HIGH-YIELD PRINCIPLES IN

Public Health Sciences

“It is a mathematical fact that fifty percent of all doctors graduate in the ``Epidemiology and
bottom half of their class.” Biostatistics 252
—Unknown
``Ethics 260
“There are two kinds of statistics: the kind you look up and the kind you
make up.” ``The Well Patient 264
—Rex Stout
``Healthcare Delivery 265
“On a long enough timeline, the survival rate for everyone drops to zero.”
—Chuck Palahniuk ``Quality and Safety 267
“There are three kinds of lies: lies, damned lies, and statistics.”
—Mark Twain

A heterogenous mix of epidemiology, biostatistics, ethics, law, healthcare

delivery, patient safety, quality improvement, and more falls under the
heading of public health sciences. Biostatistics and epidemiology are the
foundations of evidence-based medicine and are very high yield. Make
sure you can quickly apply biostatistical equations such as sensitivity,
specificity, and predictive values in a problem-solving format. Also, know
how to set up your own 2×2 tables. Quality improvement and patient
safety topics were introduced a few years ago on the exam and represent
trends in health system science. Medical ethics questions often require
application of principles. Typically, you are presented with a patient
scenario and then asked how you would respond.

251

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 252 SECTION II Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics Pu

PUBLIC HEALTH SCIENCES—EPIDEMIOLOGY AND BIOSTATISTICS

``

Observational studies
STUDY TYPE DESIGN
Cross-sectional study Frequency of disease and frequency of risk-
related factors are assessed in the present.
Asks, “What is happening?”
Case-control study Compares a group of people with disease to a
group without disease.
Looks to see if odds of prior exposure or risk
factor differs by disease state.
Asks, “What happened?”
Cohort study Compares a group with a given exposure or risk
factor to a group without such exposure.
Looks to see if exposure or risk factor is
associated with later development of disease.
Can be prospective (asks, “Who will
develop disease?”) or retrospective (asks,
“Who developed the disease [exposed vs
nonexposed]?”).
Twin concordance Compares the frequency with which both
study monozygotic twins vs both dizygotic twins
develop the same disease.
Adoption study Compares siblings raised by biological vs
adoptive parents.
MEASURES/EXAMPLE
Disease prevalence.
Can show risk factor association with disease, but
does not establish causality.
Odds ratio (OR).
Patients with COPD had higher odds of a
smoking history than those without COPD.
Relative risk (RR).
Smokers had a higher risk of developing COPD
than nonsmokers.
Measures heritability and influence of
environmental factors (“nature vs nurture”).
Measures heritability and influence of
environmental factors.

Clinical trial Experimental study involving humans. Compares therapeutic benefits of 2 or more treatments,
or of treatment and placebo. Study quality improves when study is randomized, controlled, and
double-blinded (ie, neither patient nor doctor knows whether the patient is in the treatment or
control group). Triple-blind refers to the additional blinding of the researchers analyzing the data.
Four phases (“Does the drug SWIM?”).
DRUG TRIALS TYPICAL STUDY SAMPLE PURPOSE
Phase I Small number of healthy volunteers or patients “Is it Safe?” Assesses safety, toxicity,
with disease of interest. pharmacokinetics, and pharmacodynamics.
Phase II Moderate number of patients with disease of “Does it Work?” Assesses treatment efficacy,
interest. optimal dosing, and adverse effects.
Phase III Large number of patients randomly assigned “Is it as good or better?” Compares the new
either to the treatment under investigation or treatment to the current standard of care (any
to the best available treatment (or placebo). Improvement?).
Phase IV Postmarketing surveillance of patients after “Can it stay?” Detects rare or long-term
treatment is approved. adverse effects. Can result in treatment being
withdrawn from Market.

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statistics Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 253

Evaluation of Uses 2 × 2 table comparing test results with the Disease

–
diagnostic tests actual presence of disease.
Sensitivity and specificity are fixed properties PPV
TP FP = TP/(TP + FP)
of a test. PPV and NPV vary depending on

Test
NPV
disease prevalence in population being tested. – FN TN = TN/(TN + FN)

Sensitivity Specificity Prevalence

TP + FN
= TP/(TP + FN) = TN/(TN + FP) (TP + FN + FP + TN)

