and
                       thereby protecting their possibly pregnant mothers from being infected. Young girls have the
                       potential benefit of lifelong immunity to protect themselves, but there is little/no direct benefit
                       to boys.

                        Mr. and Mrs. Thompson object to their son, Josh, receiving the vaccine on the grounds that it
                        is exposing him to risk without commensurate benefit, and without his consent. They also
                        object to the immunization of any young males.

    - issues:           •   Assume the vaccine has been associated with a severe form of rheumatoid-like arthritis.
                            Is it appropriate to expose a child to a risk of serious harm with no compensating benefit
                            in the name of public health?
                        •   The Thompsons argue that any woman seeking immunity from rubella can get the
                            vaccine herself and the immunization of children is not necessary to protect the public
                            health. What is your response?
                        •   If Josh develops crippling arthritis from the vaccine and asks why you, as his
                            pediatrician, were not representing his interests, what would you say?

- case 3: Saving One Life at the Cost of Others
   - clinical case:   Alice has an immune disorder with 100% mortality in the first year of life. Bone marrow
                      transplant has a 70-90% likelihood of long-term survival. Her parents, who are Amish, refuse
                      to consent so it can only be provided with a court order. Her primary physician predicts that
                                                                           Patient, Doctor, & Society 2: NOTES (page 101 of 117)



                         legal proceedings will result in cessation of referrals to UWH from the entire Amish
                         community. Within one week of his prediction, two seriously ill infants die as a consequence
                         of refusing referral to UWH.

    - issues:            •   What is the justification of saving one life at the cost of two? Suppose two became ten? Is
                             there any number that would lead you to say it wasn’t worth it?
                         •   What is the basis of the pediatrician’s obligation to Alice? What is the basis of his
                             obligation to the rest of the Amish community? Is one obligation stronger than the other?
                         •   Is this case different from financial tradeoffs; e.g., spending $1 million to save one life
                             when the money could save many more lives if spent elsewhere.

individual vs. society
- most clinical decisions have public health implications
  - antibiotics:       increasing burden of antibiotic resistance
  - vaccination:       fairness of compulsory treatment
                       fairness of allowing some people to “opt out” in herd immunity
  - patient billing:   costs, burdens, and justice of health care in general




                 FIGURE: Balancing the Individual vs. the Society




Health Literacy
                                                                                                            March 6th, 2007

•     Define health literacy.

- health literacy
   - definition:         the ability to read, understand, and use health information to make appropriate health care
                         decisions and follow instructions for treatment.

    - factors:           patient factors include:
                                                                           Patient, Doctor, & Society 2: NOTES (page 102 of 117)



                        - general literacy
                        - amount of experience in the health care system
                        - cultural factors (language traditions)

                        clinician factors include:
                        - complexity of information presented
                        - communication of material


•     Recognize the scope of the problem of limited health literacy in the United States.

- health literacy in the United States
   - study:              National Assessment of Adult Literacy (NAAL), 2003
   - method:             survey including 28 items related to health literacy
                         - stratified national random sample of 19,000 adults
                         - most comprehensive view of U.S. adults to date
                         - included instructions in English and Spanish
   - results:            reported in 4 levels, according to prose, document, and quantitative skills
                         - below basic:      reading instructions, noting dates
                         - basic:            understanding of pamphlets and simple articles
                         - intermediate: use of simple tables, reading labels for content
                         - proficient:       use of complex tables, evaluation of information to determine relevance

                        TABLE: NAAL Levels
                         level        expectation                                         prevalence
                         below basic  reading instructions, dates                             14
                         basic        understanding pamphlets                                 22
                         intermediate simple tables, reading labels                           53
                         proficient   complex tables, relevance of information                12

    - interpretation:   significant amount of patients have limited health literacy
                        lower rates of health literacy in:
                        - elderly         (almost 33%)
                        - minorities      (especially Hispanic)
                        - low education (especially less than HS)

issues in health literacy
- nondisclosure of limited literacy
   - effect:           most people of limited literacy will not disclose this (75% will not disclose to physicians)
   - implication:      people will not tell if they don’t understand; we must be able to figure this out




                FIGURE: Nondisclosure of Health Literacy
                                                                            Patient, Doctor, & Society 2: NOTES (page 103 of 117)




