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Get Free Read & Download Files Mksap 16 General Internal Medicine PDF. MKSAP 16 GENERAL INTERNAL MEDICINE. Download: Mksap 16 General. Get Free Access To | Mksap 16 General Internal Medicine PDF Now. MKSAP 16 GENERAL INTERNAL MEDICINE. Download: Mksap 16 General Internal. The Medical Knowledge Self-Assessment Program® (MKSAP® 16) provides you with the most current and critical information on General Internal Medicine so.
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It also marks its evolution into an innovative learning system to better meet the changing educational needs and learning styles of all internists.
All of these topics are uniquely focused on the needs of generalists and subspecialists outside of endocrinology and metabolism. Places its emphasis on concepts, not formulas, for more clinical-based guidance. Next Mksap 17 Nephrology Provides examples, analogies, and memorization tips to make the material easier to absorb. Uses an easy-to-understand presentation and writing style to make the material easily accessible.
The book contains more than multiple-choice questions that follow the exam format. Preface In these pages, you will find updated information on the clinical evaluation of kidney function, fluids and electrolytes, acidbase disorders, hypertension, chronic tubulointerstitial diseases, glomerular diseases, kidney manifestations of gammopathies, genetic disorders and kidney disease, acute kidney injury, kidney stones, the kidney in pregnancy, and chronic kidney disease.
Next MKSAP 16 Sample Using this source, physicians will access a virtual blueprint for exam preparation and acquire clear guidance on question format, types of questions, and hints on topics commonly encountered on the test. Serum levels, however, are affected bythyroid status, inflammation, diabetic status, and corticos-teroid use.
Take any of the on. If trade-name products manufactured by answers. Wills Eye Institute. The information is answer sheet. There is no additional fee for this service. Make sure you cal credit commensurate with the extent of their participation culate your score and fax the answer sheet to in the activity. Where a trade name is record your answers. Pay a S10 processing fee per answer sheet and submit the ing material. PA MKSAP The American College of Physicians designates this endur 3. Physicians should claim only the lax.
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All rights reserved. For your convenience. Feeding tubes are not recommended for terminal cancer. Owing to limitations of currently available screening tests and unclear benefits of screening. Preventive Services Task Force recommends Patients with chronic fatigue for longer than 1 mondi against routine screening for hepatitis C virus infection in rarely have abnormalities on either physical or laboratory the general population.
Preventive Services Task Force.
Lp a lipoprotein piratory tract infections and acute bronchitis in nonelderly level. The goals are to improve to be insufficient. Preventive Services Task Force recommends formed only when clearly indicated see Item 7. Item Preventive Services Task Force recommends life—whether prolonged hospitalization.
The American College of Physicians and the American medical knowledge content that we feel meet the below defi nition of high-value care and bring us closer to our goal of Academy of Family Physicians both recommend diat clini cians have individualized discussions widi dieir patients improving patient outcomes while conserving finite resources.
There is no specific role for diagnostic testing in the assess screening for coronary artery disease is not recommended ment and management of chronic noncancer pain because in low-risk persons. A recommendation to urements and support obtaining PSA levels after such dis choose diagnostic and management strategies lor patients in cussions in patients 50 years and older who have life specific clinical situations diat balances clinical benefit widi cost expectancies of at least 10 years see Item The initiative comprises several programs recommended.
Palliative care consultation programs are associated widi Below are the High-Value Care Recommendations for the significant hospital cost savings.
Item 4. HDL subspecies. There is no role for antibiotic eye drops in the treatment Neurocardiogenic and ordiostatic syncope both are gener of viral conjunctivitis see Item Interventions to prevent pressure ulcers are much more Because many episodes of erectile dysfunction are tran cost effective than the prolonged and intensive efforts sient.
In the management of epistaxis. Tests with the lowest likelihood of affecting diagnosis or Initial evaluation of women with dysmenorrhea includes a management of syncope include head CT scan.
Program Adult Treatment Panel III ATP III guidelines Visualizing a hemorrhoid or odier source of rectal bleed do not recommend measuring or treating any of these risk ing in a low-risk patient younger than 40 years widiout factors when managing lipid levels see Item Mechanical neck pain outside of die setting of acute For die diagnosis of sinusitis.