Sensitivity (true- Proportion of all people with disease who test = TP / (TP + FN)
positive rate) positive, or the probability that when the = 1 – FN rate
disease is present, the test is positive. SN-N-OUT = highly SeNsitive test, when
Value approaching 100% is desirable for ruling Negative, rules OUT disease
out disease and indicates a low false-negative If sensitivity is 100%, then FN is zero. So, all
rate. High sensitivity test used for screening in negatives must be TNs.
diseases with low prevalence.
Specificity (true- Proportion of all people without disease who = TN / (TN + FP)
negative rate) test negative, or the probability that when the = 1 – FP rate
disease is absent, the test is negative. SP-P-IN = highly SPecific test, when Positive,
Value approaching 100% is desirable for rules IN disease
ruling in disease and indicates a low false- If specificity is 100%, then FP is zero. So, all
positive rate. High specificity test used for positives must be TPs.
confirmation after a positive screening test.
Positive predictive Probability that a person who has a positive test PPV = TP / (TP + FP)
value result actually has the disease. PPV varies directly with pretest probability
(baseline risk, such as prevalence of disease):
high pretest probability Ž high PPV
Negative predictive Probability that a person with a negative test NPV = TN / (TN + FN)
value result actually does not have the disease. NPV varies inversely with prevalence or pretest
probability

POSSIBLE CUTOFF VALUES

Disease Disease A = 100% sensitivity cutoff value
Number of people

absent present B = practical compromise between specificity and sensitivity

C = 100% specificity cutoff value

TN TP Lowering the cutoff point: ↑ Sensitivity ↑ NPV

↑ ↑ ↑
B A (↑ FP FN) Specificity PPV
↑

FN FP
Raising the cutoff point: ↑ Specificity ↑ PPV
A B C B C ( ↑ FN FP)
↑ ↑ ↑
Sensitivity NPV
↑

Test results

Likelihood ratio Likelihood that a given test result would be sensitivity TP rate
LR+ = =
expected in a patient with the target disorder 1 – specificity FP rate
compared to the likelihood that the same result
would be expected in a patient without the 1 – sensitivity FN rate
LR– = =
target disorder. specificity TN rate
LR+ > 10 and/or LR– < 0.1 indicate a very useful
diagnostic test.
LRs can be multiplied with pretest odds of
disease to estimate posttest odds.

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 a/c ad
Odds ratio = =
b/d bc

254 SECTION II Public Health Sciences   

PUBLIC HEALTH SCIENCES—Epidemiology
Relative risk =
a/(a + b)and Biostatistics
c/(c + d)
Pu
a c
Attributable risk =
a+b c+d

Quantifying risk Definitions and formulas are based on the classic Disease
2 × 2 or contingency table.

or intervention
Risk factor
a b

c d

Odds ratio Typically used in case-control studies. OR a/c ad

OR = =
depicts the odds of a certain exposure given an b/d   bc
event (eg, disease; a/c) vs the odds of exposure
in the absence of that event (eg, no disease;
b/d).
Relative risk Typically used in cohort studies. Risk of a/(a + b)
RR =
developing disease in the exposed group c/(c + d)
divided by risk in the unexposed group (eg, if
5/10 people exposed to radiation get cancer,
and 1/10 people not exposed to radiation
get cancer, the relative risk is 5, indicating a
5 times greater risk of cancer in the exposed
than unexposed). For rare diseases (low
prevalence), OR approximates RR.
RR = 1 Ž no association between exposure and
disease.
RR > 1 Ž exposure associated with  disease
occurrence.
RR < 1 Ž exposure associated with  disease
occurrence.
Attributable risk The difference in risk between exposed and a c
AR = −
unexposed groups (eg, if risk of lung cancer in a + b c + d
smokers is 21% and risk in nonsmokers is 1%,
then the attributable risk is 20%).
Relative risk reduction The proportion of risk reduction attributable to RRR = 1 − RR
the intervention as compared to a control (eg,
if 2% of patients who receive a flu shot develop
the flu, while 8% of unvaccinated patients
develop the flu, then RR = 2/8 = 0.25, and
RRR = 0.75).
Absolute risk The difference in risk (not the proportion) c a
ARR = −
reduction attributable to the intervention as compared c+d a+b
to a control (eg, if 8% of people who receive
a placebo vaccine develop the flu vs 2%
of people who receive a flu vaccine, then
ARR = 8% − 2% = 6% = .06).
Number needed to Number of patients who need to be treated for NNT = 1/ARR
treat 1 patient to benefit. Lower number = better
treatment.
Number needed to Number of patients who need to be exposed to NNH = 1/AR
harm a risk factor for 1 patient to be harmed. Higher
number = safer exposure.