- literacy in the health care setting
   - complexity of medical information
      - population reading average:                 8th grade level
      - conveyance of medical information:          college level

    - note that health literacy can be an issue even with those of adequate literacy
       - specialized language (even difficulties between subspecialties)
       - inexperience with system

- specific areas of concern
   - general clarity:             poorer in lower health literacy      (p < 0.01)
   - elicitation of problems:     no statistical difference            (p = 0.33)
   - explanation of condition:    poorer in lower health literacy      (p = 0.03)
   - explanation of care:         poorer in lower health literacy      (p = 0.03)


•     Examine the relationship between general literacy and health literacy.

- health literacy and general literacy
   - relationship:      health literacy generally correlated with general literacy
   - corollary:         relationship is not absolute
                        - proficient levels:    3% of HS equivalent education
                        - below basic levels: 3% of graduate equivalent education




               FIGURE: Health Literacy (NAAL Rating) vs. Literacy (Education Level)



•     Recognize consequences of not attending to health literacy issues in patients.
                                                                             Patient, Doctor, & Society 2: NOTES (page 104 of 117)



- health implications of limited literacy
   - worse health outcomes:           across all SES, in many disease states
                                      - asthma:    how to use an inhaler
                                      - diabetes: symptoms of hypoglycemia
                                      - HTN:       relationship of weight loss and exercise
                                      - general:   how to read a thermometer

    - increased healthcare costs:       $50-$73 billion/year attributable to low literacy
                                        - excess hospitalizations
                                        - longer hospital stays
                                        - increased use of ED
                                        - higher acuity illnesses


•     Recognize clues for limited health literacy.

- research tools
   - rapid estimate of adult literacy (REALM)
   - test of functional health literacy in adults (TOFHLA)

- clinical tools
   - prescription bottle test:      pull out a bottle the patient has not seen, “Tell me how you would take this.”
   - nutrition label test:          pull out a nutrition label, “Tell me some information about this.”
   - patient profile:               “How happy are you with the way you read?”
   - brown bag test:                assessment of medication; read labels vs. open bottle
   - prior experiences:             direct questioning about health care experience
                                    - “It is important to me that I explain things in an understandable way.”
                                    - “I would like to know if I am not clear.”
                                    - “Have you had experiences in the past where things have not been clear?”
                                    - “Are there ways doctors have used that have worked well for you?”

- clues that may indicate limited health literacy
   - incomplete / inaccurate registration forms
   - frequently missed appointments
   - nonadherence to treatment regimens
   - lack of follow-through with tests / referrals
   - “difficult / angry patient”


•     Review techniques to enhance patient’s health literacy.

- techniques to enhance communication
   - consolidation:   limit amount of information and repeat it
   - simplification:  use plain, non-medical language
   - use of visuals:  show or draw pictures (models, posters)
   - summarization: use teach-back or show me technique
                      - “Do you understand?” is insufficient (lends to socially acceptable answer)
                      - ask patients to explain or demonstrate
                      - reteach using alternative approach if patient understanding is inadequate
   - speed:           slow down
   - understanding:   create a shame-free environment
                                                                       Patient, Doctor, & Society 2: NOTES (page 105 of 117)




EBM Communication:
    Bringing the Evidence Back to the Patient
                                                                                                        March 6th, 2007

•    Describe the steps to communicating evidence with patients.

communicating evidence with patients
- elicit the patient’s expectations and concerns
   - considerations: can save time by not explaining information the patient already knows; can draw out bias
   - methods             conversation should include:
                         - expectations: “What leads you to ask about aspirin?”
                         - knowledge:     “What do you know about it already?
                         - concerns:      “Do you have any concerns about the use of aspirin?”
                                          “What have you heard about the negatives of taking aspirin?”

