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Boards and Beyond: Behavioral Science

1. Basic Pharmacology
2. Behavioral Science
3. Biochemistry
4. Biostatistics and Epidemiology
5. Cardiology
6. Cell Biology
7. Dermatology
8. Endocrinology
9. Gastroenterology
10. Genetics
11. Hematology
12. Immunology
13. Infectious Disease
14. Musculoskeletal
15. Neurology
16. Pathology
17. Psychiatry
18. Pulmonology
19. Renal
20. Reproductive
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- Core Ethical Principles

1. Autonomy
 Adult patients have the right to make decisions about their own healthcare
 Obligation to tell the truth, ensure confidentiality, and create conditions necessary
for autonomous choice (informed consent)
 Must ALWAYS honor their preference in accepting or not accepting medical care
2. Beneficence
 Physicians have the duty to act in the patient’s best interest
 May conflict with autonomy (an informed patient has the right to decide) or what is
best for society (ex. mandatory TB treatment)
 Traditionally, patient interest supersedes
3. Non-Maleficence
 Do no harm
 Must be balanced against beneficence
 If benefits outweigh the risks, a patient may make an informed decision to proceed
4. Justice
 Treat patients fairly and equally
 Use health resources equitably
 Triage: Distributive justice; see sickest patients first because it is more fair

- Ethical Situations
• Gift from pharmaceutical company?
 Cash, tickets to a game, vacations, Rolex watch, etc. are NEVER acceptable
 Decline any gift if there is a conflict of interest
 Gifts that directly benefit patients (ex. a new handicap ramp) may be accepted
 Educational or low value (<$100) gifts may be accepted
 Special educational funding for medical students, residents, etc. may be accepted
• Honoraria (ex. drug company pays physician to due speech on new drug for cancer)
 Acceptable, but MUST be disclosed to audience before giving speech
• Gifts from patients? Small gifts are okay, but don’t accept a new watch, car, etc.
• Romantic relationship with patient? NEVER okay  Sexual misconduct (AMA rule)
• Doctors have the right to decline care for a patient
 However, once you begin care for a patient you cannot refuse treatment, but you
can still refer them to another doctor
 Ex: Dr. doesn’t want to perform abortion? You must refer them to another provider
• You should NOT give medical care (non-emergency) to family and friends
• Do not EVER ask a patient (during history taking) if they want a family member to leave the room
 Politely ask the family member (not the patient) if they could step out of the room
• Patient non-adherent to medications?
1) Provide written instructions
2) Simplify the treatment regimen
3) Ask patient to repeat the treatment regimen back to you
• Jehovah’s witness hemorrhaging and requires blood, but declines transfusion?
 Transfusion can be refused by adults, but TRANSFUSE MINORS (don’t need court order)
• Kid comes to ER with black eye and bruises on buttocks; parent says, “they fell off their bike?”
 Report suspected child abuse. Contact child protective services to ensure child is safe.
• Minors may consent for OCPs, prenatal care, STD treatment, and treatment for substance abuse
• Emancipated minors have full capability of giving their own consent for any medical treatment
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- Informed Consent
• Disclosures:
1) Explain diagnosis
2) Explain proposed treatment
3) Explain alternative treatment options
4) Explain risks and benefits of the proposed treatment
5) Explain risks of refusing the proposed treatment
• Ensure patient has ability to comprehend and understand
 Use medical language interpreter if needed
• Ensure patient has capacity to make their own medical decisions
• Ensure patient has full voluntariness
 Ensure they are making this decision free from any coercion or manipulation
• Ensure the patient knows they have the power to revoke written consent at any time (even orally)
• Scenarios where informed consent is not put to use:
1) Waiver: Patient waives the right of informed consent (patient can refuse by signing waiver)
2) Incompetent: Patient is deemed to lack the capacity of decision making
3) Therapeutic Privilege: The privilege of a provider to withhold information if disclosure would
severely harm a patient (ex. psychiatric patients  psychological threat)
4) Emergency: Implied consent overrides informed consent

