History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency 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

14Mar2009

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 patientcentered 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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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 evidencebased 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 nondiseased patients? a) Sensitivity / (100 – Specificity) b) Specificity / (100 – Sensitivity) c) (100 – Sensitivity) / Specificity d) (100 – Sensitivity) / Specificity

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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

14Mar2009

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 52year-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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History & Physical Exam – Physician Competency

14Mar2009

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 anxietyrelated, 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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History & Physical Exam – Physician Competency

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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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

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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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History & Physical Exam – Physician Competency

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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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History & Physical Exam – Physician Competency

14Mar2009

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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History & Physical Exam – Physician Competency

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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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History & Physical Exam – Physician Competency AnswerKey HPE #1 1) C 2) B 3) E 4) A 5) D 6) C 7) C 8) H 9) A 10) E 11) D 12) E 13) B 14) E 15) A 16) C 17) F 18) D 19) F 20) B 21) C 22) C 23) C 24) C 25) A 26) D HPE #2 1) D 2) E 3) A 4) B 5) C 6) B 7) D 8) C 9) D 10) B 11) A 12) A 13) D 14) C 15) E 16) F 17) C 18) D 19) A 20) B 21) B 22) A 23) C 24) A 25) E 26) C 27) C 28) A 29) B 30) D 31) D HPE #3 1) C 2) B 3) D 4) A 5) E 6) A 7) F 8) C 9) A 10) C 11) D 12) B 13) C 14) D HPE #4 1) D 2) E 3) E 4) D 5) A 6) B 7) A 8) D 9) D HPE #5 1) E 2) C 3) E 4) E 5) E 6) A 7) C 8) B 9) D 10) C 11) B 12) D 13) D 14) D 15) A 16) C 17) B 18) C 19) C 20) D 21) E 22) E 23) D 24) C 25) B 26) E 27) A HPE #6 1) E 2) E 3) C 4) A 5) A 6) D 7) B 8) G 9) D 10) C 11) C 12) D 13) E 14) D 15) C HPE #7 1) E 2) B 3) A 4) F 5) C 6) D 7) A 8) C 9) B 10) D 11) B 12) C 13) B 14) C 15) B 16) B 17) A HPE #8 1) B 2) B 3) D 4) C 5) D 6) E 7) D 8) E 9) A 10) B 11) A 12) C 13) A 14) E 15) C 16) D 17) C 18) B 19) C 20) C 21) A 22) E 23) C 24) D 25) B 26) A 27) A 28) B 29) E

14Mar2009 30) C

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