Core ethical principles
• Autonomy: Obligation to respect patients as individuals and to honor their preferences in medical care. • Beneficence: Physicians have a special ethical (fiduciary) duty to act in the patient’s best interest. May conflict with autonomy. If the patient can make an informed decision, ultimately the patient has the right to decide.

• Nonmaleficence “Do no harm.” However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries fall into this category). • Justice To treat persons fairly

patients usually sign a document of consent for major medical procedures or for surgery.g. • 2. physicians must obtain consent from competent. Other hospital personnel (e. nurses) usually cannot obtain informed consent.Informed Consent: Overview • -With the exception of life-threatening emergencies. Although a signature may not be required for minor medical procedures. informed adult patients before proceeding with any medical or surgical treatment. • 1. ..

• 2. • 3. . Patient can withdraw consent for treatment at any time before the procedure (even on the way to the operating room after preanesthetic medication has been administered).Components of informed consent • 1. Patients must also be informed of the health risks and benefits of treatment and the alternatives to treatment. • 4. Patients must know the likely outcome if they do not consent to the treatment. they must be informed of and understand the health implications of their diagnosis.

cesarean section) even if the fetus will die or be seriously injured without the treatment.. Competent patients have the right to refuse to consent to a needed test or procedure for religious or other reasons even if their health will suffer or death will result from such refusal. .Special situations • 1. a competent pregnant woman has the right to refuse such intervention (e. • 2. Although medical or surgical intervention may be necessary to protect the health or life of the fetus.g.

. a doctor does not have to relay the findings immediately if the doctor believes such knowledge will adversely affect the patient's health (e.. The opinions of family members as to whether to tell the patient the diagnosis and prognosis are not relevant.g. While all of the medical findings are generally provided to a patient. The doctor can delay telling the patient the diagnosis until the patient indicates that he is ready to receive the news. a coronary patient).• 3. family members may be present when the doctor provides the diagnosis. • 4. At the patient's request.

g.. the patient must wake up and give informed consent before the additional procedure can be performed. . biopsy of an unsuspected ovarian malignancy found during a tubal ligation).Unexpected findings • -If an unexpected finding during surgery necessitates a non-emergency procedure for which the patient has not given consent (e.

E. Treatment of minors
• people younger than 18 years of age, unless emancipated • 1. Only the parent or legal guardian can give consent for surgical or medical treatment of a minor. • 2. Parental consent is not required in the treatment of minors in the following instances:
– a. Emergency situations (i.e., when the parent or guardian cannot be located and a delay in treatment can potentially harm the child) – b. Treatment of sexually transmitted diseases (STDs)

• c. Prescription of contraceptives • d. Medical care during pregnancy • e. Treatment of drug and alcohol dependence 3. About 80% of the states require parental consent when a minor seeks an abortion. 4. A court order can be obtained from a judge (within hours if necessary) if a child has a lifethreatening illness or accident and the parent or guardian refuses to consent to an established (but not an experimental) medical procedure for religious or other reasons.

• Confidentiality respects patient privacy and autonomy. Disclosing information to family and friends should be guided by what the patient would want. The patient may waive the right to confidentiality (e.g., insurance companies). A. Although physicians are expected ethically to maintain patient confidentiality, they are not required to do so if: • 1. Their patient is suspected of child or elder abuse • 2. Their patient has a significant risk of suicide • 3. Their patient poses a serious threat to another person.

Infectious diseases––physicians may have a duty to warn public officials and identifiable people at risk • 2.• Physicians can take steps to prevent harm Examples include: • 1. Suicidal/homicidal patients––physicians may hold patients involuntarily for a period of time . Impaired automobile drivers • 5. The Tarasoff decision––law requiring physician to directly inform and protect potential victim from harm. Child and/or elder abuse • 4. may involve breach of confidentiality • 3.

patient made a choice. directive is specific. the oral directive is more valid. • If patient was informed. • Problems arise from variance in interpretation. and decision was repeated over time.Oral advance directive • Incapacitated patient’s prior oral statements commonly used as guide. .

More flexible than a living will. patient directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state. Surrogate retains power unless revoked by patient. .Written advance directive • Living will––describes treatments the patient wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions. • Durable power of attorney––patient designates a surrogate to make medical decisions in the event that he/she loses decision-making capacity. Patient may also specify decisions in clinical situations. • Usually.

