Disclaimer: Notes not included for Mental Status Exam, Factors in Aggression and Violence, Advanced Interviews, and Child Abuse.

9/1/2010

Q: What are the two models of health care prevention?
A: Traditional model and IOM model.

Q: What are the three types of prevention of the traditional model?
A: Primary Prevention — treat everyone — education, promote healthy lifestyle, exercise, eating healthy foods.
Secondary Prevention — treat those at risk — screening, targeted immunizations, early intervention, self-help groups
Tertiary Prevention — treat those who are diagnosed.

Q: What is IOM?
A: Institute of Medicine

Q: What is the IOM model?
A: prevention <–> treatment <–> maintenance

Q: What are the three approaches to prevention?
A: Universal — target the entire population — warning on alcohol bottles about risk of alcohol and pregnancy.
Selective — target a population who has increased risk — educating young women about drinking and pregnancy
Indicated — target the specific people who have the highest risk — i.e. counseling pregnant women who drink

Q: What is DALY?
A: Disability Adjusted Life Years — basically the number of years in which you were NOT disabled or dead. It measures how many years of healthy life you lost.

Q: What attribute is the highest cause of mortality?
A: High blood pressure –> Tobacco Use –> High blood glucose

Q: What attribute is the highest cause of low DALY (burden of disease)?
A: childhood underweight –> Unsafe sex –> alcohol use

Q:1 in 8 deaths of adults over age 30 is due to what?
A: Smoking

Q: What is responsible for most deaths due to cervical cancer?
A: Unsafe sex

Q: Why is patient-centered care important?
A: We need to take into account the patient’s history, needs, lifestyles, and beliefs to assess their RISK and READINESS FOR CHANGE. We can treat all we want, but it is patient in the end that needs to adhere to treatment, and we need to help them in that.

Q: What are the rules to patient-physician interaction?
A: 1. Patient’s wishes, comfort and safety come first
2. Patient has autonomy to make choices
3. Don’t assume patient’s will automatically like or trust you just because you are the doctor. There’s a lot of work on your part to make this happen.
4. Be honest to patients. Don’t distort information to “convince” them of a certain treatment.
5. LISTEN to your patients, and solve the problem the patient presents.
6. EMPATHIZE
7. Give the patient a comfortable place to communicate with you.

Q: What is adherence to medical advice related to?
A: Patient’s personality traits, defense mechanisms, and how well the patient likes the doctor.

Q: WHat is adherence to medical advice NOT related to?
A: patient’s intelligence, education, sex, religion, race, socioeconomic status, marital status.

Q: Empathy vs. Sympathy:
A: Empathy — understanding the patient’s experience.
Sympathy — feeling the same emotions as the patients. NOT GOOD FOR MEDICAL PRACTICE. You don’t want to be depressed with the patient. YOU DON’T NEED TO EXPERIENCE THE PATIENT’S SAME FEELINGS TO HELP THEM.

Q: What is one of the most rapport-building techniques you can use as a doctor?
A: Empathetic Validation — shows you are really listening, and allows the patient to continue talking without feeling judged.

Q: What do patients say are the primary expectations they have of their physicians?
A: Kindness, Understanding, Interest, and Encouragement

Q: What PATIENT factors increase adherence (of a patient for treatment)?
A:
If the patient feels very sick.
If diseases limits usual activities of the patient.
If the disease had a sudden onset.
If the patient has family/peer support to comply.

Q: What PHYSICIAN factors increase adherence (of a patient for treatment)?
A:
Providing simple treatment schedules.
Providing written instructions.
Short time in waiting room.
Recommending one change at a time rather than throw it all out and expecting patient to follow all of it.
Being empathetic and non-judgmental.
Listening to patients.

Q: How do you promote attentive listening?
A:
Provide a comfortable setting.
Face the patient with attentive and relaxed posture.
Eye contact (if culturally appropriate).
Use appropriate gestures and facial expression.
Address the topic the patient wants.
Observe both verbal and nonverbal cues.

