History & Physical Exam – Physician Competency 14Mar2009 DO NOT DISTRIBUTE - 1 - HPE #1 – The Not So New AOA Competency Initiative 1) According to the Dreyfus Model of Skill Acquisition, which level corresponds to a jet fighter pilot who understands the rules, can apply them to a situation, has gained accountability and perspective, but not intuition? a) Novice b) Advanced beginner c) Competent d) Proficient e) Expert f) Master 2) Dr. David Sackett, MD said, “Every medical student should learn how to do a complete history and physical and then never again do one.” Following this, which level describes a medical student that is able to do a patient history but realize that not every question is needed for every patient? a) Novice b) Advanced beginner c) Competent d) Proficient e) Expert f) Master 3) An expert clinician is seeing a renal failure patient who wants to join a trial for a new drug therapy. The clinician reflects on what she knows about renal failure and drug interactions, what she does not know, and how she is able to learn about this new interaction. What best describes this situation? a) Perspective b) Mastery c) Intuition d) Competency e) Metacognition 4) What drives a person toward one extreme of competency versus that of mastery? a) Relationship to quality b) One’s ability c) Physician oath d) Clinical judgment e) Intuitive reasoning 5) The entire problem with medical quality can be summed up by saying that there is unnecessary and unexplained variation in practiced regarding: a) Perspective b) Mastery c) Intuition d) Competency e) Metacognition 6) At what level is variation in a clinical task first permissible? a) Novice b) Advanced beginner c) Competent
Transcript
History & Physical Exam – Physician Competency 14Mar2009
DO NOT DISTRIBUTE - 1 -
HPE #1 – The Not So New AOA Competency Initiative
1) According to the Dreyfus Model of Skill Acquisition, which level corresponds to a jet
fighter pilot who understands the rules, can apply them to a situation, has gained
accountability and perspective, but not intuition?
a) Novice
b) Advanced beginner
c) Competent
d) Proficient
e) Expert
f) Master
2) Dr. David Sackett, MD said, “Every medical student should learn how to do a
complete history and physical and then never again do one.” Following this, which level
describes a medical student that is able to do a patient history but realize that not every
question is needed for every patient?
a) Novice
b) Advanced beginner
c) Competent
d) Proficient
e) Expert
f) Master
3) An expert clinician is seeing a renal failure patient who wants to join a trial for a new
drug therapy. The clinician reflects on what she knows about renal failure and drug
interactions, what she does not know, and how she is able to learn about this new
interaction. What best describes this situation?
a) Perspective
b) Mastery
c) Intuition
d) Competency
e) Metacognition
4) What drives a person toward one extreme of competency versus that of mastery?
a) Relationship to quality
b) One’s ability
c) Physician oath
d) Clinical judgment
e) Intuitive reasoning
5) The entire problem with medical quality can be summed up by saying that there is
unnecessary and unexplained variation in practiced regarding:
a) Perspective
b) Mastery
c) Intuition
d) Competency
e) Metacognition
6) At what level is variation in a clinical task first permissible?
a) Novice
b) Advanced beginner
c) Competent
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d) Proficient
e) Expert
f) Master
7) After the 1999 Institute of Medicine (IOM) publication “To Err is Human” and the
2001 follow-up “Crossing the Quality Chasm,” what became the defining paradigm or
foundation for the competency movement?
a) Continuing education
b) Zero tolerance
c) Patient centeredness
d) Accountability
e) Pharmaceutical precautions
8) Which of the following would lead to a positive overall outcome for patients?
a) A physician limits the use of OMT in her practice because she knows that
many of the insurers will not pay fairly for the time spent delivering these services
b) A medical student, realizing that they have sufficient points to pass a course,
skips over a complicated section of knowledge because missing the questions on
that section will not influence their eventual passing or failing
c) A physician, rushing through their patient schedule, writes a prescription but
does not ask the patient if they have sufficient funds to purchase the medicine
d) A surgeon in the OR yells at a nurse who handed her the wrong instrument;
The nurse believed that instrument was what the surgeon had asked for
e) A psychiatrist allows himself to enter into an intimate relationship with a
depressed patient in his practice
f) A physician writes an antibiotic prescription for a viral infection just to get the
patient out of his office
g) A physician uses a medication recommended by a pharmaceutical
representative despite the lack of evidence suggesting that the medication is
superior to older, less costly choice
h) None of the above
9) Which of the following is most likely to occur if a student is not open to feedback from
their teachers?
a) The student will stop receiving feedback
b) The student will harm many patients
c) The student will fail a clinical rotation
d) The student will be ignored by peers
e) The student will have no future issues
10) When a student chooses a medical school to attend, where does “the finger point” as
the accountable party for that student’s success in completing the curriculum and
becoming a physician?
a) The medical school deans
b) The medical school professors
c) The medical school curriculum
d) The medical licensing board
e) The student
11) Which category in the Johari Window describes information that you do not know
but that another party does know?
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a) Known
b) Unknown
c) Secret
d) Hidden
12) Which of the following must occur within the Johari Window for information that is
not known by yourself or others to be brought into the known world?
a) Feedback
b) Disclosure
c) Revelation
d) Feedback and disclosure
e) Disclosure and revelation
13) Which competency has compassion as the central theme and involves effective
communication, gathering accurate information, and making informed decisions?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
14) Which competency recognizes that physicians are one component of a larger scheme
of care that needs to be coordinated in order that patients have the greatest chance for the
best care?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
15) Two patients come to see you with chest pain. Both are 45-year-old males and both
have similar clinical presentations and risk factors. One noticed the onset of symptoms
while in the 4th mile of a 10 mile run, and the other experienced symptoms two days
before the 1st anniversary of his recent divorce. What competency is involved in this
scenario, where the context of the presentation influences your management of the
problem?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
16) Which competency has listening as the central theme and involves therapeutic and
ethically sound relationships with patients?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
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e) Systems-based practice
f) Practice-based learning and improvement
17) Which competency is about learning from what you did yesterday to ensure that you
do it better tomorrow?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
18) Which competency involves commitments, ethics, cultural competency, and placing
the needs of the patient above self-interest?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
19) Which competency states that it is the duty of every practicing physician to “facilitate
the learning of students and other health care professionals?”