• They must also inform patients of their right to refuse treatment or resuscitation.• Health care facilities that receive Medicare payments (most hospitals and nursing homes) are required to ask patients whether they have advance directives and. . help patients to write them. if necessary.

Ethical Issues Involving HIV Infection A. . HIV-positive colleagues • -Doctors are not required to inform either patients or the medical establishment about another doctor's HIV-positive status since. he poses no risk to his patients. if the doctor follows procedures for infection control.

.. Ethically. • 3.g. with zidovudine (AZT)] against her will even if the fetus could be adversely affected by such refusal. HIV-positive patients • 1.B. Doctors are not required to maintain confidentiality when an HIV-positive patient habitually puts another person at risk by engaging in unprotected sex. a doctor cannot refuse to treat HIV-positive patients because of fear of infection. • 2. There is no legal requirement for a doctor to treat any patient. A pregnant patient at high risk for HIV infection cannot be tested for the virus or treated [(e.

Good Samaritan law • Relieves health care workers. from liability in certain emergency situations with the objective of encouraging health care workers to offer assistance. as well as laypersons in some instances. .

. patients with psychiatric disorders who are a danger to themselves or others may be hospitalized against their will (involuntary hospitalization). for up to 60 days (depending on state law) before a court hearing. In psychiatric emergency situations. patients who will not or cannot agree to be hospitalized may be hospitalized against their will or without consent with the certification of one or two physicians. • A.Involuntary and Voluntary Psychiatric Hospitalization • Under certain circumstances that vary according to state law.

. • C. Patients who are confined to mental health facilities. whether voluntarily or involuntarily. have the right to receive treatment and to refuse treatment (e.• B. Even if a psychiatric patient chooses voluntarily to be hospitalized.g. . electroconvulsive therapy). medication. he may be required to wait 24-48 hours before he is permitted to sign out against medical advice.

health care providers or family members (surrogates) must determine what the patient would have done if she were competent (the substituted judgment standard). The personal wishes of surrogates are irrelevant to the medical decision.B. Even if a health care proxy or surrogate has been making decisions for an incompetent patient. she regains the right during those periods to make decisions about her health care. if the patient regains function (competence) even briefly or intermittently. Surrogates: • 1. If an incompetent patient does not have an advance directive. . • 2.

natural. the legal standard of death (when cardiorespiratory criteria are not met) is irreversible cessation of all functions of the entire brain. A court order or relative's permission is not necessary.g. including the brain stem. Physicians certify the cause of death (e.. suicide. Legal standard of death: • 1.Death and Euthanasia A. If the patient is dead according to the legal standard. In the United States. accident) and sign the death certificate. the physician is authorized to remove life support. • 2. • 3. .

e. • 1. Physician-assisted suicide is not strictly legal in any state. • -Dr. Jack Kevorkian recently challenged the law in Michigan regarding physician-assisted suicide by actually administering a lethal injection to a patient himself and was convicted of murder.. euthanasia (mercy killing) is a criminal act and is never appropriate. those of the American Medical Association and medical specialty organizations). .g.B. the patient injects himself).. Euthanasia: • According to medical codes of ethics (e. but is not generally an indictable offense as long as the physician does not actually perform the killing (i.

. and medical care can be withheld from a terminally ill patient who has no reasonable prospect of recovery but is not legally dead. • 3. Such action by the physician is not considered euthanasia. Under some circumstances. If a competent patient requests cessation of artificial life support. food. water.• 2. it is both legal and ethical for a physician to comply with this request.

injury) • d. Duty (i. there is an established physicianpatient relationship) that causes • c.e. not by another factor). or negligence (i.e.. the damages were caused by the negligence.Medical Malpractice: Overview • 1. Damages (i. .e. Directly to the patient (i. of a • b. The elements of malpractice (the 4"D"s) are: • a.. deviation from normal standards of care).. Medical malpractice occurs when harm comes to a patient as a result of actions or inactions of a physician.. Dereliction.e.

