uWorld

Tuesday, 9 June 2015 6:53 pm

1. High Sensitivity:
a. Important for screening tests
i. Diseases that have severe consequences if left untreated
ii. Diseases that if detected early are treatable

2. Positive predictive value

a. Depends on disease prevalence

3. Setting a higher cutoff value --> Decreases sensitivity, but increases specificity

4. Validity = Accuracy; must compare with gold standard to determine accuracy

5. Reliability:
a. Quantified in terms of coefficient of variation (sd/mean) * 100

6. ARR - Percentage, actual difference in event rate between control and treatment groups
a. ARR = Control rate - Treatment rate
b. NNT = 1 / ARR
i. A lower number needed to treat = a more beneficial drug

7. Probabilities:
a. For independent events, the probability that all events will turn out the same = product of
prob each event
i. Also Probability of getting at least one positive test = ( 1 - probability of all negative)
b. Mutually exhaustive and exclusive
i. P(all negative) = p(1st sample) x p(second sample) x p (third sample)
ii. P(all negative) = 0.95 x 0.95 x 0.95
iii. P(all negative) = (0.95)3

8. Non-transmissible disease
a. Prevalence will increase if patients live longer
b. Incidence isn't affected by drugs that treat it (since disease is already present)

9. If the confidence interval does not include the null value ( 0, or if it's a cohort study then RR > 1),
the results of the mean differences or whatever are significant (p < 0.05)
a. 99% CI --> p value <0.01

10. Analyzing the results of any study:

a. Clinical significance of the effect being measured
b. Duration of measurement
c. Adverse effects

11. p > 0.5 in a study with similar design + results but small sample size
a. Increasing sample size helps detect the changes better; hence p < 0.5
b. β = the probability of missing a true positive effect; random errors.
c. Power = (1 - β) increases with increasing sample size

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 12. Berkson's bias
a. Selection bias created by selecting hospitalized patients as control group

13. Attack rate - ratio of people who contract an illness / no of people at risk
a. Food item responsible for an outbreak has the largest attack rate, and the difference in
attack rates btw those who consume the thing and those who dont

14. Effect modulation isnt a bias. It has to be described, not corrected.

a. It is a factor that effects the outcome of an exposure variable
b. Can be confused with confounding
i. Stratified analysis differentiates between the two
ii. If results are stratified based on the confounding variable, the false association
disappears

15. Pygmalion effect:

a. Researchers beliefs in the efficacy of the treatment - potentially effects the outcome

16. Hawthorne effect:

a. Study subjects change their behaviour as they become aware that they are being studied.
Affects the validity of the study
b. May change their behaviour mid way in the study
c. Minimize this by keeping those being studied unaware about that fact; but this isnt always
ethical

17. Negative predictive value (NPV)

a. Prevalence of a disease is directly related to the pretest probability of having that disease.
Hence NPV depends on the pretest probability
b. NPV = TN / TN + FN
c. Read the case; and analyze the risk factors
i. High risk individuals for HIV (drug user, multiple sex partners)
1) High pretest probability for having HIV
2) Low NPV
ii. Low risk individuals
1) High NPV, more likely that a negative test really means he/she is disease free
d. Similar concept for positive predictive value (PPV)

18. PPV: [Can you stop getting this wrong now please?]
a. TP / (TP + FP)
b. More common a disease in an area, the more likely a positive test will be TP
c. Decreases with increase in sensitivity
i. Increase in TP
ii. But at the same time FP are increased (more than TP)

19. Positive likelihood ratio & Negative likelihood ration:

a. LR [+] = Sensitivity / 1 - Specificity
b. LR [-] = (1 - Sensitivity) / Specificity

20. Ecological study [WUT D FUCK]

a. Not studying individuals (vs Cross sectional survey - studying individuals)
b. Instead you're studying a population characteristic (Vit D intake) and comparing that to an
outcome (MS)
c. Useful in generating hypothesis; but don’t make conclusions about the individuals within
these population groups - Ecological fallacy
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 these population groups - Ecological fallacy

21. Nested case control studies

a. Start with cohort studies and follow people
b. Those who develop an outcome become cases for a case control study

22. Qualitative study

a. Focused discussion groups
b. Interviews (structured / non structured)

23. Precision = reliability

24. Recall bias:

a. Retrospective case control studies
b. People with poor outcomes are more likely to recall/remember risk factors
c. Not a source of bias in prospective case controls
i. Since questionnaires are worded like "how much alcohol do you drink per day"
ii. Basically the questionnaires don’t force you to think far back into the past.