Preventive Services temic symptoms. A repeat lipid screening interval of 5 years is considered Empiric antibiotic treatment for acute pharyngitis not appropriate in low-risk patients. Comprehensive preoperative testing has not been shown required as a routine component of preoperative evalua to be helpful in cataract surgery and is not endorsed by tion see Item 8. Blood transfusion is reserved for patients with sympto Preoperative pulmonary function testing should be reserved matic anemia.
In a quasi- that ensure that the comparison groups arc selected. In Another major challenge in interpreting studies is con cluster-randomized studies. Selection bias lack generalizability.
Study Design treating physicians. Error is typically shown in scientific publica groups. A failure to observed groups. When error is not random. Many bias associated with measurement. If die CI is wide. For example. Strengths of observational studies.
There is always some error in any tors equally across both the experimental and die control research study. Bias can occur in selec ment outside of a research setting. A small sample size can also decrease the These studies require careful attention to the power of the power of a study. Bias can be domization of individual patients is unfeasible or unethical for minimized using carefully constructed research protocols example. RCTs are typically uneven distribution of patient characteristics.
Random error due to chance alone can sometimes result in Well-designed RCTs typically have a high degree of pre cision and internal validity'.
Internal validity refers to the degree to which the inves Various types of study designs are compared in Table 1. Although histori tions by way of a confidence interval CI. A confounder is a diird factor that influences bodi ized. Power is the probability of detecting a dif study. Confounding can be minimized by using mental studies. By their very nature. To minimize paring two groups of people in a well-designed study. These studies are highly susceptible to These studies are potentially subject to the ecologic fallacy.
A cross-sectional study assesses for both exposure and A case-control study retrospectively compares die expe disease at the same time point rather than prospectively or rience of patients who have a disease with those who do not retrospectively.
A case series is a report of clinical outcomes have the disease. If randomization is ineffective trial RCT of two interventions. Careful atten studies. Interpretation of the Medical Literature table 1. Cohorts are compared by following ability to establish causality but may be useful as relatively them forward in time prospectively or by looking backward inexpensive means of generating hypotheses for future in time retrospectively.
A cohort study compares the outcomes of groups tion is needed in both measurement of exposures and selec with and without exposures or treatments not initiated by the tion of controls. Case-control studies are particularly useful to Epidemiologic studies compare outcomes. Two types of bias. If data are not analyzed often one being a not practical for many clinical situations according to initially assigned placebo group Limited follow-up If key individuals are aware of duration group assignment not Limited number of blinded outcomes that can If follow-up is incomplete be assessed Limited generalizability Cluster-randomized trial Patients grouped by Same as for RCTs Same as for RCTs Same as for RCTs clusters e.
Relative comparisons. CER employs systematic The effect size. Relative risk differences may exaggerate control studies. Published studies of therapies typically express results in eidier in addition to the weaknesses of the composite studies.
Systematic reviews summarize existing experimental or obser Bias occurs when systematic differences between vational studies in a rigorous way. Systematic reviews that quantitatively combine data are called meta-analyses. Within each category.
The strength of systematic reviews lies in combining the data from many small studies to Statistical Analysis minimize the impact of random error. Systematic reviews are char acterized by a focused clinical question. CER when the event be harmed is an unfavorable outcome e. Absolute comparisons. Internal validity refers to the degree to which die inves tigators' conclusions are supported by the study.
Bodi sen www. In a health care system with many stakeholders age to yield die more commonly used posttest probability. These differences may reflect the predictive value. Pvalues are related to both PubMcd's clinical queries page offers assistance for common the degree of difference found between groups and the num clinical searches wwAv.
The predictive value www. As guidelines are evidence-supported expert opin Many measures are used to define the properties of diag nostic tests Table 3. The pretest odds vide more transparency about hospital outcomes.
Healthy Patient The Bayes theorem uses sensitivity. Understanding these characteristics for a unconscious biases of the authors and sponsoring organiza given test is essential in knowing how effective and helpful a tion.