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
20) What should a learner do if their teacher’s willingness to teach is high but the
teacher’s ability is low?
a) Improvise
b) Encourage
c) Inspire
d) Celebrate
21) What should a learner do if their teacher’s willingness to teach is low but the
teacher’s ability is high?
a) Improvise
b) Encourage
c) Inspire
d) Celebrate
22) A student is placed on a rotation with a busy internist. The internist’s reputation is
that she has been an excellent teacher in the past; however, her schedule is now so full
that she rarely has time to do anything other than give a series of “mini-lectures” related
to the diagnoses of her patients. What describes the intern’s maturity level in that she is
able to perform the task but unwilling?
a) Low maturity
b) Low/mid maturity
c) Mid/high maturity
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d) High maturity
23) In the above case, what should the student attempt to do to improve feedback?
a) Improvise
b) Encourage
c) Inspire
d) Celebrate
24) Lack of competency in which area is the number one root cause of medical error?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
25) A patient’s experience of “being cared for” is the most important marker for
physician:
a) Empathy
b) Competency
c) Sympathy
d) Benevolence
e) Professionalism
26) What is considered the currency of evidence-based medicine?
a) Randomized control trials
b) Double blind placebo trials
c) Positive predictive values
d) Likelihood ratios
e) Sensitivity and specificity
HPE #2 – Medical Knowledge & Patient Care
1) A. J. Bonar’s “The Truth About Golf” explains that grip and swing do not matter, but
what matters is the moment of truth when the clubface hits the ball. If an analogy were
related to physicians, what would be the moment of truth?
a) When the student passes the final exam for their degree
b) When the physician passes the final licensing exam
c) When the physician removes all possible blinders
d) When the physician meets the patient
e) When the physician prescribes medication
2) According to Kerr White in NEJM 1961 “The Ecology of Medical Care,” 75% of at
risk adults report an illness or injury but only 25% consult a physician. What can be said
about the majority of adults who consult a physician one or more times per month?
a) Have a chronic illness
b) Will be admitted to a community hospital within a month
c) Will be admitted to a university medical center within a month
d) Will be referred to another physician within a month
e) Are worried well
3) What major change was seen when Kerr White’s study was repeated 40 years later by
Larry Green (NEJM 2001)?
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a) No major change occurred
b) Significantly more people reported symptoms
c) Significantly more patients were admitted to academic medical centers
d) Significantly less patients sought complementary and alternative medicine
e) Significantly less patients were hospitalized
4) What reasons for visiting a primary care clinic most often results in a patient who is a
poor historian?
a) Trigger event
b) Told to come
c) Psychosocial reason
d) Health maintenance visit
e) Symptom existence causing anxiety
f) Symptom existence causing pain
5) Using Miller’s 1992 Journal of Family Practice article “Routine, Ceremony, or
Drama,” which category describes a patient who waits until the end of a visit and reveals
an important medical problem, such as by saying, “Oh by the way…?”
a) Routine
b) Drama
c) Transition ceremony
d) Maintenance ceremony
6) Which category describes a patient with chronic low back pain or chronic fatigue?
a) Routine
b) Drama
c) Transition ceremony
d) Maintenance ceremony
7) A patient presents for the third time with vague “skin problems.” After a review of her
full medical history and charts, it become clear she does not have a medical condition but
uses the “skin problems” as an excuse to visit the clinician and receive attention. What
category best describes this patient?
a) Routine
b) Drama
c) Transition ceremony
d) Maintenance ceremony
8) Asking a patient “What do you call your problem? What does your sickness do to you?
How does it work?” is a means of eliciting which of the following?
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
9) Asking a patient “Is there anything special about your problem that causes you
concern?” is a means of eliciting which of the following?
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
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10) Asking a patient “How did you hope to be helped today?” is a means of eliciting
which of the following?
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
11) Asking a patient “Have you ever had this problem before? Have you ever known
anyone else who has had this problem? Have you read about this problem?” is a means of
eliciting which of the following?
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
12) A very ill patient refused to be admitted to the hospital after an extensive workup in
the Emergency Department. It turns out that the patient’s husband had died in the same
room, so she felt if she stayed in that room she would die too. This is an example of:
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
13) A patient presents with complaints of chest pain. After questioning, it turns out the
actual problem is marital discourse. This is an example of:
a) Illness prototype
b) Request
c) Explanatory model
d) Hidden agenda
14) What deep interviewing model suggests that an empathic connection is necessary
before any patient education can be delivered?
a) Patient-centered model
b) Family systems approach
c) Three function model
d) Physician self-awareness, transference
e) Physician self-awareness, counter-transference
15) Which of the following models accounts for the difficulty a physician may have in
interviewing a drug addict, when the physician has had a family member recently pass
away due to drug addiction?
a) Patient-centered model
b) Family systems approach
c) Three function model
d) Physician self-awareness, transference
e) Physician self-awareness, counter-transference
16) What component of the SPIRIT mnemonic by Maugans for taking a spiritual history
deals with advanced directives?
a) S: Spiritual belief system
b) P: Personal spirituality
c) I: Integration and involvement in a spiritual community
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d) R: Ritualized practices and restrictions
e) I: Implications for medical care
f) T: Terminal events planning
17) A CEO for a multi-national corporation presents with complains of lumps in her
breast. Which of the following would be helpful and least likely to provoke a
psychological defense mechanism?
a) “Can’t you see that this is breast cancer?”
b) “You need to go into surgery as soon as possible.”
c) “What were your thoughts when you noticed the lump in your breast?”
d) “It would probably be a good idea to contact you family right now.”
e) “Have you confirmed this diagnosis with an internet search engine?”