9/2/2010

Q: More rules to Doctor-patient relationship:
A:
8. Tell the patient everything and offer options.
9. Allow yourself TIME to understand the patient.
10. Seek info and then check it.
11. AGREE on the problem, and NEGOTIATE the solution.
12. Let patient talk more than you.
13. Respond to the emotional context of the patient
14. Keep in mind whether or not the patient is ready to hear certain information.
15. Make eye contact. If you touch them, tell them what you are doing.

Q: What are four Doctor-Patient Models of Communication?
A:
Teacher-Student Model — doctor is dominant and controlling. patient is dependent. Used when patient is recovering from surgery.
Active-Passive Model — patient completely passive. doctor completely active. Used when patient is unconscious, immobilized, or delirious.
Friendship Model — NEVER GOOD. happens when a doctor has a psychological, emotional need for the patient. boundary between professionalism and intimacy is blurred.
Mutual Participation Model — doctor and patient depend on each other’s imput. Mutual, active participation. Used in chronic illnesses, where patient’s knowledge and acceptance of treatment is necessary for success (i.e. a diabetic must know much about the science behind diabetes in order to deal with it long term).

Q: What are some techniques for better communication with patient?
A:
1. Non-verbal techniques — nodding, leaning forward.
2. Checking — ask a question to check if what you heard was correct.
3. Clarification — ask patient to clarify
4. Reflection — paraphrase to show you’ve been listening.
5. Interruption — acknowledge what your patient is rambling about and transition to the main topic.
6. Transition — link what your patient is talking about to another topic.
7. Information Sharing — explaining the problem, establish shared expectations, and clarify goals.
8. Giving Directions — explain how to do what you want them to do.

Q: What are some non-verbal communication?
A:
1. Kinesics — body language, facial expression.
2. Body Position — leaning forward, seated position, posture
3. Touching — handshake
4. Paralanguage — the way you say things (rather than what you say)
5. Spatial — distance between patient and doctor
6. Eye Contact — can be continuous or broken.

Q: What are some supportive interventions?
A:
1. Acknowledge emotions
2. Encourage
3. Reassure
4. Use non-verbal support.

Q: What are some obstructive interventions?
A:
1. Compound questions
2. Trapping patients in their own words
3. Dismissal or minimization.
4. Premature advice
5. Not “getting” what patient isn’t saying directly (not following patient’s lead).
6. Being judgmental
7. Using nonverbal obstruction.

Q: What are Leading Questions?
A: Questions that directs someone to answer in a certain way, like what journalists often use.

Q: What leads to the strongest doctor-patient relationship and most effective communication?
A: Addressing emotions… it is essential to care, and provides an important cue and clue to patient’s well-being.

Q: How do you respond when your patient use a word that isn’t clear (i.e. “it doesn’t feel right”)?
A: Clarify the statement (i.e. “doesn’t feel right? could you tell me more?”)

Q: If a patient makes an emotional statement, like “i hate doctors”, how do you answer?
A: Address their emotion rather than the content of what they are saying. (i.e. “you sound upset. how can I help you?”)

Q: How do you respond if the patient does not want to know the information (i.e. “i don’t want to know the results.”)?
A: Try to find out why the patient isn’t ready for the info and give them time to get ready.

Q: What do you say to a patient who makes suicidal-sounding statements?
A: Directly ask “are you thinking about killing yourself?”

Q: What do you say to a patient who makes a suicidal statement?
A: Ask about the patient’s plan of killing themselves.

Q: How can you use anticipation when you ask patients questions?
A:
Anticipate questions that the patient might ask (and hasn’t asked yet) and ask it.
Anticipate fears that the patient might have (and hasn’t shown yet) and address it.

Q: What do you do when you get mixed messages from the patient?
A: acknowledge the disparity and use soft confrontation.