- Organ Donation
• Attending doctor to patient (donor) cannot ask the family for the organs
 A specialized organ procurement organization is tasked with asking the family for organs
• Family consent is required for organ donation; organ donation cards do not permit final decision

- Pregnant Mother
• Pregnant women can refuse any medical treatment, even if the baby is in danger
• In the USA, pregnant women have full autonomy of their body
• Unborn baby is NOT considered a person until they are born

- Patient Confidentiality Exceptions

• May tell family a patient’s location in hospital and if they are stable condition or not
• Potential for harm to self or others (suicidal, homicidal)
• STDs: Duty to inform sexual partners (must first encourage patient to voluntarily disclose)
• Reportable Diseases (public health concern): TB, syphilis, gonorrhea, measles, mumps
• Child/elder abuse: Reporting is mandatory
 Must get the victim alone for interview
• Patients with seizures that drive (can consult with state DMV and disclose that driver has epilepsy)

- Spousal Abuse
• Get the potential victim alone for interview
• Ask if the patient feels safe at home
• Ensure the patient has a safe place to go or a plan in case of emergency
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- Decision Making Capacity

• Legal judgement (by a US judge in court) is required to determine if a patient is competent
• Clinicians can determine if a patient has decision-making capacity
• Components:
1) Patient is an adult (18+) or legally emancipated
2) Decision remains stable over time
3) Decision is not clouded by mental status (delirium, psychosis, drug intoxication)
4) Patient is informed (knows and understands)
5) Patient expresses a clear choice (yes or no)
6) Decision is consistent with the patient’s goals or values
• Intellectual disability (Down syndrome, Fragile X, etc.) does NOT prevent decision-making
 As long as the 6 components have been met, they can make their own decisions

- Surrogate Designation
• If no power of attorney (Proxy) is available to direct medical decisions on behalf of a patient
• Hierarchy of Command:
1) Spouse
2) Adult children
3) Parents
4) Adult siblings
5) Extended relatives

- Brain Death
• Ex: Parents want to keep child on ventilator after suffering brain death in ICU
• Solution:
 Explain to family that brain death is considered legal death in the USA
 Explain there is zero chance of recovery
 Bring case to ethics board if they still do not support
 Life support can be withdrawn even if the family objects

- Disease Prevention
• Primary: Prevent disease before it occurs (prenatal vitamins, vaccines)
• Secondary: Prevent early asymptomatic disease via screening (mammogram, pap, colonoscopy)
• Tertiary: Treatment to reduce disease complications (chemotherapy, cardiac rehab)
• Quaternary: Prevent overtreatment; avoid unnecessary medical interventions
 Goal is to minimize medical intervention induced harm
 Ex: Minimize number of prescriptions to reduce polypharmacy
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- Medicare
• Federal government program funded by US taxes
• Provides health insurance for:
1) Patients 65+
2) Disabled patients under 65
3) Patient on dialysis

Part A Part B Part C Part D

Hospital payments Outpatient treatment Private insurance Prescription drug coverage
Hospice care Clinic visits, blood tests Provides A + B

- Medicaid
• Joint federal and state health assistance for poor people
• Must make under $17,000 a year in FL to be eligible (single person)

- Private Insurance
• Health Maintenance Organization (HMO):
 Insurance companies hire select providers
 Pros: Least expensive route for private insurance
 Cons: You can only get coverage if you choose an approved HMO provider
• Preferred Provider Organization (PPO):
 Pros: See any doctor you want (very flexible)
 Cons: Most expensive plan
• Point of Service Plan (POS):
 Must first see specific primary care doctor
 Can go “out of network” with a higher co-pay (but still covered)

- Hospice Care
• Expected survival <6 months
• Double Effect: The patient is dying; just make them comfy with opioids, sedatives, anxiolytics
 Making the patient comfortable outweighs potential negative side effects of the drugs
 Ex: Prioritize pain relief > respiratory depression
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- Quality and Safety Control