18) What diagnostic strategy involves a clinician coming up with a guess at a patient’s
diagnosis within 28 seconds of taking a history?
a) Pattern recognition (Aunt Millie Method)
b) Multiple branching or arborization
c) Exhaustion (Look for the Zebra method)
d) Hypothetico-deductive
19) The majority of patients with exopthalmos do not have hyperthyroidism. What
diagnostic strategy could easily lead to misdiagnosis for these patients?
a) Pattern recognition (Aunt Millie Method)
b) Multiple branching or arborization
c) Exhaustion (Look for the Zebra method)
d) Hypothetico-deductive
20) Which diagnostic strategy is considered the most effective as it is logical and rapidly
narrows the diagnostic possibilities?
a) Pattern recognition (Aunt Millie Method)
b) Multiple branching or arborization
c) Exhaustion (Look for the Zebra method)
d) Hypothetico-deductive
21) A clinician sees a patient with strange clinical symptoms and quickly diagnoses a rare
disease, stating “I just read about that in NEJM!” What heuristic does this represent?
a) Representative heuristic
b) Availability heuristic
c) Anchoring and adjustment heuristic
d) None of the above
22) What heuristic is used with the statement that pathognomonic features of a disease
occur more frequently in the healthy population than those with disease?
a) Representative heuristic
b) Availability heuristic
c) Anchoring and adjustment heuristic
d) None of the above
23) You learn early on that a 45-year-old male patient lost his father to cardiac disease
when he, himself, was 45. This may cause you to increase the likelihood of cardiac
disease existing in that patient. Rather than independently assessing each further piece of
information, you attribute added significance to facts that lead you further to the
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diagnosis than is warranted, and less significance to facts that lead you away from the
diagnosis than is warranted. This can cloud clinical judgment and is an example of:
a) Representative heuristic
b) Availability heuristic
c) Anchoring and adjustment heuristic
d) None of the above
24) According to Norman Cousins in a 1985 NEJM article, what is the LEAST likely
reason for a patient to change physicians?
a) Competency
b) Communication skills
c) Office atmosphere
d) Inability to inspire confidence in the patient
e) Personal habits or characteristics of the physician
25) Which of the following is NOT considered empathy?
a) The courage to be present to a patient who has just received catastrophic news
b) A doctor who suppresses emotional involvement with patients
c) Understanding an individual’s subjective experiences by vicariously sharing
that experience while maintaining an observant stance
d) The ability to sense the patient’s experience and feelings accurately, as well as
to communicate that understanding back to the patient
e) An emotional state involving attached concern or the physician sharing a
personal story about a similar experience
26) In “Taking Care of the Hateful Patient” by Groves (1977 NEJM), what category
would describe a patient who will return again and again to the clinic to report a regimen
did not work, sometimes acting smug and satisfied?
a) Dependent clinger
b) Entitled demander
c) Manipulative help-rejecter
d) Self-destructive deniers
Match the Groves patient category with the counter-transference feelings they evoke:
27) Dependent clinger a) Fear then counterattack upon entitlement
28) Entitled demander b) Guilt and feelings of inadequacy
29) Manipulative help-rejecter c) Aversion
30) Self-destructive deniers d) All of the above and malice
31) The working definition of non-compliance points to:
a) A patient’s underlying psychiatric condition
b) A patient who simply will not comply with a medical regimen
c) A self-destructive denier who may wish to die and “get it over with”
d) Something that the doctor does not know about their patient
HPE #3 – Interpersonal & Communication Skills
1) You say to a patient, “I’d like to see you back in two weeks for follow-up” and three
weeks goes by without a re-visit. Was there communication?
a) Yes and the doctor was responsible
b) Yes but the patient was not responsible
c) No
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2) According to Mizrahi (1984), junior residents who are schooled based on “name,
blame, and shame” when medical errors occur will act in a predictable manner. Which
predictable reasoning would involve the resident saying “that error had nothing to do
with me”?
a) Denial
b) Distancing
c) Discounting
3) In 2003, Caroline Donor Services (CDS) called Dr. Milano (a Duke adult surgeon)
regarding a heart available for transplant. Dr. Milano refused as the heart was for a
pediatric patient, and asked CDS to call Dr. Jaggers (a Duke pediatric surgeon). Dr.
Jaggers said the originally named patient was not ready and asked if Jesica Santillan was
an option. CDS called Dr. Jaggers back, offering the heart to Jesica, who died shortly
after as the heart was of the wrong blood type. Who is most likely to blame for this
communication error?
a) Dr. Milano
b) Dr. Jaggers
c) Caroline Donor Services
d) The system
4) According to Lingard, et. al. 2004 “Communication failures in the operating room,”
nearly 1/3 of all communication attempts made during a 90-hour O.R. observation were
considered failures. What was the most common category of failure?
a) Occasion (timing)
b) Content (inaccurate or missing information)
c) Purpose (issues were not resolved)
d) Audience (key individuals not included)
5) In 1927, Francis Weld Peabody discussed the relationship between a physician and
patient in the JAMA article “The Care of the Patient.” What term did he use, which
means an open, honest, complete communication to the limits allowed by a particular
relationship?
a) Empathy
b) Competency
c) Sympathy
d) Interaction
e) Intimacy
6) A study found that 54% of patient complaints are not elicited by clinicians, 45% of
patient concerns about their problems are not elicited by clinicians, physicians interrupt
their patients after an average of 18-21 seconds, and in 50% of visits the patient and
doctor do not agree on the nature of the main problem. Which of the following, along
with compassion, is likely the answer to these problems?