Q: What are the most common reasons why patients don’t adhere to a certain treatment?
A:
1. Instructions weren’t clear.
2. They didn’t like the side effects.
3. They have psychiatric symptoms that interfered with the adherence.
4. Patients like the disease’s symptoms.
5. The patient has a disorganized life and just can’t adhere to treatment.
6. Patient can’t afford the treatment.

9/3/2010

Q: What are some more rules to good Patient-Doctor relationship?
A:
16. Monitor patient’s possible transference
17. Monitor your own counter-transference.
18. Admit when you make mistakes
19. Only refer a patient to someone else when there is nothing else you can do within your abilities.
20. Address a patient’s beliefs about health.
21. Focus on the patient’s comfort.

Q: What are core beliefs that people may have?
A:
1. World — Safe vs. Unsafe
2. Nature of Self — Internal vs. External control
3. Nature of Others — Loving vs. Hurtful. Honest vs. Dishonest.
4. Purpose of Life — Spiritual journey vs. Struggle for survival. Service to others vs. Question for power.
5. Nature of God — Forgiving vs. Punishing.
6. Family — Source of love vs. Source of tension.

Q: What stress level is best for patient adherence?
A: Moderate stress or fear. So if the patient doesn’t fear, they won’t bother adhering to treatment. If they fear too much, they may burn out or give up the treatment. This curve is called the Yerkes-Dodson paradigm.

Q: What are counter-balancing threats to adherence?
A: external barriers to health care like finances. So even if the patient may fear enough to make them want to adhere, a counter-balancing threat like lack of finances might decrease their adherence.

Q: What are the stages of illness behavior?
A:
Stage 1 — Experience of Symptoms
Stage 2 — Assumption of Sick role — perceived as sick by self or others. exempted from normal responsibilities.
Stage 3 — Medical care contact
Stage 4 — Dependent patient role
Stage 5 — perceived recovery

Q: Why is stoicism bad for patients?
A:
1. They can wait too long before seeking help.
2. They might not report symptoms that would help them.
3. They might not ask questions.
4. It can lead to unrelieved pain, which hastens death.

9/6/2010

TRANFERENCE

Q: What is Transference?
A: repetition of an attitude towards early authority figures in your life to a new person, like a doctor — patients being passive and believe you will do no harm.

Q: What are some types of transference?
A:
1. Realistic Basic trust that the doctor has the best intentions for the patient.
2. Over-idealization that the doctor can solve everything
3. Eroticized fantasy — patient eroticizes the doctor
4. Basic mistrust — expecting doctor to be contemptuous and potentially abusive.
.
DEFENSE MECHANISMS

Q: What is ego?
A: Your mind’s concious of what you should be.

Q: What is the Id?
A: primitive drives for pleasure gratification, aggression, or sex.

Q: How does defense mechanism happen?
A: when Id overcomes ego so you respond to keep Id down. It is a response to stress.

Q: What are the two most common defense mechanisms in patient behavior?
A:
Denial — patient unconsciously refuses to admit or acknowledge severity of illness. At first it protects patient from fear, but if extreme, it can prevent treatment.
Regression — patient reverts to more child-like behavior — patient want more attention, more care, and want mom to be there.

Q: What intensifies the need for a defense mechanism?
A: stress of illness.

Q: What is counter-transference?
A: When a doctor treats the patient like someone who he knew in the past. It can be negative or positive feelings towards the patient.

Q: What do physicians commonly think of as a “good patient”?
A:
1. When the patient expresses the symptoms of diagnosable disorder.
2. When patient is compliant and they don’t challenge the doctor’s decisions
3. When the patient is emotionally controlled.

9/7/2010 Morning

Q: What does the doctor bring to patient-physician interaction?
A:
1. Personal beliefs about patient
2. Stereotyping of the patient
3. Putting attributes to the patient

Q: What is the Fundamental Attribution Error?
A: We tend to over-attribute our own behaviors to the nature of our current situation whereas we tend to over-attribute another person’s behavior to their personality.