A finding for the plaintiff (the patient) results in a financial award to the patient from the defendant physician or his insurance carrier. not a crime. Surgeons (including obstetricians) and anesthesiologists are the specialists most likely to be sued for malpractice. . • Psychiatrists and family practitioners are the least likely to be sued. • 3. or civil wrong. not a jail term or loss of license.• 2. Malpractice is a tort.

– b. Recently there has been an increase in the number of malpractice claims. Limits on time for personal interaction and physician autonomy.patient relationship because of: – a. This increase is due mainly to a breakdown of the traditional physician. which reduce personal contact with the doctor. partly as a result of the growth of managed care .• 4. Technological advances in medicine.

g. Punitive damages are awarded to the patient to punish the physician and set an example for the medical community. or both compensatory and punitive damages. Punitive damages are rare and are awarded only in cases of wanton carelessness or gross negligence (e. • 1. • 2.• B. Compensatory damages are given to reimburse the patient for medical bills or lost salary and to compensate the patient for pain and suffering. The patient may be awarded compensatory damages only. Damages. a drunk doctor who cuts a vital nerve).. .

or both.C. Patients who claim that they had a sexual relationship with a physician may file an ethics complaint or a medical malpractice complaint. Sexual relationships with patients • 1. Sexual relationships with current or former patients are inappropriate and are prohibited by the ethical standards of most specialty boards. • 2. .

Causes of impairment in physicians include • 1. Physical or mental illness • 3.Impaired Physicians A. Drug or alcohol abuse • 2. Impairment in functioning associated with old age .

• B. medical student. Reporting of an impaired colleague. . The legal requirement for reporting impaired colleagues varies among states. or resident is an ethical requirement because patients must be protected and the impaired colleague must be helped. • 1. An impaired medical student should be reported to the dean of the medical school or the dean of students.

usually part of the state medical society. respectively).g. An impaired resident or attending physician should be reported to the person directly in charge of him. • 3.. A licensed physician should report an impaired colleague to the state licensing board or the impaired physicians program. the residency training director or the chief of the medical staff.• 2. (e. .

Ethical situations .


"Do's" and "Do Not's" for Answering USMLE Ethical .

"Do's" and "Do Not's" for Answering USMLE Ethical .




Apgar score A 10-point scale evaluated at 1 minute and 5 minutes. .

.Low birth weight • Defined as < 2500 g. Caused by prematurity or intrauterine growth retardation. Associated with greater incidence of physical and emotional problems. • Complications include infections. respiratory distress syndrome. and persistent fetal circulation. intraventricular hemorrhage. necrotizing enterocolitis.



and dryness 2. hypertension. Sleep patterns–– ↓ REM sleep. Intelligence does not ↓ . heart disease. ↓ slow-wave sleep. longer refractory period • Women––vaginal shortening. ↑ awakenings during the night 3. Common medical conditions––arthritis. Sexual changes:. osteoporosis Sexual interest does not ↓. ↑ sleep latency. • Men––slower erection/ejaculation. thinning.Changes in the elderly 1.

↑ fat . hearing. Psychiatric disorders (excluding comorbidities) are found at a lower prevalence among the healthy elderly than at other life stages • 5. GI function • 8.• 4. ↓ renal. ↓ muscle mass. immune response. ↓ vision. pulmonary. ladder control • 7. ↑ suicide rate (males 65–74 years of age have the highest suicide rate in the United States) • 6.

becomes curly. areolae are no longer raised . ↑ penis size/length 4↑ penis width. darkens.Tanner stages of sexual development Stages 1Childhood 2Pubic hair begins to develop (adrenarche). development of glans. darker scrotal skin. ↑ size of testes. breast tissue elevation 3↑ pubic hair. raised areolae 5Adult.

inhibited. May experience illusions. denial. • Pathologic grief includes excessively intense or prolonged grief or grief that is delayed. delusions. guilt. and somatic symptoms. • Typically lasts 6 months to 1 year. • May experience depressive symptoms. and hallucinations. . or denied.Grief • Normal bereavement characterized by shock.

Bargaining. and > 1 stage can be present at once. • Death Arrives Bringing Grave Adjustments.Kübler-Ross grief stages • Denial. . • Stages do not necessarily occur in this order. Anger. Acceptance. Grieving.