- establish rapport
   - considerations:    important to establish rapport so the patient is willing to listen
   - methods:           conversation should include:
                        - summarization: “So let me make sure I understand your point of view…”
                        - explanation:    “Let me explain my perspective on this…”

- provide evidence, including uncertainties
   - considerations: amount of information to give based on patient preference
                       - maximal: specific, numerical
                       - minimal: global, qualitative (preference of most patients)
   - methods:          numerous forms of communicating information
                       - oral
                       - written
                       - videotape
                       - graphical representation
                       - decision aide programs
   - content:          benefits and risks
                       quality of information and level of uncertainty

- present recommendations
   - considerations: recommendations should be based on quality of evidence
                     - weak evidence:       present options
                     - strong evidence:     present a recommendation with justifications
   - method:         synthesis of patent expectations, with concerns regarding quality of evidence

- check for understanding and agreement
   - considerations: very important to ensure patient understanding
   - method:          check for understanding and agreement
                      - “Does that make sense to you?”
                      - “Have I explained that clearly?”
                      - “How would you summarize what I said?”
                      - “What do you think of my recommendations?”


    BOX: Communicating Evidence With Patients
     • elicit the patient’s expectations and concerns
                                                                        Patient, Doctor, & Society 2: NOTES (page 106 of 117)




     • establish rapport
     • provide evidence, including uncertainties
     • present recommendations
     • check for understanding and agreement




•     Identify common pitfalls to communicating evidence to patients.

- components of effective communication
   - sender
   - message
   - receiver

pitfalls to communication
- pitfalls to communicating evidence
   - there may not be a question to answer
   - health literacy issues
   - relating words to percents
   - presenting data in terms of mortality vs. survival
   - statistical manipulations

- numbers can be misleading
   - relative risk reduction:    “…34% reduction in heart attacks over 5 years…”
   - absolute risk reduction:    “…1.4% less incidence of heart attacks over 5 years…”
   - number needed to treat:     “…I have to treat 71 people for 5 years to benefit one person.”
   - frequency:                  “…1-2 fewer patients out of 100 will have a heart attack… over 5 years.”

- avoiding pitfalls
   - general points
      - determine the patient’s perspective on the problem
      - determine how much information the patient wants to know
      - use health literacy techniques
      - use numbers carefully
      - allow time for questions

    - recommendations for communicating numbers
       - use absolute risk, not relative risk
       - use frequencies, not number needed to treat
       - use familiar comparisons




Recognizing and Responding to Domestic Violence
                                                                                                       March 16th, 2007

- tools of the abuser
   - isolation        (one of the most clever ways of abusing someone)
   - emotional abuse
   - economic abuse
                                                                           Patient, Doctor, & Society 2: NOTES (page 107 of 117)



    - sexual abuse
    - using children
    - threats
    - physical abuse
    - intimidation

- cycle of violence
   - tension:           conflict, argument, intimidation, feeling that there will be a blow-up
   - violence:          yelling, screaming, breaking furniture, physical violence
   - honeymoon:         apologies, promises, forgiveness




               FIGURE: Cycle of Violence


•     Recognize the mental and physical health ramifications of violence.

- epidemiology
   - epidemiology of abuse
      - abuse is the single most common cause of injury to women
      - only 5% of battered women are identified as battered women and treated appropriately
      - battered women are treated differently (labeled, administered tranquilizers / pain medication)

    - gender-based differences
       - 70% of crimes against males committed by strangers
       - 70% of crimes against females committed by relatives / partners

- ramifications of domestic abuse
   - health consequences
      - 22-35% of women in emergency services are battered women
      - 50% of injuries to women are related to battering
      - 50% of women in alcohol / drug treatment have been battered
      - 1 out of 6 women say “yes” when asked if they have been hit, slapped, or kicked in this pregnancy
      - 1 out of 4 suicide attempts related to battering (1 out of 2 in black women)
      - 30% of women murdered in this country are victims of battering

    - emotional consequences
       - lowered self esteem
                                                                            Patient, Doctor, & Society 2: NOTES (page 108 of 117)



      - humiliation
      - shame
      - embarrassment


•     Describe the role health care workers can play in identifying and responding to battered women.