Textbooks and important to recognize that differences found to be statisti review articles typically offer "predigested" evidence on a clin cally significant in large trials may not be clinically important.
A useful compilation of guidelines is also available at sitivity and specificity are properties of the test itself and do not vary with the prevalence of disease. Defining risk in absolute terms and calculating die increasing prevalence of the disease being tested for. The posttest odds can be converted to a percent Table 4. The audiors grade their recommendations based on the quality of die evidence 0.
The likelihood ratio LR is die ratio of and Trends the probability of a particular test result positive or negative Many recent national initiatives attempt to improve qualitv among patients widi a disease to the probability of that same and safety of patient care.
In Defining risk in absolute terms and calculating num the example above. Number needed to stand the magnitude of difference in the sample harm NNH is die reciprocal of the absolute risk increase effect size. A P value allows the reader to assess how likely any dif ference seen is due to chance alone. ACP JournalWise www. A nomogram is available to calculate posttest probability using pretest probability and LR without having to convert pretest probability to odds see www.
This measurement can be complex. Value in health care is defined by the outcomes achieved Frail elderly persons with limited life expectancies radier than by the volumes of procedures performed or services should have different outcome measures than younger rendered. Eor example. Routine Care of the Healthy Patient table 3. To determine value. Concierge medicine Relationship between a patient and a physician in which the www.
None are outcome measurements. Important Health Care Initiatives. The screening comes more heavily than the processes utilized in care. Routine Care of the Healthy Patient table 4. Early example. PQRS [formerly including an incentive payment for eligible professionals PQRI1 who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries National Committee Not-for-profit organization dedicated to improving health www. This method Screening.
A key goal of the ACO structure is to control growth of health care costs while maintaining or improving quality of care. Performance measures stressing value will increased survival or improved quality of life compared with emphasize outcomes and the costs to achieve those out identification at a later. Length bias occurs dence-based recommendations on screening for a wide when the variable rate of progression of a disease is not range of conditions www.
The U. Routine Care of the Healthy Patient that the frequency of false-positive and false-negative results patient anxiety. Other vival statistics.
Lead-time bias occurs when a the optimal use of specific screening tests. Screening is not indicated in women following hysterectomy and without previous high-risk Pap smears. Cervical cancer Screen with Pap smear: The American College of Physicians ACP has ing morbidity and mortality is best accomplished with ran developed a number of clinical practice guidelines.
Gonorrhea Sexually active women who are at increased risk of infection Asymptomatic Pregnant women at weeks' gestation or at the first prenatal visit. Table 5 summarizes these asymptomatic phase for example. A Web-based study than a patient with a more rapidly progressing cancer. Screening may be discontinued at age 65 years in non-high-risk women with no recent abnormal Pap smears. Three types of bias are commonly statements.
Appropriate screening tests include a Owing to the increasing rate of obesity in our society. The cludes that evidence is insufficient to recommend screening in Seventh Report of the Joint National Committee on men.
Aldiough the USPSTF concludes Diabetes Association recommends screening all adults age that there is insufficient evidence to recommend screening for 45 years and older without risk factors and all adults with a illicit substance use.
A recent study confirms the impor lifetime cigarettes. There was itary hemochromatosis.
They make no recommendation for tance of using multiple measurements to make the diagnosis or against screening men who have never smoked and rec of hypertension and the potential error in using only one ommend against routine screening for AAA in women measurement.
Executive periodic physical examinations. There is also evidence that asking only one question. Because of insufficient evidence. According to JNC 7 guidelines. A positive response to any of demia in certain populations based on age. Screening for alcohol misuse. Preventive Health Care recommend screening and perform The USPSTF recommends screening for type 2 dia ing behavioral counseling interventions to reduce alcohol betes in asymptomatic adults with a sustained blood pressure misuse by adults.
There is little evidence to able and there is no consensus interval. At die very least. The National Cholesterol diagnosis and treatment. ACP practice guidelines from recommend screen Prevention.
The USPSTF recommends screening for osteoporosis in The USPSTF recommends screening all adults age 18 all women age 65 years or older and also in younger women years and older for hypertension but concludes that evidence with an elevated fracture risk. In contrast.