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statistics Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 255

Incidence vs # of new cases (during a specified Incidence looks at new cases (incidents).
Incidence =
prevalence # of people at risk    time period)
# of existing cases (at a point in Prevalence looks at all current cases.
Recurrence Prevalence =
Total # of people    time)
Incidence
in a population
Prevalence Prevalence = average duration
Incidence rate ×
1 – prevalence of disease
Mortality Cure
Prevalence ≈ incidence for short duration disease Prevalence ∼ pretest probability.
(eg, common cold).  prevalence Ž  PPV and  NPV.
Prevalence > incidence for chronic diseases, due to
large # of existing cases (eg, diabetes).

Precision vs accuracy
Precision (reliability)
Accuracy (validity)
The consistency and reproducibility of a test.
The absence of random variation in a test.
The trueness of test measurements.
The absence of systematic error or bias in a test.
Random error  precision in a test.
 precision Ž  standard deviation.
 precision Ž  statistical power (1 − β).
Systematic error  accuracy in a test.

Accuracy Accuracy
High Low High Low

High High Low Low

Precision Precision

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 256 SECTION II Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics Pu

Bias and study errors

TYPE DEFINITION EXAMPLES STRATEGIES TO REDUCE BIAS
Recruiting participants
Selection bias Nonrandom sampling Berkson bias—study population Randomization
or treatment allocation selected from hospital is Ensure the choice of the right
of subjects such that less healthy than general comparison/reference group
study population is not population
representative of target Non-response bias—
population. Most commonly a participating subjects differ
sampling bias. from nonrespondents in
meaningful ways
Performing study
Recall bias Awareness of disorder alters Patients with disease recall Decrease time from exposure
recall by subjects; common in exposure after learning of to follow-up
retrospective studies. similar cases
Measurement bias Information is gathered in a Association between HTN Use objective, standardized,
systemically distorted manner. and MI not observed when and previously tested methods
using faulty automatic of data collection that are
sphygmomanometer planned ahead of time
Hawthorne effect—participants Use placebo group
change behavior upon
awareness of being observed
Procedure bias Subjects in different groups are Patients in treatment group Blinding and use of placebo
not treated the same. spend more time in highly reduce influence of
specialized hospital units participants and researchers
Observer-expectancy Researcher’s belief in the An observer expecting on procedures and
bias efficacy of a treatment changes treatment group to show signs interpretation of outcomes
the outcome of that treatment of recovery is more likely to as neither are aware of group
(aka, Pygmalion effect). document positive outcomes allocation
Interpreting results
Confounding bias When a factor is related to both Pulmonary disease is more Multiple/repeated studies
the exposure and outcome, common in coal workers Crossover studies (subjects act
but not on the causal pathway, than the general population; as their own controls)
it distorts or confuses effect of however, people who work in Matching (patients with
exposure on outcome. coal mines also smoke more similar characteristics in both
Contrast with effect frequently than the general treatment and control groups)
modification. population
Lead-time bias Early detection is confused Early detection makes it seem Measure “back-end” survival
with  survival. like survival has increased, (adjust survival according to
but the disease’s natural the severity of disease at the
history has not changed time of diagnosis)
Length-time bias Screening test detects diseases A slowly progressive cancer A randomized controlled trial
with long latency period, is more likely detected by a assigning subjects to the
while those with shorter screening test than a rapidly screening program or to no
latency period become progressive cancer screening
symptomatic earlier.

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statistics Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 257

Statistical distribution
Measures of central Mean = (sum of values)/(total number of values). Most affected by outliers (extreme values).
tendency Median = middle value of a list of data sorted If there is an even number of values, the median
from least to greatest. will be the average of the middle two values.
Mode = most common value. Least affected by outliers.
Measures of Standard deviation = how much variability σ = SD; n = sample size.
dispersion exists in a set of values, around the mean of Variance = (SD)2.
these values. SE = σ/√n.
Standard error = an estimate of how much SE  as n .
variability exists in a (theoretical) set of sample
means around the true population mean.
Normal distribution Gaussian, also called bell-shaped.
–1σ +1σ
Mean = median = mode.
–2σ +2σ
–3σ +3σ

68%
95%
99.7%
–1σ +1σ
Nonnormal distributions –2σ
–1σ +1σ
+2σ
Bimodal Suggests two different populations (eg, –3σ –2σ +2σ +3σ
–3σ +3σ
metabolic polymorphism such as fast vs 68%
slow acetylators; age at onset of Hodgkin 68%
95%
lymphoma; suicide rate by age). 95%
99.7%
Positive skew Typically, mean > median > mode. Mode 99.7%
Median
Mode
Asymmetry with longer tail on right. Median
Mean
Mean

Mode
Median
Negative skew Typically, mean < median < mode. Median
Mode
Mean
Asymmetry with longer tail on left. Mean

Statistical hypotheses
Null (H0) Hypothesis of no difference or relationship (eg, there is no association between the disease and the
risk factor in the population).
Alternative (H1) Hypothesis of some difference or relationship (eg, there is some association between the disease
and the risk factor in the population).