25. Referral bias - depends on the hospital admission/referall practices

a. Harvard will get patients from the whole country
b. Small hospital in a corner somewhere wont

26. Detection bias:

a. Having a risk factor increases the vigilance and extent of investigation, makes it more likely
that you'll identify a disease

27. Allocation bias --> Fix with randomisation

28. Sampling bias --> Non random sampling of a population; study population has characteristics
different from the target population

29. Retrospective cohort study

a. Exposure status is determined retrospectively, and patients are tracked from that time
onwards using medical records

30. Cross over study:

a. Patients serve as their own controls
b. Washout period - time gap between the two treatment phases to ensure the effect of the
first doesn’t alter the response to the second treatment

31. Case series - Descriptive study, tracks a patient with a known condition (exposure, risk factor,
disease) to document natural history or response to treatment.
a. Qualitative, not quantitative

32. Statistical tests:

a. Multiple linear regression
i. Linear relationship between a dependant variable (outcome) and 2 or more
independent variables (exposures)
b. Pearson coefficient
i. Measure of strength and direction of a linear relationship btw 2 variables

33. Kaplan-Meier plots: Measure median survival time, used in clinical trials
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 33. Kaplan-Meier plots: Measure median survival time, used in clinical trials
34. Estimating survival + the factors that affect it - Cox regression (produces a Hazard ratio)
a. Hazard ratio treated vs untreated = 0.5; you're half as likely to die

35. Correlation coefficient has nothing to do with the slope itself. A perfectly positive correlation
between two variables may have varying slope magnitudes, but the coefficient will be +1 in both
cases [important]
36. Correlation coefficient gives information about: Strength and polarity

37. Latent period:

a. The time it takes for an effect/disease to manifest
b. Short latent period
i. Infectious diseases, iv drugs
c. Long latent period
i. Cancer, heart disease, antioxidant therapy etc
ii. Continuous exposure to risk factors might be needed for a long time for its effect to
be seen on disease progression

38. Lead time bias - catching a disease earlier than you would otherwise, and then interpreting it as
extending the life of the person when in fact the disease pathogenesis hasn’t changed.

39. Observer bias - reduced by double blinding; multiple partners encode and verify the recorded
data.
a. Double blinding - patient + researcher blinded

40. Rare disease assumption

a. If the disease is rare, then a << b and c << d
b. Relative risk = Odds ratio
c. ⎯⎯⎯⎯⎯ ⎯⎯⎯⎯⎯≅ ⎯⎯/ ⎯⎯=
+ +

41. Beta error - is a random error; not a systematic error (bias)

42. Reporting statistics in papers:
a. Mean +- the standard error (not standard deviation, because standard error takes into
account the fact that your study population is a sample)
b. For 95% CI; mean +- (1.96 x se)
c. For 99% CI ; mean +- (2.58 x se)
d. . . = ⎯⎯⎯
⎯⎯
√

43. Case control study: You chose controls vs cases by outcome variable only; exposure variable is not
important.
a. Kids with AML vs Kids who don’t have AML; then ascertain the exposures
b. Matching to decrease the effects of confounders - using only independent variables aren't
tested.
i. Things like age, race etc are accounted for by matching
c. If you do a non-random selection based on exposure values, your results will be screwed
with bias.

44. Attrition bias - is a type of selection bias (Systematic error) due to loss of subjects in a follow up
study, wherein the lost subjects differ in risk of developing outcome. (heavy smokers lost in a
study taking smoking as a risk factor for lung cancer)

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 45. Random misclassification bias
a. Using an incorrect method to classify groups; ie not using a pediatric cuff to measure bp of
kids --> random misclassification error in both groups.