The CDC recommends screening median breast cancer reduction of Lp a lipoprotein level. Routine Care of the Healthy Patient nontraditional risk factors. Owing to insufficient evi Mammography. The infection should be limited to sexually active women who are ACS does not recommend using MRI for breast cancer at increased risk of infection same risk factors as for chlamy screening in average-risk women and finds the evidence dial infection.
Features of the family history that should but not in other persons. The task force recommends against screening regarding breast self-examination to be insufficient. No men low-risk men and women and states that there is insufficient tion is made of what age to stop annual screening mammog evidence for screening in all other groups.
Whereas two randomized controlled trials have infection. For average-risk women. A woman's individual risk of developing recommends screening with annual MRI alternating every. Screening mammogra The Centers for Disease Control and Prevention CDC rec phy may be less effective for average-risk women between die ommend that all persons between the ages of 13 and 64 ages of 40 and 49 years owing to the lower incidence of breast years be screened for HIV infection. The ACS breast cancer.
This approach yields a persons at increased risk. There American Medical Association. A recent study supports these infection in all women 24 years of age or younger who are recommendations. Despite most women at 12 to 16 weeks' gestation or at the first prenatal patients having a family history of breast cancer.
HIV positivity. Preventive Services 21 y Every 3 y. Owing to poor specificity'. The presence of benign prostatic hyperplasia symp test should be immediately repeated.
The USPSTF rec screening for anal cancer in high-risk persons persons ommends that fair-skinned persons aged 10 to 24 years be who practice receptive anal intercourse. Risk factors for cervical cancer: When interpreted as toms should not increase the propensity to screen for atypical squamous cells of undetermined significance. The two most commonly used meth Based on the results of the Study of Tamoxifen and ods of screening for prostate cancer include prostate-specific Raloxifene STAR trial.
Colon cancer screening ACS. Men should be informed about the gaps in the evidence and should be assisted in considering their per years and older to help guide fiirdier investigation and decrease the frequency of testing. In more routine testing. Preventive Services Task Force recommends subsequent testing or procedures. The definition of family may differ among patients. The accuracy of the informa tion obtained may vary based on die method by which it is Controversy exists as to whether primary care providers have obtained for example.
Patients should be may identify patients who would benefit from genetic testing. Different types of genetic tests require at onset. Recommendations for the presence of diseases. The rhea infection women.
As demand for genetic knowl mitted infections for HrV infection. Family History and Genetic Specific components of genetic testing should include Testing the following: Older persons report more accurate referral for genetic counseling include situations in which family histories dian younger persons.
Preventive Services Task Force recommends The advent of greater availability to the public of genetic tests pregnant women be screened for HIV infection. Family history has an important role in the practice of medi legal considerations. Additional demographic and environmental data may be in which adequate physician training and patient education needed. As many common dis employment or insurance sectors. Preventive Services Task Force recommends the concept that knowledge of one's DNA is only one com screening persons at increased risk for sexually trans ponent of a complex process.
Available evidence suggests materials are available for example. Provider barriers include limited clinic time. The genetic counseling process includes a complete Aldiough a few vaccinations are recommended for all adults. Genetic counselors may also recommend to test or over time. Many recommendations have changed ing process. Routine Care of the Healthy Patient Specific indications for genetic testing include the fol Immunization lowing: Herpes zoster Live.
Tdap Varicella Live. Recommendations for their use are background suggesting an increased risk for a genetic disease updated frequently by die CDC's Advisory Committee on for example. Vaccination also reduces transmission and spread of a cern about risk to a future pregnancy because of family his disease in the population at large. One dose usually sufficient. Hepatitis B Inactivated Adults with increased risk of transmission. For all other issues as well as the potential psychological impact of vaccines.
Inactivated All adults. Patient self-report should only be considered actually reveal. Meningococcal disease Inactivated Adolescents. Booster every 10 y. Current recommendations ease. One-time Tdap for all see text pertussis Td. More than 24 different vaccines are currently come. Inactivated In addition. The live. Childhood recommendations changed in may induce a brief period of myalgia and low-grade fever. Although most vac every 10 years is highly effective in preventing these diseases.