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 258 SECTION II Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics
Outcomes of statistical hypothesis testing
Correct result Stating that there is an effect or difference when
one exists (null hypothesis rejected in favor of
alternative hypothesis).
Stating that there is no effect or difference when
none exists (null hypothesis not rejected).
Incorrect result
Type I error (α) Stating that there is an effect or difference
when none exists (null hypothesis incorrectly
rejected in favor of alternative hypothesis).
α is the probability of making a type I error. p is
judged against a preset α level of significance
(usually 0.05). If p < 0.05, then there is less
than a 5% chance that the data will show
something that is not really there.
Type II error (β) Stating that there is not an effect or difference
when one exists (null hypothesis is not rejected
when it is in fact false).
β is the probability of making a type II error. β
is related to statistical power (1 – β), which is
the probability of rejecting the null hypothesis
when it is false.
 power and  β by:
ƒƒ  sample size
ƒƒ  expected effect size
ƒƒ  precision of measurement
Confidence interval Range of values within which the true mean
of the population is expected to fall, with a
specified probability.
CI for sample mean = x̄ ± Z(SE)
The 95% CI (corresponding to α = .05) is often
used.
For the 95% CI, Z = 1.96.
For the 99% CI, Z = 2.58.
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Pu
Reality
H1 H0
Power α
Study rejects H0
( 1 – β) Type I error
Study does not reject H0 β
Correct
Type II error
Also known as false-positive error.
α = you accused an innocent man.
You can never “prove” the alternate hypothesis,
but you can reject the null hypothesis as being
very unlikely.
Also known as false-negative error.
β = you blindly let the guilty man go free.
If you  sample size, you  power. There is power
in numbers.
If the 95% CI for a mean difference between 2
variables includes 0, then there is no significant
difference and H0 is not rejected.
If the 95% CI for odds ratio or relative risk
includes 1, H0 is not rejected.
If the CIs between 2 groups do not overlap
Ž statistically significant difference exists.
If the CIs between 2 groups overlap Ž usually
no significant difference exists.
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statistics Public Health Sciences   
PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 259

Meta-analysis A method of statistical analysis that pools summary data (eg, means, RRs) from multiple studies
for a more precise estimate of the size of an effect. Also estimates heterogeneity of effect sizes
between studies.
Improves strength of evidence and generalizability of study findings. Limited by quality of
individual studies and bias in study selection.

Common statistical tests

t-test Checks differences between means of 2 groups.
ANOVA Checks differences between means of 3 or more
groups.
Chi-square (χ²) Checks differences between 2 or more
percentages or proportions of categorical
outcomes (not mean values).
Tea is meant for 2.
Example: comparing the mean blood pressure
between men and women.
3 words: ANalysis Of VAriance.
Example: comparing the mean blood pressure
between members of 3 different ethnic groups.
Pronounce Chi-tegorical.
Example: comparing the percentage of members
of 3 different ethnic groups who have essential
hypertension.

Pearson correlation r is always between −1 and +1. The closer the absolute value of r is to 1, the stronger the linear
coefficient correlation between the 2 variables.
Positive r value Ž positive correlation (as one variable , the other variable ).
Negative r value Ž negative correlation (as one variable , the other variable ).
Coefficient of determination = r 2 (amount of variance in one variable that can be explained by
variance in another variable).
r = –0.8 r = –0.4 r=0 r = +0.4 r = +0.8

Strong negative Weak negative No correlation Weak positive Strong positive

correlation correlation correlation correlation

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 260 SECTION II Public Health Sciences   
BEHAVIORAL SCIENCE—Ethics

BEHAVIORAL SCIENCE—ETHICS
``

Core ethical principles

Autonomy Obligation to respect patients as individuals (truth-telling, confidentiality), to create conditions
necessary for autonomous choice (informed consent), and to honor their preference in accepting
or not accepting medical care.
Beneficence Physicians have a special ethical (fiduciary) 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 (eg,
mandatory TB treatment). Traditionally, patient interest supersedes.
Nonmaleficence “Do no harm.” Must be balanced against beneficence; if the benefits outweigh the risks, a patient
may make an informed decision to proceed (most surgeries and medications fall into this
category).
Justice To treat persons fairly and equitably. This does not always imply equally (eg, triage).