. These changes include decreased weight. enlarged ventricles and sulci. Senile plaques and neurofibrillary tangles are present in the normally aging brain but to a lesser extent than in dementia of the Alzheimer's type. • b. and decreased cerebral blood flow. • a.Changes in the brain occur with aging.

g. these problems do not interfere with the patient's functioning and he is able to live independently. • 2. However. in the absence of brain disease. . Slight memory problems may occur in normal aging. intelligence remains approximately the same throughout life. (e. the patient may forget the name of a new acquaintance).• Cognitive changes • 1. Although learning speed may decrease..

satisfaction. Many elderly people achieve ego integrity.e.. (i. and pride in one's past accomplishments) or a sense of despair and worthlessness (Erikson's stage of ego integrity versus despair).• In late adulthood there is either a sense of ego integrity. .

• (1) Factors associated with depression in the elderly include loss of spouse. and decline of health. decreased social status. and friends. other family members. Depression is the most common psychiatric disorder in the elderly. Suicide is more common in the elderly than in the general population.Psychopathology and related problems • a. .

This misdiagnosed disorder is referred to as pseudodementia because it is associated with memory loss and cognitive problems • (3) Depression can be treated successfully with supportive psychotherapy in conjunction with pharmacotherapy or electroconvulsive therapy. .• (2) Depression may mimic and thus be misdiagnosed as Alzheimer's disease.



Diseases (e. ethanol) • 2. 17OH corticosteroids. diabetes) • 3. Drugs (e. neuroleptics. cholesterol. Sexual dysfunction Differential diagnosis includes: • 1.g.. antihypertensives. and mucosal circulation. SSRIs. gastrocolic reflex. affects water absorption. muscular tonicity.g. depression.. performance anxiety) . lipids.Stress effects • Stress induces production of free fatty acids.g.. Psychological (e. catecholamines.

5–24. 18.Body-mass index BMI • is a measure of weight adjusted for height.9 normal. 25.0–29.0 obese. > 30. • • • • < 18.9 overweight.5 underweight. .

Sleep stages .

Serotonergic predominance of raphe nucleus key to initiating sleep • 2.• 1. Extraocular movements during REM due to activity of PPRF (paramedian pontine reticular formation/conjugate gaze center) . NE reduces REM sleep • 3.

• 4. REM sleep having the same EEG pattern as while awake and alert has spawned the terms “paradoxical sleep” and “desynchronized sleep” • 5. Benzodiazepines shorten stage 4 sleep; thus useful for night terrors and sleepwalking • 6. Imipramine is used to treat enuresis because it ↓ stage 4 sleep

REM sleep
• ↑ and variable pulse, REM, ↑ and variable blood pressure, penile/clitoral tumescence. Occurs every 90 minutes; duration ↑ through the night. ACh is the principal neurotransmitter involved in REM sleep. REM sleep ↓ with age. • REM sleep is like sex: ↑ pulse, penile/ clitoral tumescence, ↓ with age.

• Disordered regulation of sleep-wake cycles. May include hypnagogic (just before sleep) or hypnopompic (just before awakening) hallucinations. The patient’s nocturnal and narcoleptic sleep episodes start off with REM sleep. • Cataplexy (loss of all muscle tone following a strong emotional stimulus) in some patients. Strong genetic component. Treat with stimulants (e.g., amphetamines).

• 3°– reduce disability from disease (e. vaccination).g...Disease prevention • 1°– prevent disease occurrence (e. exogenous insulin for diabetes). Pap smear)..g.g. • PDR: Prevent Detect Reduce Disability . • 2°– early detection of disease (e.


Reportable diseases .

COPD. suicide. • Age 15–24= Injuries. injuries. suicide. heart disease. • Age 65+ = Heart disease. maternal complications of pregnancy. respiratory distress syndrome. cancer. • Age 25–64 =Cancer. short gestation/low birth weight. stroke. homicide. heart disease. cancer. . cancer. congenital anomalies. pneumonia. stroke. • Age 1–14= Injuries. sudden infant death syndrome. homicide.Leading causes of death in the United States by age • Infants= Congenital anomalies. influenza. heart disease.