Multiple vaccines can be given at the same tetanus and diphtheria combined with acellular pertussis time. Patients without a history of severe egg series unless they have serologic evidence of varicella immu allergy can be vaccinated.
Two types of regardless of the timing of their last Td booster. Postpartum women. Each season. The inactivated vaccine is given as a sin since Because of anti cination with at least one dose of Tdap is particularly important genic drift.
Manufacturer's guidelines for activity fades in their community. This includes patients older traindicated in patients with immunodeficiency.
Persons born before in the United States gle intramuscular injection and is approved for adults of any are considered likely to have immunity resulting from child age. As diis is a rel vaccination are used: Pregnant women should not be vaccinated. The inactivated varicella vaccination. Routine Care of the Healthy Patient Vaccines with live. The from a single to a two-step varicella vaccination. Vaccination has workers. Because recent data suggest that the actual burden of pertussis in persons older than 65 years may be at Influenza is a respiratory virus that spreads seasonally.
Both types are contraindicated in patients with a history hood exposure. Each is developed during the spring based on projections of the most likely strains to be responsible for the Vaccinations Recommended for Some Adults following winter's infections. Restarting a vaccina three-shot series in childhood followed by booster vaccination tion sequence is rarely. In order to achieve vaccination events should be planned starting in the fall.
Patient or parent self-report is not con vaccine often produces local reaction at the vaccine site and sidered reliable. Persons born after A single dose is recommended for all persons aged 65 to genital warts and cervical cancer. Patients vaccinated of 9 and 26 years.
Revaccination after 5 years cervical lesions and genital warts. CA valent pneumococcal conjugate vaccine has been approved by the ACIP for use in patients 19 years of age and older with immunocompromising conditions. Vaccination against the years or older and those 19 to 64 years with specific risk factors most pathogenic serotcypes has been shown to reduce infec Table 8. In clinical trials. All adults aged 60 years and patients is not yet available. DA valent pneumococcal conjugate vaccine has been FDA approved for use in patients 50 years of age and older.
The CDC recom years after their initial vaccination if die ' were initially vacci mends catch-up vaccination of women to age 26 years and nated between die ages of 60 and 64 years. Aldiough it is also FDA-approved older should be vaccinated unless vaccination is contraindi for use in persons 50 years of age and older.
There is no current men to age 21 years but permits vaccination of men up to age recommendation for additional boosters and no recommen 26 years. Both a bivalent and quadrivalent vaccine exist. HIV infection. Vaccination is recommended for all girls before age 65 years should receive a booster at 65 years.
Chronic pulmonary disease including asthma and COPD whichever is later Diabetes mellitus Chronic liver disease including cirrhosis Alcoholism Cigarette smoking Cerebrospinal fluid leak Cochlear implant Immunocompromised HIV infection Two doses separated by 5 y Chronic kidney disease or nephrotic syndrome Malignancy leukemia. Routine Care of the Healthy Patient A more concentrated version of the live attenuated virus functional or anatomic asplenia. The vaccine is an inactivated is recommended in patients who have asplenia or immuno vaccine and is licensed for males and females between the ages compromise.
A are licensed and recommended for females. Unvaccinated adults living in college Special Considerations for Health Care Workers dormitories or who are in the military should receive a single Heal til care workers have additional vaccination requirements. Health care workers.
Patients with ability to act as a vector to spread diseases to or between asplenia and those with complement deficiencies should patients. Younger adults vvidiout either a consists of two injections separated by at least 6 months.
Adults born before are considered vvidiout evidence of liver dysfunction. MMR is a live. Hepatitis A vaccination is also recom Measles. Immunization typically immune to these diseases. In adults. The tis A vaccination is recommended for adults with increased like vaccine is administered as a series of three injections.
Several Meningococcal Disease vaccination strategies exist. The vaccination is the United States after die introduction of universal child not recommended for patients widi chronic hepatitis B or C hood vaccination.
Annual influenza vaccination is also rec cally spread by children. Vaccination against meningococcus is primarily recom mended for adolescents. All health care workers should be vaccinated against receive boosters every 5 years. As hepatitis A epidemics are typi time Tdap vaccination. Many studies attest to the suc activity counseling. Most Lifestyle Risk Factors studies that have demonstrated a benefit relied on specially Behavioral Counseling trained health educators or nurses.