Informed consent A process (not just a document/signature) that
requires:
ƒƒ Disclosure: discussion of pertinent
information
ƒƒ Understanding: ability to comprehend
ƒƒ Capacity: ability to reason and make one’s
own decisions (distinct from competence, a
legal determination)
ƒƒ Voluntariness: freedom from coercion and
manipulation
Patients must have an intelligent understanding
of their diagnosis and the risks/benefits of
proposed treatment and alternative options,
including no treatment.
Patient must be informed that he or she can
revoke written consent at any time, even orally.
Exceptions to informed consent (WIPE it away):
ƒƒ Waiver—patient explicitly waives the right of
informed consent
ƒƒ Legally Incompetent—patient lacks decision-
making capacity (obtain consent from legal
surrogate)
ƒƒ Therapeutic Privilege—withholding
information when disclosure would severely
harm the patient or undermine informed
decision-making capacity
ƒƒ Emergency situation—implied consent may
apply

Consent for minors
A minor is generally any person < 18 years old.
Parental consent laws in relation to healthcare
vary by state. In general, parental consent
should be obtained, but exceptions exist for
emergency treatment (eg, blood transfusions)
or if minor is legally emancipated (eg, married,
self supporting, or in the military).
Situations in which parental consent is usually
not required:
ƒƒ Sex (contraception, STIs, pregnancy)
ƒƒ Drugs (substance abuse)
ƒƒ Rock and roll (emergency/trauma)
Physicians should always encourage healthy
minor-guardian communication.
Physician should seek a minor’s assent even if
their consent is not required.

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 Public Health Sciences   
BEHAVIORAL SCIENCE—Ethics SECTION II 261

Decision-making Physician must determine whether the patient is psychologically and legally capable of making a
capacity particular healthcare decision. Note that decisions made with capacity cannot be revoked simply
if the patient later loses capacity.
Capacity is determined by a physician for a specific healthcare-related decision (eg, to refuse
medical care). Competency is determined by a judge and usually refers to more global categories
of decision making (eg, legally unable to make any healthcare-related decision).
Components (think GIEMSA):
ƒƒ Decision is consistent with patient’s values and Goals
ƒƒ Patient is Informed (knows and understands)
ƒƒ Patient Expresses a choice
ƒƒ Decision is not a result of altered Mental status (eg, delirium, psychosis, intoxication), Mood
disorder
ƒƒ Decision remains Stable over time
ƒƒ Patient is ≥ 18 years of Age or otherwise legally emancipated

Advance directives Instructions given by a patient in anticipation of the need for a medical decision. Details vary per
state law.
Oral advance directive Incapacitated patient’s prior oral statements commonly used as guide. Problems arise from variance
in interpretation. If patient was informed, directive was specific, patient made a choice, and
decision was repeated over time to multiple people, then the oral directive is more valid.
Written advance Specifies specific healthcare interventions that a patient anticipates he or she would accept or reject
directive during treatment for a critical or life-threatening illness. A living will is an example.
Medical power of Patient designates an agent to make medical decisions in the event that he/she loses decision-
attorney making capacity. Patient may also specify decisions in clinical situations. Can be revoked by
patient if decision-making capacity is intact. More flexible than a living will.
Do not resuscitate DNR order prohibits cardiopulmonary resuscitation (CPR). Other resuscitative measures that may
order follow (eg, intubation) are also typically avoided.

Surrogate decision- If a patient loses decision-making capacity and has not prepared an advance directive, individuals
maker (surrogates) who know the patient must determine what the patient would have done. Priority of
surrogates: spouse Ž adult Children Ž Parents Ž Siblings Ž other relatives (the spouse ChiPS
in).