Q:

Q: What are the “difficult” patients?
A:
1. Reticent Patient — use close-ended question, then open-ended.
2. Overly Talkative Patient — courteously interrupt the patient.
3. Silent Patient — silence can be due to interviewer’s lack of sensitivity, or perhaps patient doesn’t trust you yet.
4. Anxious Patient — be careful not to become overly reassuring, as this can block communication.
5. Depressed Patient — talk openly about depression.
6. Crying Patient — ask about the crying. DON’T IGNORE IT!!

CULTURAL COMPETENCE

Q: More Rules:
A:
22. Find out patient’s religious beliefs and health care beliefs, and practice appropriately.
23. Find out patient’s culture and any cultural practices that may impact care.

Q: Why is being accepted, identified, and supported by a cultural group important?
A: Because it gives us a sense of security.

Q: What’s the difference between culture and ethnicity in the clinical

setting.
A: In the clinical setting, treat them as synonymous.

Q: What is cultural competence (vs. cultural awareness, cultural sensitivity)?
A: The ability to offer good care within different value systems, acting with respect and understanding of others without imposing our own beliefs and attitudes on other people. It’s not merely the awareness of culture or the awareness of differences.

Q: What is the cultural competence continuum?
A:
1. Cultural Destructiveness — acknowledgement of only one way of being. Denies all other cultures.
2. Cultural Incapacity — belief in “separate but equal” and doesn’t respond to other cultures.
3. Cultural Blindness — the assumption that everyone is alike.
4. Cultural Pre-competence — supports diversity
5. Cultural Competence — actively seeking ways to incorporate other cultures into practice.
6. Cultural Proficiency — advocating cultural relations among different groups.

Q: What are the steps towards becoming culturally competent?
A:
1. Develop Self Awareness
2. Understand there is a “Western Culture of Medicine”
3. Use strategies to interview patients about their beliefs

Q: What is the AWARE model?
A:
A — Accept another person’s behavior without judging it in terms of your own culture
W — Wonder what another person’s behavior mean in their own cultural context
A — Ask what another person’s behavior means to them.
R — Research another’s culture, to understand their behavior in the context of their culture
E — Explain what their behaviors mean in their medical culture.

Q: Why does prejudice exist?
A:
1. Allows people to avoid doubt and fear
2. Gives people a scapegoat to blame for things.
3. Boosts self-esteem
4. Helps people bond to each other, away from “the others.”
5. It justifies a group’s dominance over another.

Q: How does prejudice form?
A: When you believe something long enough, then you think it’s true. So it often begins early in childhood.

Q: Disease vs. Illness?
A: Disease = objective
Illness = subjective — response to being unwell — because it is subjective, it is impacted by psychological, social, and cultural factors So you can have disease without illness and illness without disease!!!

Q: Western medicine typically focuses on ____ while Folk healers typically focuses on ____.
A: Western Medicine — disease
Folk Healers — illness

Q: What kind of cultural beliefs do people have about health?
A: What is illness? What causes illness? What helps with illness? Who’s best to go to for illness?

Q: Do you predict what a patient will be like merely because of their culture?
A: NO!! Instead, listen to the patient, and take into account possible cultural impacts.

Q: What do all the explanatory models have in common?
A: How they feel about it.

Studies show that there is significant increase in sudden deaths following ward rounds at the hospital.

9/7/2010 Afternoon

MOTIVATIONAL INTERVIEWING

Q: What must remain the focus for a successful disease management program?
A: self-management focus — help them become self-motivated

Q: What is the transtheoretical model?
A: It says that individuals progress through a series of changes. Patients can go backwards or forwards through the stages.