Follow-up is critical to assess patient progress. Diet and Physical Activity Despite a large body of literature attesting to the benefits of counseling interventions for increasing physical activity.
Motivational interviewing is one form of a brief interven Physician evaluation before embarking on an exercise program is recommended only if there is a history of tion.
Several advisory patients may be ambivalent about making behavioral changes. Brief interventions usually involve one been experienced when trying to exercise in die past. Self-efficacy model. Benefits beyond 1 year are limited and require contin uses patient-identified issues to initiate and continue the ued high-intensity interventions.
Many providers give physical activity behaviors. The evidence for changes in physio patients information and advice in an effort to convince them logic outcomes was strongest for high-intensity counseling inter to change behavior. One framework for administer adults older than 60 years without contraindications. Brief interventions can easily be administered in a busy adults without contraindications.
Key features of motivational interviewing "control" and does not tell the patient what he or she are that the patient chooses the agenda. Classic motivational interviewing teaches that contacts in person. A standard alcoholic beverage is consid emphasis on nonconfrontational strategies and discussion of ered to be one ounce beer. Brief advice from a during hospitalization and continues after discharge increases the odds of long-term abstinence.
For sequences. Smoking cessation counseling that begins should be performed for all patients. Hazardous drinking is a pattern of tobacco use at every visit. The Joint Commission physician has been shown to increase tobacco cessation rates.
Have you ever felt bad or Guilty about your drinking? Have you ever had a Varenicline has been demonstrated to be more effective than drink first thing in the morning to steady your nerves or get bupropion. Have you nations of nicotine replacement therapy available as nicotine ever felt you should Cut down on your drinking? Have peo gum. The specific method or alcohol use. Smoking is a leading cause of illness and death in the United States.
Smoking is no longer viewed as a habit but as a chronic Hospitalization provides a unique counseling opportu. One sim but without meeting criteria for dependence. Harmful drinking refers to alcohol consumption behaviors. It consists often questions and is problem-solving skills and social support has been shown to easy to administer. High-intensity counseling greater The USPSTF recommends screening and counseling for time and number of sessions is more effective than low.
Clinicians should choose a screening test The various options offer alterna tives for patients with contraindications. Alcohol misuse includes "risky" or "hazardous" and "harm Current recommendations are that all clinicians assess ful" drinking patterns.
Clinicians should encourage every patient to make resulting in negative psychological. Q ment options. With a cutoff of two posi tive answers. Alcohol ple approach for use in the clinical setting is the 5 A's Ask. The four-item CAGE questionnaire may also be used. The Alcohol Smoking and to 16 hours or 10 sessions. Additional risks associated with illicit drug use doms and other contraceptives. A single-item screening question.
The item Drug Abuse Screening Test active adolescents are lacking. Frequent follow-up and reassessment are assistance.
Patients with drug abuse are more patients. Victims of tional interviewing may be used for counseling. Recommendations and specificity but is considered too long for use in die pri regarding counseling for low-risk adults and non-sexually mary care setting. Risk factors for intimate partner to die longer DAST Counseling issues chronic lung disease usually from associated tobacco use. Adults considered at adolescents are not known. Routine Care of the Healthy Patient appropriate to their practice.
The effects of screening HPV. It has excellent sensitivity care office are effective for reducing STIs. Currently no chiatric illness. Evidence exists. Patients with a history of alcohol or other All sexually active adolescents are considered at increased risk substance abuse are at higher risk for alcohol abuse or relapse for STIs.
Risk factors specific for elder abuse include increasing Once patients have been identified as using drugs. No guidelines clearly delineate how often alcohol screen pitalization and continues after discharge increases ing should be performed. The USPSTF recommends that providers harmful as any use carries a risk for health and legal ramifica take a sexual history and perform risk assessment during peri tions.
In this model. One is the "lean thinking" model developed by Toyota. Studies suggest that women cuss and address medical errors or concerns that an error may occur if the system is not changed. Efforts to improve instruments can accurately identify women experiencing inti patient safety also encourage the growth and discussion of mate partner violence.