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 262 SECTION II Public Health Sciences  
Ethical situations
SITUATION
Patient is not adherent.
Patient desires an unnecessary
procedure.
Patient has difficulty taking
medications.
Family members ask for information
about patient’s prognosis.
A patient’s family member asks you
not to disclose the results of a test
if the prognosis is poor because
the patient will be “unable to
handle it.”
A 17-year-old girl is pregnant and
requests an abortion.
A 15-year-old girl is pregnant and
wants to keep the child. Her
parents want you to tell her to give
the child up for adoption.
A terminally ill patient requests
physician assistance in ending his/
her own life.
Patient is suicidal.
Patient states that he/she finds you
attractive.
A woman who had a mastectomy
says she now feels “ugly.”
Patient is angry about the long time
he/she spent in the waiting room.
Patient is upset with the way he/she
was treated by another doctor.
An invasive test is performed on the
wrong patient.
A patient requires a treatment not
covered by his/her insurance.
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BEHAVIORAL SCIENCE—Ethics
APPROPRIATE RESPONSE
Attempt to identify the reason for nonadherence and determine his/her willingness to
change; do not coerce the patient into adhering and do not refer him/her to another
physician.
Attempt to understand why the patient wants the procedure and address underlying
concerns. Do not refuse to see the patient and do not refer him/her to another
physician. Avoid performing unnecessary procedures.
Provide written instructions; attempt to simplify treatment regimens; use teach-back
method (ask patient to repeat regimen back to physician) to ensure comprehension.
Avoid discussing issues with relatives without the patient’s permission.
Attempt to identify why the family member believes such information would be
detrimental to the patient’s condition. Explain that as long as the patient has decision-
making capacity and does not indicate otherwise, communication of information
concerning his/her care will not be withheld. However, if you believe the patient
might seriously harm himself or others if informed, then you may invoke therapeutic
privilege and withhold the information.
Many states require parental notification or consent for minors for an abortion. Unless
there are specific medical risks associated with pregnancy, a physician should not
sway the patient’s decision for, or against, an elective abortion (regardless of maternal
age or fetal condition).
The patient retains the right to make decisions regarding her child, even if her parents
disagree. Provide information to the teenager about the practical issues of caring for
a baby. Discuss the options, if requested. Encourage discussion between the teenager
and her parents to reach the best decision.
In the overwhelming majority of states, refuse involvement in any form of physician-
assisted suicide. Physicians may, however, prescribe medically appropriate analgesics
that coincidentally shorten the patient’s life.
Assess the seriousness of the threat. If it is serious, suggest that the patient remain in the
hospital voluntarily; patient can be hospitalized involuntarily if he/she refuses.
Ask direct, closed-ended questions and use a chaperone if necessary. Romantic
relationships with patients are never appropriate. It may be necessary to transition care
to another physician.
Find out why the patient feels this way. Do not offer falsely reassuring statements (eg,
“You still look good”).
Acknowledge the patient’s anger, but do not take a patient’s anger personally. Apologize
for any inconvenience. Stay away from efforts to explain the delay.
Suggest that the patient speak directly to that physician regarding his/her concerns. If
the problem is with a member of the office staff, tell the patient you will speak to that
person.
Regardless of the outcome, a physician is ethically obligated to inform a patient that a
mistake has been made.
Never limit or deny care because of the expense in time or money. Discuss all
treatment options with patients, even if some are not covered by their insurance
companies.
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 Public Health Sciences  
Ethical situations (continued)
SITUATION
A 7-year-old boy loses a sister to
cancer and now feels responsible.
Patient is victim of intimate partner
violence.
Patient wants to try alternative or
holistic medicine.
Physician colleague presents to
work impaired.
Patient is officially determined to
suffer brain death. Patient’s family
insists on maintaining life support
indefinitely because patient is still
moving when touched.
A pharmaceutical company offers
you a sponsorship in exchange for
advertising its new drug.
An adult refuses care because it is
against his/her religious beliefs.
Mother and 15-year-old daughter
are unresponsive following a
car accident and are bleeding
internally. Father says do not
transfuse because they are
Jehovah’s Witnesses.
A 2-year-old girl presents with
injuries inconsistent with parental
story.
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BEHAVIORAL SCIENCE—Ethics SECTION II 263
APPROPRIATE RESPONSE
At ages 5–7, children begin to understand that death is permanent, that all life
functions end completely at death, and that everything that is alive eventually
dies. Provide a direct, concrete description of his sister’s death. Avoid clichés and
euphemisms. Reassure the boy that he is not responsible. Identify and normalize fears
and feelings. Encourage play and healthy coping behaviors (eg, remembering her in
his own way).
Ask if patient is safe and has an emergency plan. Do not necessarily pressure patient to
leave his or her partner, or disclose the incident to the authorities (unless required by
state law).
Find out why and allow patient to do so as long as there are no contraindications,
medication interactions, or adverse effects to the new treatment.
If impaired or incompetent, colleague is a threat to patient safety. Report the situation
to local supervisory personnel. Should the organization fail to take action, alert the
state licensing board.
Gently explain to family that there is no chance of recovery, and that brain death is
equivalent to death. Movement is due to spinal arc reflex and is not voluntary. Bring
case to appropriate ethics board regarding futility of care and withdrawal of life
support.
Reject this offer. Generally, decline gifts and sponsorships to avoid any appearance of
conflict of interest. The AMA Code of Ethics does make exceptions for gifts directly
benefitting patients; gifts of minimal value; special funding for medical education
of students, residents, fellows; grants whose recipients are chosen by independent
institutional criteria; and funds that are distributed without attribution to sponsors.
Work with the patient by either explaining the treatment or pursuing alternative
treatments. However, a physician should never force a competent adult to receive care
if it is contrary to the patient’s religious beliefs.
Transfuse daughter, but do not transfuse mother. Emergent care can be refused by the
healthcare proxy for an adult, particularly when patient preferences are known or
reasonably inferred, but not for a minor based solely on faith.
Contact child protective services and ensure child is in a safe location. Physicians are
required by law to report any reasonable suspicion of child abuse or endangerment.
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Confidentiality Confidentiality respects patient privacy and autonomy. If the patient is incapacitated or the
situation is emergent, disclosing information to family and friends should be guided by
professional judgment of patient’s best interest. The patient may voluntarily waive the right to
confidentiality (eg, insurance company request).
General principles for exceptions to confidentiality:
ƒƒ Potential physical harm to others is serious and imminent
ƒƒ Likelihood of harm to self is great
ƒƒ No alternative means exist to warn or to protect those at risk
ƒƒ Physicians can take steps to prevent harm
Examples of exceptions to patient confidentiality (many are state-specific) include the following
(“The physician’s good judgment SAVED the day”):
ƒƒ Suicidal/homicidal patients
ƒƒ Abuse (children, elderly, and/or prisoners)
ƒƒ Duty to protect—State-specific laws that sometimes allow physician to inform or somehow
protect potential Victim from harm.
ƒƒ Epileptic patients and other impaired automobile drivers.
ƒƒ Reportable Diseases (eg, STIs, hepatitis, food poisoning); physicians may have a duty to warn
public officials, who will then notify people at risk. Dangerous communicable diseases, such as
TB or Ebola, may require involuntary treatment.