46. Skew of a curve:

a. Determined by the direction of the tail
b. Median is a better central tendency for data if skew is present
c. Positive skew:
i. Mean > Median > Mode
d. Normal distribution:
i. Mean = Median = Mode

47. Power of attorney

a. Person who is awarded power of attorney makes medical decisions for the patient
i. Relative
ii. If no relatives exist & patient is incapcitated, a court appointed power of attorney
maybe
b. Medical errors must be reported to the person holding power of attorney
i. Disclose error as soon as error is known (confirm with staff if error has been made if
not totally clear). Doesn’t matter if harm wasn't done.
ii. Patients are less likely to bring litigation

48. Risk management staff = ensures hospital can handle lawsuits

49. Systems-based approach to preventing medical errors:

a. Root cause analysis
i. Figure out what, why and where things went wrong
ii. Interviews and shit
b. Recommendations based on root cause come after the initial analysis

50. Advance directives

a. Must ask about these as part of the hospitalization process
i. Preferably in outpatient setting
ii. Readdress during hospitalization
b. Living will
i. Intubation, CPR, enteral feeding, life prolonging interventions
c. Health care proxy
i. Someone to take medical decisions in his place, according to the patients wishes as
outlines in the living will
d. If advance directives are absent, then you must provide emergency services to the patient
before doing anything like contacting family or whatever.

51. Surgical sterilization in a younger childless female

a. Review risks and benefits of procedure
b. Ask if she has discussed with SO
i. She doesn’t need his consent however
ii. SO will be supporting her through recovery, and it's best if he knows.
c. Don’t immediately refer out to a surgeon to snip the tubes

52. Situations in which minors (<18 years) don’t require parental consent:
Medical • Emergency care
• STD
• Substance abuse & rehab (most states)
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 • Substance abuse & rehab (most states)
• Prenatal care (most states)
• Remember that most states require prior consent before
abortion, 1/3 require notification but no consent

• Few states allow physician to inform the parent/legal

a. guardian against minors wishes

Emancipated minor • Homeless

doesn’t need consent • Parent
of any kind • Married
• Military
• Financially independent
• High school graduate

53. Advance directives when absent, surrogate (spouse --> adult children) is asked what the patient
would have wanted and follow that. If everyone is uncomfortable with patients preference but
know it is what he would have wanted, then do that.

54. Not treating patient because of personal beliefs when the patient is under your care - patient
abandonment. You must refer to someone else if you feel you are morally conflicted.

55. It is rarely appropriate to interject your own beliefs regarding religion, without solicitation of your
ideas by the patient.
a. Use religion to ease patients burden; not criticize or disagree with it
b. Offer a chaplain if end of life care etc; offer your own consolation if emergent

56. Report elder abuse if care-giver refuses to let the physician talk to the patient privately to ask
more questions and confirm

57. Reflection:
a. Interview technique where the physician repeats what he has just been told.
b. Allows patient to clarify points that have been misunderstood; reassures patient that
physician is listening

58. Support:
a. Acknowledging the patients feelings, but not saying 'I understand'. Rather saying stuff like 'a
lot of people in your shoes feel the same way'

59. Summarization:
a. Several ideas whittled down to key statements

60. Open ended questions:

a. Make the patient feel heard
b. Prevents the physician from missing out on important parts of history
c. Rapport
d. Increase specific questions to confirm/clarify things as the history progresses

61. Intellectualization = extensive, academic-type thought to avoid emotional issues. Immature

defense mechanism.
a. Thinking about steps of an operation in meticulous detail once a patient dies to suppress
feelings of failure.
b. Different from isolation of affect; read Psych
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 b. Different from isolation of affect; read Psych
c. (vs rationalization - Oh this experience of cancer has been good for me because xyz)

62. Suppression - Consciously making efforts to stop worrying about results till they're released;
mature

63. Prevalence = (incidence) x (Time)

a. Increased quality of care prolongs the duration of disease that cant be cured (Ie people
don’t die); hence prevalence increases.
b. Increased diagnostic accuracy - increases incidence and prevalence
c. High mortality rate - decreases prevalence, or prevalence kept stable

64. Treating friends and family is ethically justifiable only under exceptional emergency situations.
a. Just say you're not comfortable prescribing someone you're not treating

65. Empathy wins, paternalistic directives / condescending, judgemental tones lose.

66. Drug non-compliance :
a. More common when lots of drugs with multiple times per day schedules

67. When can you violate HIPAA:

a. Patient is present and doesn’t object to sharing information when given reasobale
opportunity
b. Emergency situation - Patient is not present; provider determines that sharing information
is in the patients best interests
i. HIPAA doesn't require proof of identity
ii. Give general details (xyz suffered an MI)
iii. Refrain from specifics (MI due to cocaine overdose or whatever)

68. Jehovas witness:

a. Card that identifies desire to refuse blood products
b. Surrogate decision maker (if patient is incapacitated)
c. Kids - always treat in emergencies
i. Come to the childs best interests if not emergency, involve religious people + ethics
committees.
ii. Court order if necessary
d. Adults - always treat despite whatever if no card / surrogate

69. Empathy and all that wishy washy bs

a. Empathy = "I can understand, bla bla"; emphasis on the 'I'

70. Mode - most frequently observed value; resistant to outliers (vs mean which is very sensitive)
71. Confrontation - only to draw patients attention to discrepancies to whatever he or she is saying.
72. Always use a trained interpreter - they will help insure unintentional omissions, additions,
substitutions, opinions, etc arent given. Family members may not be familiar with medical terms
and may not have good english.