a) Empathy
b) Competency
c) Sympathy
d) Interaction
e) Intimacy
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7) A physician looks at his schedule and says, “Oh that frequent flyer again, he’ll
probably complain about how bad doctors are.” What barrier to effective communication
does this example describe?
a) Time
b) Complexity
c) Jargon
d) Cultural and socioeconomic differences
e) Power relationships
f) Judgments
8) What model of the doctor-patient relationship promotes passive-aggressive patient
behavior and is collusive in that both doctors and patients are using one another for
selfish, albeit subconscious, gain?
a) Shared decision-making model
b) Consumerist model
c) Paternalistic model
d) All of the above
f) None of the above
9) Which of the following models of the doctor-patient relationship is best for chronic
problems?
a) Shared decision-making model
b) Consumerist model
c) Paternalistic model
d) All of the above
f) None of the above
10) What is the primary tool that physicians have to understand where the barriers to our
communication exist?
a) Competency
b) Patient-centeredness
c) Mindfulness
d) Empathy
e) Listening
f) Vulnerability
11) What is considered inversely proportional to the degree to which physicians set aside
their conversation for a patient (distance)?
a) Competency
b) Patient-centeredness
c) Mindfulness
d) Empathy
e) Listening
f) Vulnerability
12) Which of the following literally translates into “an action taken toward unity,” or an
action taken toward a common ground (“on the same page”)?
a) Compassion
b) Communication
c) Empathy
d) Competency
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e) Mindfulness
13) When is the highest risk period for any patient, regarding medical errors?
a) Upon admission to the Emergency Department
b) Upon entering a primary care clinic
c) During a hand-off
d) While stable in the Intensive Care Unit
e) While being monitored by nursing staff
14) What is the primary skill necessary to affect communication?
a) Compassion
b) Mindfulness
c) Vulnerability
d) Listening
e) Alignment
HPE #4 – Professionalism
1) Non-adherence to what competency most often leads to loss of licensure?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
2) All of the following oaths follow the common theme of a commitment to patient-
centered care. Which oath contains the phrase “above all, do no harm?”
a) Osteopathic Oath
b) Oath of Maimonides
c) Hippocratic Oath, classic version
d) Hippocratic Oath, modern version
e) None of the above
3) Which of the following is the most critical factor in professionalism, relating to one’s
manifest commitments, stated commitments, and desired commitments?
a) Compassion
b) Mindfulness
c) Introspection
d) Consistency
e) Alignment
4) What is the hallmark of integrity?
a) Professionalism
b) Mindfulness
c) Introspection
d) Consistency
e) Alignment
5) Which of the following describes a behavior that is rooted in a conversation generated
on behalf of the society, or moreover when a physician acts as an agent for all other
physicians?
a) Professionalism
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b) Mindfulness
c) Introspection
d) Consistency
e) Alignment
6) Of the following aspirations to professionalism from the American Board of Internal
Medicine’s “Project Professionalism,” which involves fulfilling an implied contract with
the patient?
a) Altruism
b) Accountability
c) Excellence
d) Duty
e) Honor & Integrity
f) Respect
7) Also from “Project Professionalism,” which of the following ways physicians go
astray describes a clinician who breaches confidentiality to alert the media that a famous
movie star is undergoing surgery?
a) Abuse of Power
b) Arrogance
c) Greed
d) Misrepresentation
e) Impairment
f) Lack of Conscientiousness
g) Conflict of Interest
8) A young rheumatologist tells an elderly woman “you have nothing to worry about
because I have an IQ of 170.” This is an example of:
a) Self-righteousness
b) Arrogance
c) Ignorance
d) All of the above
9) Research shows that the vast majority of physicians believe that they cannot be
influenced by gifts and other methods of pampering. Which of the following is true
regarding this statement?
a) Physicians are entirely correct and are not influenced by gifts
b) Physicians are mostly correct and are usually not influenced by gifts
c) Physicians are mostly incorrect and are occasionally influenced by gifts
d) Physicians are entirely incorrect and are influenced by gifts
HPE #5 – Practice-Based Learning & Improvement
1) What is the single most important strategy in moving from competency to mastery?
a) Studying evidence-based medicine
b) Seeing a large number of patients
c) Seeing a wide variety of patients
d) Internet education
e) Teaching others
2) The half-life of medical knowledge is believed to be:
a) One-year
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b) Two-years
c) Four-years
d) Ten-years
e) 25-years
3) Which of the following describes the best method to keep up with medical literature as
it is published on a daily basis?
a) Read the 46 new randomized control trials (RCTs) first
b) Read the 1000 new Medline articles first
c) Read the 3000 new medical papers per day
d) Sort through the 60 pounds of guidelines first
e) It is humanly impossible to keep up without first filtering
4) Approximately what percentage of physicians read one hour or less per week?
a) 3%
b) 8%
c) 20%
d) 23%
e) 50%
5) The likelihood that a patient will be involved in a medical error with a clinician who is
aged 50 or older is how much higher when compared with younger physicians?
a) Errors are 2 times more likely
b) Errors are 3 times more likely
c) Errors are 4 times more likely
d) Errors are 5 times more likely
e) Errors are 6 times more likely
6) When comparing sources of medical education, which of the following was observed
far more than it was reported? (Gorman, Bull Med Libr Assoc 1994;82:140-6)
a) Human sources
b) Printed sources
c) Pharmacology textbooks
d) Medical textbooks
e) Medical journals
f) Drug company information
7) The majority of research contributions in medical literature are from ____ and are
applicable to a ____ patient population.
a) Generalists; Specific
b) Generalists; Majority of the
c) Specialists; Specific
d) Specialists; Majority of the
8) Which of the following is true regarding large lecture format education programs for
practitioners?