• Medication Reconciliation: Identification of the most accurate medication list for a patient
• Antimicrobial Stewardship: Hospital committee that monitors Abx use to prevent resistance
• Forcing Functions: Systems that prevent errors (ex. cannot order meds until allergies inputted)
• Process Improvement (PDSA) Model: Plan, Do, Study, Act
• SBAR: Situation, Background, Assessment, Recommendation
 Standardized communication used by nurses when calling the doctor

- Geriatrics
• Drugs that precipitate falls:
 Hypnotics (BZ1 agonists): Zolpidem, Zaleplon, esZopiclone
 Benzodiazepines: Alprazolam, clonazepam
• Fall prevention: Exercise, tai chi
 There is NO evidence that walkers or canes help prevent falls
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Infant and ch il
Mile stone dates are ranges that have been approximated and vary by source. Children not meeting
d development
milestones may need assessment for potential developmental delay.
AGE MOTOR SOCIAL VERBAL/COGN ITIVE

Infant
Parents St art Obser ving,
0-12 mo P rimi tive reflex es disappear Social smile (by 2 mo) O rie nts- first to voice (by
Moro (by 3 mo), rooting (by Strang er anxiet y (by 6 mo) 4 mo), then to nam e and
4 mo), palmar (by 6 mo), Separation anxiet y (by 9 mo) gestures (by 9 mo)
Babinski (by 12 mo) O b je ct permanence (by 9 mo)
Posture- lifts head up prone (by O ratory- says "mama " and
1 mo), rolls and sits (by 6 mo), "dada " (by 10 mo)
crawls (by 8 mo), stands (by
10 mo), walks (by 12- 18 mo)
P icks - passestoys hand to
hand (by 6 mo), P in cer grasp
(by 10 mo)
Points to objects (by 12 mo)
Toddler Child Re arin g Working,
12-36 mo C ruises, take s first steps (b y Recrea tion- parallel play (by Words- uses 50-200 words by
12 mo) 24- 36 mo) 2 yr, uses 300+ words by 3 yr.

C limbs stairs (b y 18 mo) Rapprochement - moves away

C ubes stacked - number
= age (yr) x 3
C utlery- feeds self with fork
and spoon (by 20 mo)
Kicks ball (by 24 mo)
Preschool Don't
3-5 yr Drive - t ric ycle (3 wheels at
3 yr)
D rawin gs- co pies line or
circle, stick figure (by 4 yr)
D exterit y- hops on one foot
(by 4 yr), uses buttons or
zippers , grooms self (by 5 yr)
from and returns to moth er
(by 24 mo)
Real iza tion- core gender
id entity form ed (by 36 mo)
Forget, they're still
F reedom - comfortab ly spends
part of day away from mother
(by 3 yr)
Friends - cooperative play, has
imaginar y friend s (by 4 yr)
Lea rning!
Language - understands 1000
words by 3 yr (3 zeros), uses
complete sente nces and
prepositions (by 4 yr)
Legends - can tell detailed
stories (b y 4 yr)

Low birth weight Defi ned as < 2500 g. Caused by prematurit y or intrauterine growth restriction (IUGR). Associated
with t risk of sudden infant death synd rome (SIDS) and with t o vera ll mortalit y.

Medical error analysis

DES IGN METHODS

Ro ot cause ana lysis
Retrospective approa ch. Applied aft er fail ure Uses rec ords and participant interview s to identify
eve nt to prevent rec u rrence . all the und erlyin g proble ms (eg, process,
people, environ men t, equipment , materials,
manage ment) tha t led to an error.
Failure mode and
Forward-looking app roac h. Applie d before Uses in duc tive reasoning to identify all the ways
effects analysis
process i mple mentation to prevent failure a process mig ht fail and prioritizes th em by
occurrence. th eir probability of o ccu rrence and im pact on
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patients.
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