73. BAC (Blood alcohol content) > 0.10% results in intoxication, slurred speech, impaired decision
making capacity. BAC > 0.20% results in marked motor impairment, loss of consciousness, memory
blackouts.
a. Incapacitation = can't make medical decisions
b. In emergent setting, patient may be restrained since he's drunk + temporarily incapacitated.

74. Attributable risk percent (ARP)

−1
× 100
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 −1
a. ⎯⎯⎯⎯⎯⎯⎯× 100

75. Involving risk management or ethics committee is frequently an incorrect choice because you're
expected to handle situations yourself; but it is appropriate when someone threatens a lawsuit.

76. EMTALA - inappropriate transfer, discharge, refusal of treatment in emergency setting.

a. Must be screened appropriately
b. Stabilized; no consideration of ability to pay

77. Linear regression

a. A line that fits a linear equation, best describing a cause-effect relationship
b. Different from correlation coefficient:
i. Linear regression - btw dependent & independent variable
ii. Correlation - btw 2 measured variables
c. However Pearson's R2 = regression coefficient

78. Not all treatments end up helping people; NNH = the number of people who must be treated
before adverse event occurs.

79. Assess misunderstanding + Educate patients about the drugs, dangers of not adhering to a
schedule, loss of efficacy etc. Don’t assume that writing things down or telling them to do it
paternalistically will help.

80. Sexual history:

a. Neutral, open, non-judgmental
b. Questions should be direct
c. "Are your sexual partners women, men, or both?"

81. Patient confidentiality:

a. Neither confirm or deny whether the patient of interest is a patient or not.
b. Literally don’t talk about patients. At all.

82. DNR
a. No intubation / mechanical ventilation
b. No defibrillation / iv drugs to acutely treat terminal rhythm
c. No chest compressions
d. Any extra requests from patients are cool too
e. If no documentation, order to follow:
i. Spouse > Adult kids > Parents > Adult Siblings

83. Have 2 independent health care workers verify the surgical site / patient / procedure (not
together). Have a surgical timeout immediately prior to the procedure to do a final verification.

84. Always use trained fucking translators unless it clearly is an emergency

85. Be aware of literacy limitations of patients:

a. Make them watch a video / explore alternate learning methods
b. Certain populations / socioeconomic groups are more likely to be illiterate
c. Patients will hide that shit because they'll be ashamed of it

86. Prevention of disease

Primary Prevents disease from Health promotion activities (regular
happening exercise, no smoking, weight loss)
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 happening exercise, no smoking, weight loss)

a. Secondary Detecting disease before Case finding

symptoms occur community screening
Tertiary Treating disease to prevent Disability limitations
progression / complications Rehabilitation (physical therapy after
stroke)

87. Health risk assessment:

a. Using questionnaires to calculate the 'risk age'
b. If risk age > chronological age; patient has a higher risk of death

88. 68/95/99 rule - 1SD / 2SD / 3SD for a normal distributed curve

89. Physicians are justified in obtaining a court injunction to proceed with life saving medical
treatment of the child.

90. Relationship with past patients is okay if non-psychiatric. Must terminate a patient-physician
relationship before beginning a personal one.

91. Don’t use trailing zeroes or abbreviations in drug orders

92. Computerized systems will flag inappropriate drugs, interactions, allergies, dosage limits etc but
not warn of an inappropriate dose
93. Closed loop communication:
a. Person receiving - repeat order
b. Person sending - 'yes' after hearing the receiver repeat the order

94. Ascertainment + Observer bias - results from mislabeling of exposed/unexposed or cases/controls

95. Opioid analgesics - majority of overdose related deaths

96. All adolescent visits should include an opportunity to interview the patient alone and discuss
topics like drugs, sex, whatever (esp when the parents presence is interfering with obtaining
honest answers)

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