- role of physicians
   - ask all women about violence issues (in a private situation), and be prepared to hear the patient’s answer
      - help identify abuse
      - let the patient know the setting is safe for talking about abuse
      - promote safety
      - break isolation
      - help the patient regain control of his / her life

    - give information about community resources

    - address safety issues

    - know reporting requirements
       - respect her right not to disclose or to refuse intervention
       - document her decision, as well as any known / suspected abuse

    - document

    - create a supportive environment
       - posters and leaflets
       - ongoing training and support
       - active protocol development


    BOX: Role of the Physician
     • ask all women
     • give information and resources
     • address safety issues
     • know reporting requirements
     • document
     • create a supportive environment



- mandatory reporting requirements for:
  - child abuse or neglect is disclosed / highly suspect
  - question regarding patient’s medical competency
  - gunshot wounds or life-threatening injuries
  - clinical judgment of high risk for life-threatening or serious injury


•     Ask appropriate questions of women who may be experiencing violence.

- SAVE screening for abuse
   - screen
      - method:      screen all patients for abuse
                     - ensure a safe environment, with privacy (do not ask around the partner)
                     - normalize the experience (I ask everybody about this question)
                                                                          Patient, Doctor, & Society 2: NOTES (page 109 of 117)



      - examples:       “Violence is such a big problem for many people, and it impacts health in so many ways…”

    - ask
       - method:        ask questions in a nonjudgmental way
       - examples:      “How are things going in your relationship?”
                        “Have you ever been hit, kicked, slapped, shoved, or felt threatened in any way?

    - validate
       - method:        validate the patient
                        - do not blame or shame the abused person
                        - be nonjudgmental and supportive
      - examples:       “I’m so sorry this happened to you.”
                        “This is not your fault.”
                        “There is help available.”

    - evaluate
       - method:        evaluate, educate, and refer
                        obtain more information in order to offer the best resources
                        unless mandatory, respect the patient’s wishes regarding reporting
      - examples:       ask the patient what he / she needs
                        - “How are you dealing with this?”
                        - “How can I help? What do you need?”


•     Provide victims with information on community resources.

- resources
   - National Domestic Violence Hotline:       1800-799-SAFE
   - Family Violence Prevention Fund:          http://www.endabuse.org


•     Understand how an inappropriate response of the health care system may actually be a factor that
      contributes to the consequences of violence.

- inappropriate responses of the health care system
   - effects:         may result in lost trust
                      may further instigate violence

    - examples:         actions / questions to avoid include:
                        - asking in front of the abuser
                        - acting judgmental or pushy
                        - reporting against the patient’s wishes


•     Identify how the role of the health care system / health care practitioners is different from the role of other
      systems / other professionals in recognizing and responding to domestic violence.

- role of systems
   - health care:       screening, information, resources, and support
   - crisis centers:    information, resources, and support
   - police:            criminal prosecution
                                                                           Patient, Doctor, & Society 2: NOTES (page 110 of 117)




Ethics: Conscience Clauses
                                                                                                          March 20th, 2007

•   Define “conscience clause.”

- conscience clause
   - definition:       legal right to refuse provide certain medical services for reasons of religion or conscience
   - interpretation:   allows health care providers to opt out of practices they disagree with
   - clinical:         arose largely out of Roe v. Wade


•   Describe situations in which a professional’s conscience can directly conflict with a patient’s right to health
    care.

- issues of conscience
   - provision of services to a person with whom you find morally reprehensible
   - provision of services to a person with whom you vehemently disagree
   - provision of services with which you do not agree
      - abortions
      - vaccinations
      - sildenafil
      - fertility services for single people
      - birth control and other contraceptives
      - pain medications
      - therapies created using stem cell research
      - therapies created using animal research (get out of medicine now if this one’s a problem…




              FIGURE: Sildenafil



•   Discuss the extent to which professionals have a duty to ensure patient access to all professional services.

- range of protections is expanding in certain areas, including:
   - ability to opt out of services
   - discrimination in hiring, promotions
   - medical malpractice


•   Discuss alternatives when personal conscience conflicts with patient rights.

- alternatives to providing services
   - referral to another provider
   - refusal to refer, but inform about the range of legally available options
   - refusal to refer, refusal to inform
                                                                         Patient, Doctor, & Society 2: NOTES (page 111 of 117)




Student Finances
                                                                                          Wednesday, April 11th, 2007

•     Appreciate how your financial future depends not only on the health care financial environment, but to a
      greater extent on your personal decisions and philosophy.

Student finances will not be covered for the PDS III final exam.