PUBLIC HEALTH SCIENCES—THE WELL PATIENT

``

Car seats for children Children should ride in rear-facing car seats until they are 2 years old and in car seats with a
harness until they are 4 years. Older children should use a booster seat until they are 8 years old
or until the seat belt fits properly. Children < 12 years old should not ride in a seat with a front-
facing airbag.

Changes in the Sexual changes:

elderly ƒƒ Men—slower erection/ejaculation, longer refractory period.
ƒƒ Women—vaginal shortening, thinning, and dryness.
Sleep patterns:  REM and slow-wave sleep;  sleep onset latency;  early awakenings.
 suicide rate.
 vision and hearing.
 immune response.
 renal, pulmonary, and GI function.
 muscle mass,  fat.
Intelligence does not decrease.

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Disease prevention
Primary disease Prevent disease before it occurs (eg, HPV vaccination)
prevention
Secondary disease Screen early for and manage existing but asymptomatic disease (eg, Pap smear for cervical cancer)
prevention
Tertiary disease Treatment to reduce complications from disease that is ongoing or has long-term effects
prevention (eg, chemotherapy)
Quaternary disease Identifying patients at risk of unnecessary treatment, protecting from the harm of new interventions
prevention (eg, electronic sharing of patient records to avoid duplicating recent imaging studies)

Major medical insurance plans

PLAN PROVIDERS
Exclusive provider Restricted to limited panel
organization (except emergencies)
Health maintenance Restricted to limited panel
organization (except emergencies)
Point of service Patient can see providers
outside network
Preferred provider Patient can see providers
organization outside network
PAYMENTS
Denied for any service that
does not meet established,
evidence-based guidelines
Higher copays and
deductibles for out-of-
network services
Higher copays and
deductibles for all services
SPECIALIST CARE
No referral required
Requires referral from
primary care provider
Requires referral from
primary care provider
No referral required

Healthcare payment models

Bundled payment Healthcare organization receives a set amount per service, regardless of ultimate cost, to be divided
among all providers and facilities involved.
Capitation Physicians receive a set amount per patient assigned to them per period of time, regardless of how
much the patient uses the healthcare system. Used by some HMOs.
Discounted fee-for- Patient pays for each individual service at a discounted rate predetermined by providers and payers
service (eg, PPOs).
Fee-for-service Patient pays for each individual service.
Global payment Patient pays for all expenses associated with a single incident of care with a single payment. Most
commonly used during elective surgeries, as it covers the cost of surgery as well as the necessary
pre- and postoperative visits.

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Medicare and Medicare and Medicaid—federal social MedicarE is for Elderly.