a) Are likely the most useful form of continuing medical education (CME)
b) Allows for incorporation of erroneous false data due to perception
c) Result in high retention of key pieces of information
d) Is an uncommon educational strategy
9) In evidence-based medicine, learning should be driven by:
a) Medical journals only, such as the 1994 study on ASA and family practitioners
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b) Guidelines only, such as the study showing all cardiologists follow their own
guidelines
c) The need to apply a question to a general population
d) The need to answer a specific question in patient care
e) Changes brought about by industry and pharmaceutical representatives
10) Important articles in evidence-based medicine follow what mnemonic?
a) PB&J: Patient-Based important Journals
b) FEPC: Finding Evidence in Patient Cases
c) POEM: Patient-Oriented Evidence that Matters
d) OJ-GI: Objectives Journals with Generalist Information
e) SEFFP: Specific Evidence For Family Practitioners
11) Which component of the PICO mnemonic for dissecting a clinical question applies to
the phrase “…does the addition of an ACE inhibitor to their current regimen…”?
a) Patient
b) Intervention
c) Comparison
d) Outcome
12) When confronted with a patient presentation, which of the following things to
consider is NOT a component of patient-centeredness?
a) Most likely problem
b) Most serious problem
c) Most treatable problem
d) Most expensive problem
13) Which of the following is NOT a question to ask when formulating an evidence-
based medicine search?
a) Who is the patient?
b) What is the problem?
c) What is the intervention?
d) What is the medication?
e) What is the outcome?
14) Which of the following terms answers the question, “does this information apply to
my patient?”
a) Importance
b) Sensitivity
c) Specificity
d) Validity
e) Accuracy
15) Likelihood ratios are considered the currently of evidence based medicine. How is a
positive likelihood ratio (LR+) determined, which is the probability that a finding is
present in diseased patients compared with the probability that it will be present in non-
diseased patients?
a) Sensitivity / (100 – Specificity)
b) Specificity / (100 – Sensitivity)
c) (100 – Sensitivity) / Specificity
d) (100 – Sensitivity) / Specificity
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16) What is the formula for a negative likelihood ratio (LR-), meaning the probability
that a finding will not be present in the non-diseased patient compared with the
probability that it will be present in the diseased patient?
a) Sensitivity / (100 – Specificity)
b) Specificity / (100 – Sensitivity)
c) (100 – Sensitivity) / Specificity
d) (100 – Sensitivity) / Specificity
17) Which of the following likelihood ratios is considered moderate evidence to rule in
disease?
a) >10
b) 5-10
c) 2-5
d) 0.5-2
e) 0.2-0.5
f) 0.1-0.2
g) <0.1
18) What is the LR+ and LR- for a test with 90% sensitivity and 60% specificity?
a) 0.66 and 0.14
b) 1.23 and 0.66
c) 2.55 and 0.16
d) 6 and 1
e) 0.9 and 0.4
19) What is the interpretation of the likelihood ratios in the above scenario, where
sensitivity is 90% and specificity is 60%?
a) No evidence to rule in disease and moderate evidence to rule out disease
b) No evidence to rule in disease and no evidence to rule out disease
c) Weak evidence to rule in disease and moderate evidence to rule out disease
d) Moderate evidence to rule in disease and no evidence to rule out disease
e) No evidence to rule in disease and weak evidence to rule out disease
20) A rapid strep test with 95% sensitivity and 99% specificity yields an LR+ of 95 and
an LR- or 0.5. What is the interpretation of these likelihood ratios?
a) Strong evidence to rule in disease and strong evidence to rule out disease
b) Moderate evidence to rule in disease and moderate evidence to rule out disease
c) Weak evidence to rule in disease and moderate evidence to rule out disease
d) Strong evidence to rule in disease and weak evidence to rule out disease
e) Moderate evidence to rule in disease and strong evidence to rule out disease
21) The prostate specific antigen (PSA) test has a sensitivity of 75% and a specificity of
60%. The test has a predictive value of 31.5% based on current prevalence estimates.
Calculate the LR+ and LR-, and then interpret the results:
a) Strong evidence to rule in (5.5) and no evidence to rule out (0.66)
b) Moderate evidence to rule in (3.33) and weak evidence to rule out (0.33)
c) Weak evidence to rule in (1.11) and moderate evidence to rule out (.11)
d) Strong evidence to rule in (6.66) and weak evidence to rule out (0.2)
e) No evidence to rule in (1.83) and weak evidence to rule out (0.45)
22) Which of the following describes the how many patients need to receive care in order
to prevent one additional bad event?
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a) Control event rate (CER)
b) Experimental event rate (EER)
c) Relative risk reduction (RRR)
d) Absolute risk reduction (ARR)
e) Number needed to treat (NNR)
23) What is the formula for absolute risk reduction (AAR)?
a) (CER – EER) / EER
b) (EER – CER) / CER
c) CER – EER
d) EER – CER
e) NNT / 1
24) A treatment is found to have a CER of 0.264 and EER of 0.198. What is the relative
risk reduction (RRR)?
a) 46%
b) 33%
c) 25%
d) 6%
e) 3%
25) What is the NNT if CER is 0.264 and EER is 0.198?
a) 5 patients
b) 15 patients
c) 150 patients
d) 1,500 patients
e) 15,000,000 patients
26) What is the NNT if CER is 0.000000264 and EER is 0.000000198 (same relative risk
reduction)?
a) 5 patients
b) 15 patients
c) 150 patients
d) 1,500 patients
e) 15,000,000 patients
27) Which of the following is true?
a) NNT is the key term in EBM and is more useful with a lower value
b) NNT is the key term in EBM and is more useful with a higher value
c) RRR is the key term in EBM and is more useful with a lower value
d) RRR is the key term in EBM and is more useful with a higher value
e) One can calculate AAR when given an RRR value
HPE #6 – System-Based Practice
1) What competency refers to a specific outcome and care that is of optimal value?
a) Medical knowledge
b) Patient care
c) Interpersonal and communication skills
d) Professionalism
e) Systems-based practice
f) Practice-based learning and improvement
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2) Which of the following is considered the heart of the system-based practice
competency?