Six Sigma is a disciplined. Providers are often unaware that their patients are The construction of these systems has Recommendations for screening for domestic violence relied on the concept of the "Swiss cheese model" of medical errors Figure 1.
A Six Sigma process is one in which there are only 3. Improved health outcomes have been shown even be measured. Emphasis is placed on behaviors such as substance abuse and risky sexual behavior.
Many domestic violence victims are Several important quality improvement models have helped by the acknowledgment that violence is unacceptable. These changes are tested and providers have given validation.
In the report To Err is Human: The key to quality improve ment using this model is to establish what is to be accom with health. Patients with repeated traumas. Domestic violence is associated with high-risk ent in the structure of those systems. The harms to patients from such excessive testing are being increasingly recognized and docu mented. Other systems sometimes utilized are Six Sigma Health care providers' primary responsibilities in car and the Malcolm Baldrige Model for Performance Excellence.
Patient Safety pain. Human error: Model for Improvement. Patient safety been on computerized order entry. Diagnostic errors tend to result from a Measurement of Quality Improvement faulty cognitive approach for example. Inpatient ications or to adjust dosing to account for impaired kidnev or quality indicators assess quality of care inside hospitals as well liver function or other conditions requiring dosing adjust as across geographic areas.
Despite the fact diat A Medication Errors set of quality indicators have been developed to measure Between The focus of efforts to reduce medication errors has medical conditions and surgical procedures. One in five patients discharged from deadis result from misdiagnosis annually in the United States die hospital will suffer an adverse event related to medical The Baldrige model focuses on seven as claims for medication errors. Forty per delayed. The lack of attention to this organizational performance results.
Suggestions to help avoid diagnostic errors are This movement gathered momentum in timely way. Information gathered at the time of hospitalization within 30 days. Patients should fails to arrive to the primary care physician in a timely fashion receive a list of medications at the time of discharge and be and frequently does not convey important information about informed of previous medications which have been discon diagnosis. When The quality of discharge summaries is which are related to medications.
Medication hand-off. This form can effective hospitalist-to-priniary care physician communica then be compared with medications prescribed throughout tion both during hospitalization and at the time of discharge the hospitalization and at the time of discharge. Based on Trowbridge RL. Settling on a diagnosis early in the diagnostic process despite data that refute the diagnosis or support another premature closure Representativeness heuristic: Application of pattern recognition a patient's presentation fits a "typical" case.
Med Teach. This infor month. Fourteen percent of elderly improved with the use of standardized content Table Timely follow-up with a primary care mary care providers. Twelve tips for teaching avoidance of diagnostic errors. Patient Safety table Diagnosing based upon what is most easily available in the physician's mind e.
Health Information Technology and Patient Safety Professionalism and Health information technology comes in three general forms: Ethics computerized physician order entry CPOE.
Follow-up issues CPOE can allow multiple physicians to enter potentially con Pending studies and laboratory tests flicting orders simultaneously. The Discharge medications and reasons for any changes from admission medications potential for new errors is present in all systems.
An EHR interface can prompt Results of procedures and significant testing physicians to order needed medications. Poorly designed systems can introduce even more errors. This obligation requires that cian. A patient's EHR comprises a collection of clinical data Reason for hospitalization notes. Each goal provides specific nize drug interactions among prescribed medications or to adjust dosing to account for impaired kidney or objectives and metrics.
CPOE eliminates medication error related to physician physicians honestly assess their knowledge and skills and Health information technology is not a panacea.
CPOE improves efficiency Dates of admission and discharge by eliminating delays between order entry and order receipt. The EHR should Discharge diagnosis allow multiple users. Each of Professionalism these technologies can be used in an inpatient or outpatient In exchange for the authority to train. Suggested Content of a Standardized handwriting. Health informa dential physicians.
Patient autonomy Patients' decisions about their care must be paramount. European Federation of Internal Medicine. Report and analyze medical errors in order to maintain trust. Manage conflicts of interest Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage.
Providing unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others.