Caring for Lesbian, Gay, Bisexual, and
     Transgendered People
                                                                                          Wednesday, April 18th, 2007

- history
   - 1969:         patrons of Stonewall Bar in New York riot in streets (start of modern gay rights)
   - 1973:         homosexuality no longer an APA mental disorder
   - 1981:          “Gay and Lesbian Medical Association” established to advocate LGBT rights in medicine
   - 1993:         AMA includes sexual orientation into non-discrimination statement

- community resources
   - adolescent peer groups
   - coming out support groups
   - AODA groups, treatment centers
   - domestic violence services
   - parenting groups
   - Parents and Friends of Lesbians and Gays (PFLAG)


•     Review how to take a social and sexual history that is inclusive of all patients, including LGBT people.

- improving comfort level
   - do not assume heterosexuality
   - accept knowledge of sexuality as routine
   - respect and welcome the partner (ensure that the partner is treated as would be any other spouse)
   - use inclusive language

- using inclusive language
   - social history (before sexual history)
      - “Who are the important people in your life?”
      - “Whom do you include in your immediate family?”
      - “Are you married, partnered, divorced, widowed?”
      - “Do you have a life partner or lover?”

    - sexual history
       - “Is birth control an issue for you?”
       - “Are you currently sexually active? Men, women, both?”
                                                                           Patient, Doctor, & Society 2: NOTES (page 112 of 117)



      - “Over your lifetime, have your sexual partners been men, women, both, or neither?”


•     List the differences between transgendered, transsexual, and inter-sexed individuals. Use correct
      terminology and pronouns when communicating with transgendered individuals.

- defining sexual behavior
   - women who have sex with women (WSW)
   - men who have sex with men (MSM)

    BOX: Sexual Behavior
     Do not use the terms “gay” or “lesbian” when inquiring about sexual behavior. Many persons engaging in
      same-sex behaviors (WSW, MSM) may not identify as gay or lesbian.



- defining discrimination
   - heterosexism: assumption of heterosexuality and a “societal norm” with institutions excluding gays and lesbians
   - homophobia: fear / hatred of homosexuals and homosexuality
      - external:      perpetuation of stereotypes depicting gays and lesbians as immoral, child molesters, etc.
                       overtly observed or experienced expression of bias
                       - social avoidance
                       - verbal abuse
                       - employment, housing, and religious discrimination
                       - physical battery

      - internal:       learned biases in LGB peoples’ own beliefs
                        - “They won’t love me if they know.”
                        - “My relationship is not as valuable.”
                        - “I’m sick, immoral, undesirable, unfeminine…”

- defining gender identity
   - transgender:      umbrella term for people who transcend the typical dichotomous gender paradigm
                       - transsexual
                       - drag kings / queens
                       - cross dressers
                       - two spirit
                       - inter-sex

    - transsexual:      replaced in DSM-IV as Gender Identity Disorder, with criteria that include:
                        - strong, persistent cross-gender identification
                        - persistent discomfort with gender
                        - not concurrent with inter-sex
                        - causes clinically-significant distress / impairment

- defining gender
   - transgendered woman:        male to female (MTF)
   - transgendered man:          female to male

    BOX: Sexual Behavior
     Always refer to a person by their presenting gender, regardless of surgical status, ease of “passing,” or
       hormonal status.
                                                                           Patient, Doctor, & Society 2: NOTES (page 113 of 117)



- language in the medical record
   - transsexual (or transgendered) woman/man
   - pre-operative / post-operative transsexual woman
   - transsexual man s/p bilateral mastectomy and TVHBSO
        (transvaginal hysterectomy and bilateral salpingo-oophorectomy)


•     Understand the struggles faced by LGBT persons within medical and social settings through a panel
      discussion.