a) Professionalism
b) Mindfulness
c) Introspection
d) Consistency
e) Quality
3) What Shortell stage of integration is considered the “holy grail” concerning quality?
a) Functional integration
b) Physician-system
c) Clinical integration
d) All of the above
4) What Shortell stage of integration is seen in a group practice (non-hospital) with
physicians working together but not necessarily sharing clinical protocols and
algorithms?
a) Functional integration
b) Physician-system
c) Clinical integration
5) Which of the following is NOT true of barriers to clinical integration?
a) We have a model to demonstrate the cost-effectiveness of a quality of care
approach
b) We emphasize our own individuality and autonomy
c) Medical education and practice leads to a sense of elitism
d) Uneven evidence about outcomes exists
e) We are frightened by evaluation
6) Minimization of unnecessary and unexplained variation is the IOM definition of:
a) Professionalism
b) Efficacy
c) Accuracy
d) Quality
e) Consistency
7) The IOM report “To Err is Human” established that 44,000-98,000 patient deaths
annually are iatrogenic, making this the ____ leading cause of death in the United States.
a) 5th
b) 6th
c) 7th
d) 8th
e) 9th
8) The “100k Campaign” describes which of the following ways hospitals can save lives?
a) Deployment of rapid response teams
b) Delivery of reliable, evidence-based care for acute myocardial infarction
c) Medication reconciliation
d) Prevention of central line infections
e) Prevention of surgical site infections
f) Prevention of ventilator-assisted pneumonias
g) All of the above
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9) Which component of the IOM four-tiered approach to achieve a better safety record
has been the most variable thus far?
a) Establish a national focus
b) Identify and learn from errors
c) Raise performance standards
d) Implement safety systems
10) Which of the following is true of W. Edward Deming’s processes as they apply to
medicine?
a) Eliminate the bottom 10% of employees based on errors
b) Avoid the Shewhart Cycle of plan, do, check, act (PDCA)
c) Focus on improving process not poor employees
d) Those who feel punished for reporting errors will continue to do so
e) Mass inspection after the fact is the most effective way to improve quality
11) What is the number one variation issue (unexplained and unnecessary) related to
health care quality?
a) Invasive procedures
b) Cost and reimbursement
c) Access to health care
d) Timeliness of trauma facilities
e) Primary care practice guidelines
12) Which of the following is true regarding this
graph displaying two different variations with
regard to population outcomes?
a) Neither graph demonstrates variation
b) Overall variation (area under the curve) does not change
c) AB (one standard deviation) < CD (one standard deviation)
d) The taller, thinner graph on the right demonstrates less variation
e) The mean and mode of the left graph are higher than the right graph
13) Which of the following is part of the old paradigm for medical quality improvement?
a) Guidelines and defined outcomes
b) Collaboration practice
c) Clinical indicators
d) Satisfaction variables
e) Peer review and incident reporting
14) Which of the following organizations is dedicated to improving safety, quality, and
affordability of health care, and is composed of Fortune 500 companies?
a) National Advisory Council on Nurse Education and Practice (NACNEP)
b) National Academy for State Health Policy (NASHP)
c) Council on Graduate Medical Education (COGME)
d) The Leapfrog Group
e) The Delta Group
15) Which of the following is true of Pennsylvania Act 13 (2003)?
a) Near-miss reporting is optional for medical errors without significant
consequences for the patient
b) Punitive damages shall now be awarded in medical error cases
c) Disclosure of medical errors by physicians is mandatory
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d) A physician is not liable if they fail to seek a patient’s informed consent
e) No clinician owes a duty to his or her patients with regard to informed consent
HPE #7 – Online Forum Questions
1) Patients want physicians who are at what competency level?
a) Advanced beginner
b) Competent
c) Proficient
d) Experts
e) Masters
2) Which of the following patient statements is an example of an illness prototype?
a) “I think my stomach aches began to occur when I returned from my trip to
India.”
b) “I’m sure this is what I have – it’s exactly the same as the description I read in
TIME Magazine.”
c) “I’m here because I need an antibiotic for my sore throat”
d) “Doctor, by the way, there’s one more thing that I want to discuss with you.”
3) Wrong site surgery (e.g. amputating the incorrect limb) is a major concern in surgical
care and communication issues are felt to be a significant contributing factor. Which of
the following innovations holds promise in reducing the number of wrong site surgical
errors?
a) Use of checklists (similar to those used by airline pilots in cockpit checks)
b) Surgeons arriving early for surgery to double-check the correct site of surgery
c) Identifying one person, other than the physician, who will identify the correct
surgical site
d) Marking the surgical site with an indelible marker immediately prior to surgery
4) The physician who told an 85-year-old mother on her first visit, “Faye, you have
nothing to worry about. I have an IQ of 170,” violated which of the aspirations of
professionalism?
a) Altruism
b) Accountability
c) Excellence
d) Duty
e) Honor and Integrity
f) Respect for others
5) Upon hearing the physician's instructions to go for a barium enema examination, a 52-
year-old patient responded with the statement, "Isn't there another test you can order for
me?" In response the physician states, "Don't worry about it. You'll do fine." Several
weeks later the physician receives a report that says, "Patient failed to show for
procedure." In this case:
a) The patient's failure to communicate responsibly with the physician accounted
for this poor outcome
b) The physician appropriately reinforced the importance of the test to the patient
c) Applying the litmus test of communication, it can be said that communication
did not occur in this scenario
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d) The physician erred in not sending a "reminder letter" to the patient regarding
the appointment for the barium enema
6) NNT is calculated as:
a) 1/CER
b) 1/EER
c) 1/RRR
d) 1/ARR
7) The Report that "kick-started" the modern competency movement was:
a) To Err Is Human
b) The Lalonde Report
c) Crossing the Quality Chasm
d) The Ecology of Care
e) Health Professions Education
8) A reason that it may not be valid for primary care physicians to receive the majority of
their continuing education from sub-specialists is:
a) Primary care physicians are not sophisticated enough to understand the jargon
used by sub-specialists
b) The knowledge used by sub-specialists is rarely utilized in primary care
medicine
c) The "funnel theory" suggests that sub-specialty patients are very different from
primary care patients
d) Much of what sub-specialists do is governed by specialty societies and is
outside of the scope of primary care
9) Which of the following is true of the Shewhart Cycle, which is a tool for continuous
quality improvement (CQI)?