Q: What are the stagesof the transtheoretical model?
A:
1. Precontemplation — not considering change, because of self-efficacy, contentment, or knowledge of risks/consequences.
2. Contemplation — considering change, but hasn’t because of indecisiveness
3. Determination — committed to change within a month. Barriers: still making plan decisions, loss of commitment
4. Action — begin changing behavior. Barriers: failure, overconfidence
5. Maintenance — has maintained changed behavior for 6 months. Barriers: stress, failure
6. Relapse — when you go back to unwanted behavior. This is natural.
7. Termination — when you’ve stabilized the new behavior until the point that relapse is unlikely to happen again.

Q: Are most people willing to change?
A: In general, people are ambivalent to change.

Q: Why are people generally ambivalent to change?
A: Because they may not know what changes are needed, or they may have a misunderstanding of the seriousness of the condition, or they may not know how to change.

Q: What criteria are needed for assessment questions?
A: It must be accurate, non-leading, non-judgmental, and respectful.

Q: So what is the goal of motivational interviewing?
A: reduce ambivalence in people so they are self-willing to change.

Q: What does resistance look like?
A: Arguing (discounting, challenging), Interrupting (cutting off), Denying (blaming others, minimizing), Ignoring.

Q: What is the pattern of information exchange we must do?
A: Elicit readiness and interest to change –> Provide feedback that is NEUTRAL (so avoid the word “you”) –> Elicit patient’s thoughts.

Q: What are the four things you need to do early on in the motivational interview?
A:
1. Develop Rapport — set partnership. Have a conversation, not interrogation. Be nonjudgmental and value the patient’s perspective
2. Set Agenda — Let patient direct the agenda. Give them choices rather than dictate to them.
3. Assess importance of the issue to the patient and confidence of patient to change.
4. Increase patient’s motivation for change.

Q: If a patient says on a scale from 1-10, their motivation for change is 6, what do you say?
A: Ask why is it 6 and not a 1? This shows the patient cares about issue. But then ask, why 6 and not a 10? Then find out what is holding the patient back from full confidence and work from there. Reduce the resistance.

Q: How do you get patient’s out of resistance?
A: Emphasize personal choice so patient doesn’t feel “trapped” by the physician.
Reassess the patient’s readiness, importance, and confidence
Have partnership alongside patient.

9/8/2010

DIFFERENT CULTURAL PRACTICES

9/9/2010

Q: Touching the head is insulting to who?
A: Buddhists

Q: Constant eye contact is disrespectful for who?
A: Asians and Native Americans

Q: Offering the left hand is offensive to who?
A: Muslims

Q: Gesturing with fingers pointing upward is insulting to who?
A: Southeast Asians

Q: Predicting dire consequences is bad to who?
A: Asians, Africans, Muslims

Q: Discussing Social Connections is polite to who?
A: Native Americans, Latinos, Caribbean people, and Asians

Q: Discussing non-medical topics first is polite to who?
A: Latinos, Southeast Asians

Q: Addressing elderly in kinship terms is polite to who?
A: Native Americans, Asians.

Q: Addressing elderly in kinship terms is impolite to who?
A: Many European Americans

Q: Offering to shake hands is polite to who?
A: European Americans and African Americans

Q: Telling bad news to family members before telling patient is appropriate for who?
A: Japanese, Italians, Russians, Mexican

Q: Telling bad news to family members before telling patient is inappropriate for who?
A: Western Medicine

Q: Signing consent forms may be offensive to who?
A: some Arab patients

Q: What do Roman Catholics do during death?
A: Clergyman gives Holy Communion and Last Rites to the dying. Baptism for very ill newborn.

Q: How is death treated in Jewish culture?
A: No embalming, no autopsies. burial within 24 hrs.

Q: How is death treated in Muslim culture?
A: Lie facing Mecca when dying or dead. Family members prepare the body and non-muslims can’t touch body unless they’re wearing gloves. Family members stay with body until the burial. No autopsies or organ donation. Bury within 24 hrs.

Q: What do Sikhs do during death?
A: recite from holy book. hair and beard can’t be cut after death.

Q: What is Empacho?
A: Massage and dietary changes to treat an GI illness in Latino culture.