Participate in the processes of self-regulation. It also creates the expecta professionalism with the public's health: Improve quality of care Work collaboratively with other professionals to reduce medical errors. Improve access to care Work to eliminate barriers to access based on education.
Professionalism and Ethics pursue learning where gaps exist. In the routine delivery of patient care. Appropriate patient relations Given the inherent vulnerability and dependency of patients. Equity requires the promotion of public health and preventive medicine. Professional responsibilities Undergo self-assessment and external scrutiny of all aspects of one's performance.
The Charter on Cost-Conscious Care initiative strives to promote this com Medical Professionalism comprises three principles and mitment by helping physicians assess die value and the costs ten commitments Table Three commitments link of specific interventions.
Honesty with patients Obtain informed consent for treatment or research. Patient confidentiality Privacy of information is essential to patient trust and even more pressing with electronic medical records.
Scientific knowledge Uphold scientific standards. Just distribution of resources Work with other physicians. Professional Commitment Competence Physicians must be committed to lifelong learning and to maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care.
Principles and Commitments of Professionalism Principle or Commitment Comment Fundamental Principle Primacy of patient welfare Altruism is a central trust factor in the physician-patient relationship. A commitment to social justice today's healdi care environment and fundamental to demon requires physicians to guard the health of the public by elim strating professionalism with trainees.
Medical professionalism in the new millennium: Ann Intern Med.
Such compromises are especially threatening with for-profit industries. Physicians have an obligation to recognize. Teamwork and collabora sons have access to quality health care. Market forces.
Social justice Physicians should work actively to eliminate discrimination in health care. American Board of Internal Medicine. A given Consent decision does not have to be rational. The greater the complexity of the decision. To obtain informed consent. Advance directives fall into two broad cat a recommendation if there is a preferred course of action. Advance addition.
The core components of decisional capacity are understand The role of the surrogate is to strive to make decisions ing the situation at hand. Although example. A decision that seems inconsistent is a prompt to further explore the patient's beliefs. Instructive directives are subject such as surgery require written informed consent.
The clinician must assess harm and little to no benefit to the patient. A living cate a decision. Most jurisdic of complex decisions were considered fully informed. If it does. A common reflect what most people would do in that situation. In a study of outpatient practices. They may also be be characterized by three domains: For exam patients to read and understand.
This is typically standards for informed decision-making. Assessing understanding can be challenging. Complexity' can receive cardiopulmonary resuscitation. Many U. Informed consent requires that the patient understand the nature of the decision being made or intervention being pro Advance Directives and Surrogate Decision- posed. Patients source of ethical challenges in practice is that while the who are able to understand the consequences may refuse life- authority' for decision-making rests with the patient.
In egories: If not. By convention. A diagnosis of dementia or a men the public by eliminating unsafe and low-value serv tal illness does not necessarily mean that a patient is incapable ices that generate expenses for care with potential of making health care decisions.
Withholding or Withdrawing Treatment Physician-Assisted Suicide and Euthanasia Although a primary goal of care is usually to sustain life. A treatment is futile either when it has a very low Active administration of a drug with die intent to cause death is illegal in all states. KEY POINTS A scenario in which life-sustaining treatment no longer A terminally ill patient may be given a treatment that offers benefit to the patient who wants it can be more chal may hasten death when the primary intent is to pro lenging.
The emotional implica may hasten the death of" a dying patient is a heavily debated tions may differ whether one withholds care never starts a area of medical ethics. Professionalism and Ethics decisions. All ment. In some circumstances. A common example is high The two most common reasons to withhold or withdraw doses of"opiate analgesics used to relieve pain or dyspnea in a treatment are that the patient or the surrogate has decided patient who is dying.
In most cases. If the care providers' intentions. Most agree by virtue of the principle treatment or withdraws care stops a treatment previously of double effect that it is ethically permissible to give a termi started. If"the physician feels that a specific intervention is unlikely to produce an out C o n fi d e n t i a l i t y come that the patient would find to be meaningfully benefi Implicit in the physician-patient relationship is a commitment cial.
Although physicians have to confidentiality. If the surrogate has no knowledge of what the patient wants them. If the patient has decided that he or she no longer cian aid in dying.