a) It also referred to as the PCDA cycle
b) It is also referred to as the Deming cycle
c) It explains why communication issues cause medical errors
d) It is of value in calculating the cost of implementing quality measures
10) What period of time during which a patient undergoes care is deemed to be the
highest risk time relative to communication errors?
a) During the admission process to hospitals
b) Filling prescriptions
c) During ICU (intensive care unit) admissions
d) During periods of hand-offs (e.g. transfer from ER to ward)
11) Which of the following describes a potential consequence of the Leapfrog Group's
efforts?
a) Physicians will refuse to treat patients of Leapfrog employers
b) Leapfrog employers will require care only at specified hospitals and physicians
c) Healthcare costs will rise
d) Six-Sigma quality will become the standard used to monitor outpatient practice
12) A 37-year-old female patient seeks care for her 11-year-old daughter who is
experiencing recurrent abdominal pain. The physician believes this may be anxiety-
related, however the patient is demanding a CT scan to rule out serious disease. (The
evidence suggests, based on the presentation, that a CT scan is not indicated.) What is
the best course of action for the physician?
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a) Order the CT scan
b) Refer the patient to a gastroenterologist
c) View this as a “patient request” and ask appropriate follow-up “probing-type”
questions
d) View this as a difficult patient and apologize for not ordering the CT scan
while holding firm to your chosen action plan.
13) A pharmaceutical representative tells you that his company’s product, “Atoozee” is
the preferred agent in its class because it demonstrated a reduction in symptoms of 50%
compared to the leading agent in its class, “Sertaintude”, with no increase in adverse
effect. Based on this conversation, what should the physician do?
a) Prescribe Atoozee because of its clear superiority
b) Ask the representative whether the 50% reduction is relative or absolute
c) Switch to Atoozee once the NNH is known
d) Continue prescribing Setaintude because a 50% reduction is not clinically
significant
14) In telling his parents that their teenage son, an all-state football player, cannot play in
his senior season due to the splenomegaly associated with infectious mononucleosis,
which of the following statements by the physician best expresses empathy?
a) “My son had a similar issue when he was in high school and I remember how
awful I felt.”
b) “There’s no discussion on this, unless you don’t care if he dies.”
c) “It seems to me that this news has hit you very hard. How can I best help you?”
d) “I know you are taking this news very hard. You have to be strong for your
son.”
15) Reflecting on her medical school notes, a physician suggests to her medical staff that
creating clinical integration would be a step in the right direction for improving the
quality of care at the hospital. Which of the following statements, based on known
barriers toward clinical integration, might she predict would be a reason given against
moving toward clinical integration?
a) “We don’t have the time to set up the systems necessary to clinical integrate.”
b) “We don’t want the whole world seeing our outcomes. They’ll never
understand how to interpret them.”
c) “Our computer system won’t be able to handle clinical integration.”
d) “Unless the nurses join us in our quest toward clinical integration, the effort
will not succeed.”
16) Which of the following word pairs is most closely associated with one another?
a) Sympathy; Care
b) Care; Empathy
c) Mindlessness; Empathy
d) Care; Consumerism
17) A 30-year-old physician reports to a 71-year-old male patient that his biopsy results
are consistent with the diagnosis of carcinoma. She then details the course of events that
must occur over the next week in order to begin the process of treating the disease. At the
end of the discussion, the physician asks the patient if he has any questions and he
responds, “Do you think this could be cancer?” Which of the following statements best
describes what could explain the patient’s question?
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a) By definition, communication did not occur
b) Because the patient is 71, it can be assumed that he has age-related hearing loss
c) The patient is obviously in denial and there is no chance that he will accept the
diagnosis of cancer
d) In all likelihood, because of her own biases in caring for the elderly, the
physician did not say “carcinoma” even though she thinks she did use the word
HPE #8 – Optional Material
1) A retiree with memory loss blames his spouse saying “she has become so demanding
of me since I’ve retired.” This is an example of what defense mechanism?
a) Denial
b) Displacement
c) Projection
d) Suppression
e) Rationalization
2) Rather than seeing needed care, a patient uses intellectualization as a defense
mechanism after spending a great deal of time researching symptoms on the Internet.
What category of defense mechanism is this?
a) Input
b) Internal processing
c) Output
d) Decider (Executive)
3) A patient presents with vague pain and psychological symptoms. History reveals they
lost their son in a car accident exactly one year ago. What defense mechanism may be in
place for this patient?
a) Denial
b) Displacement
c) Projection
d) Suppression
e) Rationalization
4) A patient is diagnosed with angina pectoris and subsequently increases the frequency
and intensity of jogging. This is known as counterphobic behavior and is categorized as
what defense mechanism?
a) Input
b) Internal processing
c) Output
d) Decider (Executive)
5) A patient with anxiety neuroses due to prior sexual abuse begins to identify with their
abuser and even begins taking on a behavior set of their abuser. What category of defense
mechanism is this?
a) Input
b) Internal processing
c) Output
d) Decider (Executive)
6) Which of the following occurred in the Tuskegee Syphilis Experiment?
a) Patients with syphilis were told and treated immediately
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b) Patients with syphilis were told but not treated
c) Patients with syphilis were not told but given treatment
d) Patients with syphilis were told and given placebo
e) Patients with syphilis were not told and were not treated
7) Which of the following styles of medicine was used up until about 20 years ago, and
has since fallen into disfavor?