Q: What is Mal de Ojo?
A: Evil Eye — curse from jealous person in Latino Culture. Treat to wearing amulet, sweeping body with eggs, bay leaves, prayer, etc.

Q: Is Coining Abuse?
A: only when it causes REPEATED HARM.

Q: What is Moxibustion?
A: therapeutic burningg of moxa herb or yard on the skin.

Q: How do you deal with folk beliefs?
A: Most folk beliefs are harmless so it can be included in the medical treatment. Since so many people believe in a lot of this stuff, you can’t ignore it in your patients.

Q: In the Asian “Hot and Cold” concept, what are Hot conditions?
A: Fever, infections, diarrhea, kidney problems, skin rash, sore throat, liver problems, ulcer, constipation.

Q: How do you treat hot and cold conditions?
A: treat hot conditions with cold foods/treatments. treat cold conditions with hot foods/treatments.

Q: What are Cold conditions?
A: Cancer, pneumonia, malaria, joint pain, menstrual period pain, earache, tuberculosis, stomach cramps

Q: What are Hot foods?
A: Chocolate, cheese, temperate zone fruits, eggs, peas, aromatic beverages, oils, chili pepper, penicillin, tobacco, ginger, garlic, cinnamon, vitamins, cod liver oil.

Q: What are Cold foods?
A: Fresh veggies, tropical fruits, dairy products, fish, chicken goat, honey, cod fish, raisins, barley, chrysanthemum tea, linden, sage, milk of magnesia.

HEALTH CARE LITERACY

Q: What is LEP?
A: Limited English Proficiency

Q: Who has LEP?
A: People who don’t speak English

Q: What grade level of education provides enough literacy skill to read and understand health care?
A: 8th grade

Q: What is low functional health literacy?
A:
1. Lack background knowledge in health
2. Lack medical vocab
3. Lack experience in health care system
4. Lack knowledge to navigate health care system

Q: What percentage of adults are health literacy proficient?
A: 12-18%

Q: Are most health illiterate individuals immigrants?
A: NO!!

Q: Why are patients more and more at risk for health illteracy?
A: Because we are relying more on written instruction. Healthcare system is also getting more and more complex. Reliance on internet when 80% of Americans don’t use internet for health info.

Q: Who is most at risk for health illiteracy?
A: Old people, minorities, people with limited education, low socioeconomic statis, and people with chronic disease.

Q: At what grade level does the average american read at?
A: 8th grade level. Most health education stuff is written at 12th grade level or higher.

Q: What are some signs that someone probably doesn’t know how to read?
A: If they keep making excuses — “I’ll read it when I get home” rather than read it at the clinic and get embarrassed.
they keep perceiving resistnace. They usually don’t have much questions. They miss appointments, and they don’t adhere to treatment.

Q: How do you ask about education?
A: “How happy are you with how you read?”

Q: What is the Teach-Back method?
A: Asking patient to repeat what you said to see they understand.

Q: What question do you NOT ask to ask about understanding?
A: “Do you understand?”

Q: How do you know a patient is LEP?
A:
1. If they ask few questions or doesn’t initiate conversation
2. If they just nod or say “yes” when that’s not the most appropriate answer
3. If their answers are inappropriate or inconsistent with the question

Q: What’s the best person to use to help LEP?
A: “fluent” doctor –> qualified medical interpreter –> 2-way video remote interpreters (MARTTI)

Q: What does MARTTI stand for?
A: My Accessible Real-Time Trusted Interpreter

Q: When do you use an Ad Hoc Interpreter?
A: ONLY during emergency options when there’s NO ONE ELSE available!!!

Q: What type of interpreter is the most available?
A: Trained telephonic interpreter

Q: What type of interpreter is the most professional?
A: Trained onsite interpreter

Q: What type of interpreter is the most comfortable to the patient?
A: Bilingual doctor

Q: What type of interpreter has the highest interpreting quality?
A: Trained onsite interpreter and trained telephonic interpreter.