- hiding homosexuality
   - social isolation:        drives hidden subculture
   - personal isolation:      requires continual dishonesty, assumptions
   - energy-consuming:        every answer / action requires cost-benefit analysis
   - perpetuation of bias:    heterosexuals unaware of gays / lesbians as colleagues, friends, or family members


- health care issues in LGB populations
   - discrimination: overt discrimination
                        fear of discrimination

    - access:             limited partner access to insurance
                          no legal role for partners in medical decision-making without power of attorney

    - health behaviors:   suicide 3x more likely in gay adolescents
                          substance abuse 2-3x more likely in gays and lesbians


- misperceptions regarding LGB populations
  - domestic violence
     - perception:    domestic violence is not a problem in LGB relationships
     - reality:       similar prevalence between homosexuals and heterosexuals
                      - abusers use homophobia as a means of control
                      - most state statutes are not inclusive of partners
                      - shelters / resources are often not welcoming

    - pap smears
       - perception:      pap smears are not important in lesbians because this is transmitted with MF contact
       - reality:         pap smears are just as important in lesbians
                          - 75-90% of lesbians were previously sexually active with men
                          - cervical dysplasia found in 2.7%, HPV in 37% of lesbians
                          - HPV transmission has been documented between female partners

    - gay men and HIV
       - perception:  being gay leads to higher risk of HIV infection
       - reality:     behaviors more common in gay communities lead to higher risk of HIV in MSM
                      - idea of behavior vs. identity
                      - a true, monogamous relationship will be no more likely to result in new HIV infection

    - parenting
       - perception:      raising children in an LGB household will turn them into “teh gay”
       - reality:         children in LGB households have no differences in issues such as:
                          - intelligence
                          - gender role preference
                          - family and peer relations
                          - sexual identity
                                                                             Patient, Doctor, & Society 2: NOTES (page 114 of 117)



    - epidemiology: parenting is a strong desire of many gay couples
                    - 30-62% of lesbians express the desire to parent
                    - 8-10 million children are currently being raised in LGB households


- issues to address with gay and lesbian couples
   - HIV / AIDS:       still overwhelmingly affects gay community

  - STIs in MSM:          overall increased incidence of STIs, anal cancer
                          - proper screening, symptom history
                          - immunize against hepatitis B, hepatitis A

  - parenting:            certain issues may present more problems in LGB households with children, including:
                          - secrecy and disclosure
                          - harassment
                          - sexuality
                          - adolescent rebellion
                          - legal issues             (e.g. in Wisconsin, partner is unable to adopt)

  - medical records: may play a role in child custody / visitation, employment, military discharge
                     - discuss medical charts with patient beforehand
                     - inform patient and discuss release of information

- gender reassignment criteria
   - eligibility criteria: 18 years old
                           knowledge of hormones
                           either 3 month real-life experience or psychotherapy of duration specified by therapist

  - readiness criteria:   consolidation of gender identity during real-life experience or therapy
                          improving or stable mental health
                          hormones likely to be taken in a responsible manner

  - legal criteria:       no consistent legal standard
                          - living in role
                          - hormonal therapy
                          - gender reassignment surgery




Approach to a Patient with Vaginal Bleeding
                                                                                                  Tuesday, April 24th, 2007

- normal menstrual cycling
   - hypothalamic GnRH stimulates pituitary release of FSH and LH
   - follicle develops, increasing estrogen production
   - estrogen leads to mid-cycle LH surge, which triggers ovulation
   - corpus luteum forms, increasing progesterone production and stimulating endometrial secretory activity

- anovulation
   - disorder:            absence of ovulation in a person for whom it would normally be expected
   - etiology:            disturbance in the hypothalamic-pituitary-ovarian (HPO) axis
                          - puberty and perimenopause
                                                                         Patient, Doctor, & Society 2: NOTES (page 115 of 117)



                        - situational stress, weight loss, exercise training
                        - endocrine disorders
                        - polycystic ovarian syndrome (PCOS)
    - effect:           increased bleeding
    - mechanism:        decreased oocyte sensitivity to FSH and LH
                        - LH surge fails to occur, leading to anovulation
                        - failure of luteal formation leads to lack of progesterone
                        - estrogen builds up and eventually drops, leading to unpredictable endometrial shedding


•     State the normal menstrual interval.

- menstrual interval
  - regular menstrual interval:      mean of 28 days, standard deviation of 3.9 days
  - “normal” menstrual interval:     28 ± 7 days (21-35 days)


•     Define polymenorrhea, oligomenorrhea, menorrhagia, hypomenorrhea, metrorrhagia, and
      menometrorrhagia.