a) Informative
b) Interpretive
c) Deliberative
d) Paternalistic
8) Which of the following should be done when a patient appears to be non-compliant?
a) Double doses to make up for misses doses
b) Have ancillary staff call the patient every morning
c) Give up on the patient, as they are not engaging in a cooperative relationship
d) Schedule more appointments with the patient and try to appear empathetic
e) Take a harder look at the variables we have not addressed
9) A patient with chronic problems has several prolonged referrals with no clear intent
and no clear physician ownership. This unprofessional behavior is an example of:
a) Collusion of anonymity
b) Consultation bias
c) Proxy for skill
d) Non-compliance
e) Searching for a caring attitude
10) Which of the following messages is a tried and true way to communicate difficult
information?
a) The nurse said Murphy sign was negative…
b) When I heard that the nurses were afraid to be around you…
c) The intern processed the lab results on time…
d) When the chart was transferred to our floor, it said 5mg…
e) Our team came up with a diagnosis of…
11) What rule is used for Bayes theorem for pre-test probability?
a) 20-80, if patient’s risk is <20% then the test likely won’t help
b) 80-20, if patient’s risk is >80% then the test likely won’t help
c) 40-60, if patient’s risk is <20% then the test likely won’t help
d) 60-40, if patient’s risk is <20% then the test likely won’t help
12) Which of the following describes a tests ability to differentiate healthy patients from
sick patients?
a) Predictive value
b) Sensitivity
c) Specificity
d) Validity
e) Accuracy
13) Which of the following is a patient characteristic (not test characteristic) that helps a
physician determine if a patient does or does not have a disease?
a) Predictive value
b) Sensitivity
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c) Specificity
d) Validity
e) Bayes Theorem
14) Which of the following implies that the probability of having a disease after a test is
completed is related to the probability of having that same disease before you have even
had the test?
a) Predictive value
b) Sensitivity
c) Specificity
d) Validity
e) Bayes Theorem
15) As a statistical p-value falls, which of the following happens?
a) Accuracy increased
b) Accuracy decreased
c) Precision increased
d) Precision decreased
e) Statistical and clinical significance become equal
16) When looking at the number needed to harm (NNH) in an extended clinical study,
which of the following may be true and concerning regarding patients who dropped out
of a trial early?
a) They were not actually indicated for the study
b) They did not feel the treatment was effective
c) The treatment was found to be useless for those patients
d) They may have had early, yet mild, side effects
e) Cause versus effect is not an issue in these patients
17) Which of the following would indicated a drug that is harmful to patients?
a) High NNT and NNH
b) Low NNT and NNH
c) High NNT and low NNH
d) Low NNT and high NNH
18) Which of the following is true of class “A” evidence in EBM?
a) High level of evidence, high subjectivity
b) High level of evidence, low subjectivity
c) Low level of evidence, high subjectivity
d) Low level of evidence, low subjectivity
e) Likely a POEM (patient-oriented evidence that matters)
f) Likely not a DOE (disease-oriented evidence)
19) Of the following reasons given for reading a journal, which may be valid?
a) To impress others
b) To keep abreast with professional news
c) To distinguish useful from useless therapy
d) To learn the clinical course of prognosis of a disorder
e) To determine etiology or causation
20) Removal of variation from practice is a benefit of:
a) Using high sensitivity tests
b) Using high specificity tests
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c) Using guidelines
d) Using case studies
e) Using medical journals
21) Advanced Cardiac Life Support (ACLS) protocols are an example of:
a) Critical pathways
b) Case management
c) Practice guidelines
22) Physicians respond well to data and would most like to see their performance:
a) Appreciated by patients
b) Appreciated by health care staff
c) Matching that of the community standard
d) Saving the most money and taking the least time
e) Exceeding national benchmarks
23) Which of the following would NOT be categorized as class “C” evidence?
a) Clinical guideline
b) Clinical protocol
c) Clinical standard
24) What is the key factor in six-sigma management?
a) Autonomy
b) Non-punitive environment
c) Technical skill and precision
d) Teamwork
e) Quality
25) If used properly, which of the following is the most important tool available for
helping individual physicians?
a) Pharmacists
b) Electronic medical records (EMRs)
c) Pre-filled patient care reports (PCRs)
d) Practice standards and guidelines
e) Community-based standard of care
f) Hospital-based quality systems
26) What did the O’Meara study show?
a) Patient preference can be more important than EBM guidelines
b) Community-based standards of care do not always match EBM guidelines
c) Risk of mortality is much higher in patients who feel “scared” prior to surgery
d) Quality improvement standards have a drastic effect on patient outcome
e) Evidence based medicine should become the standard of care
27) A Fishbone Diagram:
a) Can change a hospital’s quality of care with one simple procedure change
b) Can document every misstep within a medical system regarding surgery
c) Allows physicians to perform risk-management prior to procedures
d) Creates giant leaps forward in health care quality while reducing cost
e) Shows all the useful processes within a system that are not changeable
28) The Reinertsen Group studied variation in American Medicine by looking at what
key statistic?
a) Hospital-specific nosocomial infection rate
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b) Hospital-specific mortality rate
c) Hospital-specific disclosure of medical error
d) Hospital-specific non-disclosure of serious events
29) When a physician discloses a medical error and says “I’m sorry,” how does the risk
of lawsuit change?
a) Increases 1,000-fold
b) Increases 100-fold
c) Decreases 10-fold
d) Decreases 100-fold
e) Decreases 1,000-fold
30) What is David Nash’s immutable law?
a) Unnecessary variation will always exist
b) Top hospitals have better communication
c) Quality care always costs less
d) Top hospitals have nurses with the most autonomy
e) Evidence-based medicine is the most effective tool for patient care
James Lamberg
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