Medicaid healthcare programs that originated from MedicaiD is for Destitute.
amendments to the Social Security Act.
Medicare is available to patients ≥ 65 years old, The 4 parts of Medicare:
< 65 with certain disabilities, and those with ƒƒ Part A: HospitAl insurance, home hospice
end-stage renal disease. care
Medicaid is joint federal and state health ƒƒ Part B: Basic medical bills (eg, doctor’s fees,
assistance for people with limited income and/ diagnostic testing)
or resources. ƒƒ Part C: (parts A + B = Combo) delivered by
approved private companies
ƒƒ Part D: Prescription Drugs

Hospice care Medical care focused on providing comfort and palliation instead of definitive cure. Available to
patients on Medicare or Medicaid and in most private insurance plans whose life expectancy is
< 6 months.
During end-of-life care, priority is given to improving the patient’s comfort and relieving pain
(often includes opioid, sedative, or anxiolytic medications). Facilitating comfort is prioritized
over potential side effects (eg, respiratory depression). This prioritization of positive effects over
negative effects is known as the principle of double effect.

Common causes of death (US) by age

< 1 YR 1–14 YR 15–34 YR 35–44 YR 45–64 YR 65+ YR
#1 Congenital Unintentional Unintentional Unintentional Cancer Heart disease
malformations injury injury injury
#2 Preterm birth Cancer Suicide Cancer Heart disease Cancer
#3 SIDS Congenital Homicide Heart disease Unintentional Chronic
malformations injury respiratory
disease

Hospitalized Defined as readmission for any reason within 30 days of discharge from original admission.
conditions Readmissions may be reduced by discharge planning and outpatient follow-up appointments.
with frequent
readmissions
MEDICARE MEDICAID PRIVATE INSURANCE UNINSURED

#1 Congestive HF Mood disorders Maintenance of Mood disorders

chemotherapy or
radiotherapy
#2 Septicemia Schizophrenia/ Mood disorders Alcohol-related
psychotic disorders disorders
#3 Pneumonia Diabetes mellitus with Complications of Diabetes mellitus with
complications surgical procedures complications
or medical care

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Safety culture Organizational environment in which everyone Event reporting systems collect data on errors for
can freely bring up safety concerns without internal and external monitoring.
fear of censure. Facilitates error identification.

Human factors design
Forcing functions (those that prevent Deficient designs hinder workflow and lead to
undesirable actions [eg, connecting feeding staff workarounds that bypass safety features
syringe to IV tubing]) are the most effective. (eg, patient ID barcodes affixed to computers
Standardization improves process reliability (eg, due to unreadable wristbands).
clinical pathways, guidelines, checklists).
Simplification reduces wasteful activities (eg,
consolidating electronic medical records).

PDSA cycle Process improvement model to test changes in

real clinical setting. Impact on patients:
ƒƒ Plan—define problem and solution Act Plan
ƒƒ Do—test new process
ƒƒ Study—measure and analyze data Study Do
ƒƒ Act—integrate new process into regular
workflow

Quality measurements
MEASURE EXAMPLE

Structural Physical equipment, resources, facilities Number of diabetes educators

Process Performance of system as planned Percentage of diabetic patients whose HbA1c was
measured in the past 6 months
Outcome Impact on patients Average HbA1c of patients with diabetes
Balancing Impact on other systems/outcomes Incidence of hypoglycemia among patients who
tried an intervention to lower HbA1c

Swiss cheese model Focuses on systems and conditions rather than

Potential failures
an individual’s error. The risk of a threat in defense strategy

becoming a reality is mitigated by differing Hazard

layers and types of defenses. Patient harm can
occur despite multiple safeguards when “the
holes in the cheese line up.”

Harm
Defense
strategies

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Types of medical May involve patient identification, diagnosis, monitoring, nosocomial infection, medications,
errors procedures, devices, documentation, handoffs. Medical errors should be disclosed to patients,
independent of immediate outcome (harmful or not).
Active error Occurs at level of frontline operator (eg, wrong Immediate impact.
IV pump dose programmed).
Latent error Occurs in processes indirect from operator but Accident waiting to happen.
impacts patient care (eg, different types of IV
pumps used within same hospital).

Medical error analysis

DESIGN METHODS
Root cause analysis Retrospective approach. Applied after failure Uses records and participant interviews to identify
event to prevent recurrence. all the underlying problems (eg, process,
people, environment, equipment, materials,
management) that led to an error.
Failure mode and Forward-looking approach. Applied before Uses inductive reasoning to identify all the ways
effects analysis process implementation to prevent failure a process might fail and prioritizes them by
occurrence. their probability of occurrence and impact on
patients.

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