- terms of abnormal menstruation
   - polymenorrhea:       decreased interval (< 21 days)
   - oligomenorrhea:      increased interval (> 35 days)
   - menorrhagia:         increased flow
   - hypomenorrhea:       decreased flow
   - metrorrhagia:        irregular bleeding
   - menometrorrhagia:    heavy, irregular bleeding


•     Identify the important history to obtain in a patient with vaginal bleeding.

- important history in vaginal bleeding
   - current menstrual interval      (comparison to normal)
   - current menstrual flow          (comparison to normal)
   - sexual history                  (unprotected intercourse, bleeding during intercourse)
   - contraceptive use
   - gynecological history           (pregnancies, surgeries)
   - emotional / physical stress
   - medication history              (hormones, ASA, NSAIDs)
   - thyroid symptoms
   - other bleeding / bruising


•     Identify the PE maneuvers appropriate in a patient with vaginal bleeding.

- physical examination
   - vital signs (signs of intravascular loss)
   - pelvic exam
   - targeted exams with suggestive symptoms
      - skin (including hirsutism)
      - thyroid


•     List the differential diagnosis for vaginal bleeding by age group, including reproductive age, perimenopause,
      and postmenopause.
•     Know the bleeding patterns most commonly associated with the disorders of reproductive age women.
                                                                        Patient, Doctor, & Society 2: NOTES (page 116 of 117)




- differential diagnosis by age group
   - reproductive age
      - menorrhagia pattern
        - uterine fibroids
        - bleeding disorders
        - endometrial cancer

    - post-coital bleeding
       - cervical polyps
       - cervicitis (PID)
       - cervical cancer

    - metrorrhagia pattern
      - pregnancy (including ectopic
      - hypothalamic dysfunction (stress, weight loss, chronic illness, overexercise)
      - polycystic ovarian syndrome (PCOS)
      - thyroid dysfunction
      - oral contraceptives

  - perimenopause
     - characterized by metrorrhagia from anovulatory cycles
     - may result in menorrhagia

  - postmenopause
     - uterine fibroids
     - endometrial cancer
     - cervical polyp / cervicitis / cancer
     - atrophic vaginitis
     - hormone replacement therapy




Ordinary Wizarding Levels (OSCE): Objectives
                                                                                             Tuesday, April 24th, 2007

WORKING WITH INTERPRETERS
• Demonstrate the following when interviewing a patient through an interpreter:
         • speak directly to the patient, not the interpreter
         • speak at an even pace in relatively short sentences
         • avoid jargon or technical terms
         • expect that everything you say will be interpreted


GASTROINTESTINAL SYSTEM
• Elicit a focused gastrointestinal history.
• Inspect the abdomen.
• Auscultate the abdomen for bowel sounds and bruits.
• Percuss the upper and lower borders of the liver and spleen.
• Palpate all four quadrants of the abdomen initially lightly, then deeply (including abdominal aorta).
• Palpate the liver and spleen.
• Test for irritation of the obturator and iliopsoas muscles to help diagnose appendicitis.
                                                                     Patient, Doctor, & Society 2: NOTES (page 117 of 117)



•   Check for rebound tenderness.
•   Test for ascites using shifting dullness and fluid wave.
•   Develop a differential diagnosis for abdominal pain.


DIABETES CASE STUDY / HEALTH LITERACY
• Assess patient for literacy using the following questions:
             • Have you had experiences where doctors have not been clear?
             • Are there ways doctors have explained information that have worked well for you?
             • How happy are you with the way you read?
• Assess patient for literacy using the “brown bag test” (reviewing their medications).
• Demonstrate the following when communicating with a patient:
             • Limit the amount of information given and repeat it
             • Speak slowly, use plain, non-medical language
             • Check with the patient for understanding using the “teach back” technique
             • Provide opportunities for the patient to ask questions


ORAL PRESENTATIONS
• Demonstrate the following when performing an oral presentation:
         • speak with an appropriate volume
         • speak clearly
         • speak at a moderate pace (not too fast, not too slow)
         • do not read notes, good eye contact
         • avoid “umms” and “errrs”
         • appear relaxed (not too rigid or slouchy)
         • gesture appropriately (no excessive use of hands)
         • transition smoothly from one section to another
         • tell story in chronological order
         • use appropriate medical terminology

				
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