• Medicare Part A = hospital. • MedicarE is for Elderly.Medicare and Medicare • are federal programs that Medicaid originated from amendments to the Social Security Act. • MedicaiD is for Destitute. • Medicaid is federal and state assistance for very low income people. Part B = doctor bills. .

Studies Methods: • Studies can be divided into two types. design a study protocol. . purely observational and experimental. and perform some type of intervention. • Observational studies look at events that will happen with little or no manipulation by the person performing the study. • Experimental studies often require the person performing the study to assemble subjects.

It answers basic questions.CROSS-SECTIONAL STUDY • Assesses a population of patients at a given point in time. or survey. To determine how many hemophiliacs had HIV/AIDS in 1988. a cross-sectional study. could have been performed of this population to fi nd that the number was over 50%. how many people have a disease?” or “How many people have risk factors in population X?” Think of a cross sectional study as a large survey taken at a point in time. some physicians notice that hemophiliacs had a high incidence of AIDS. . • Example: In the 1980s. “In a given population. such as.

• A case series is simply a collection of case studies that document a similar patient presentation or disease manifestation. generally used to document a unique manifestation of a disease.Observational Studies CASE STUDY OR CASE SERIES • A written description of a patient or particular problem. • Example: Case studies began to appear in the early 1980s that documented rare opportunistic infections in apparently healthy young patients. the first incidence of a new disease. . These were some of the earliest documentations of HIV/AIDS before the disease was recognized. or some clinical presentation that might be of interest to other physicians.

CASE-CONTROL STUDY • Compares two groups of people: • Those with a condition or disease versus similar persons without the condition or disease. . he or she is matched with a demographically similar person without the condition (control). • Once a person with the condition is identified (a case). • The two groups are then compared for differences that may provide insight into possible causes or risk factors.


race-. • A group of HIV-positive hemophiliacs was identified. it was found that the HIV-positive hemophiliacs were far more likely to have received more blood transfusions than the controls. and location-control hemophiliac who did not contract the disease. . • When the data were analyzed for differences between the two groups. sex-.• Example: To determine why some hemophiliacs contracted HIV/AIDS in the 1980s when many others did not. a case-control study was performed. and each case was matched to an age-.

It is expected that some individuals in the study will develop the condition or complication being studied. the participants do not have the condition or disease being studied.COHORT STUDY • Examines a large group and watches it evolve over time. at the outset. • Example: To determine the risk of HIV transmission in IV drug users. Generally. identify a cohort of HIV-negative IV drug users and follow them for 10 years. .


such trials are doubleblind. meaning that neither the subjects nor the experimenters know who is receiving the actual treatment and who is receiving the placebo. The other group is given the intervention being studied (see Figure 2-3). • Subjects are divided into at least two groups. technique. or other intervention. • Often.Experimental Studies CLINICAL TRIAL • A direct test of a drug. with one group acting as a control that receives either a placebo or the current standard of care treatment. .


• Example: To test a new HIV drug. Experimenters do not know who is receiving the actual drug versus the placebo. the group assignment is revealed to allow for comparison of the outcomes. similar HIV subjects are recruited and divided randomly into treatment and placebo groups. At the end of the experiment. .

. • After the experiment is performed once. with the control group often given a placebo. or crossed over. participants are switched. this is a variation of a casecontrol study. • Thus each participant receives both treatments at different times and can act as his or her own control.. into the opposite treatment group and the experiment is run again.CROSS-OVER STUDY • Participants are randomized into one of two treatment groups. however. In essence.


• Because the effect is not permanent. and the effects are measured.• Example: A drug that may temporarily raise CD4 T-cell counts in HIV positive individuals is being tested. Half of the subjects are assigned to a treatment group the other half to a placebo group. One can compare each subject’s response to the drug and the placebo. . one could repeat the experiment with switched groups.

• May be limited by quality of individual studies or bias in study selection.Meta-analysis • Pools data from several studies to come to an overall conclusion. Achieves greater statistical power and integrates results of similar studies. . Highest echelon of clinical evidence.

Prevalence vs. incidence .

.Evaluation of diagnostic tests • Uses 2 × 2 table comparing test results with the actual presence of disease.

= Sensitivity = TP / (TP + FN) Use sensitive tests to rule a condition out.Sensitivity • Proportion of all people with disease who test positive. • Value approaching 1 is desirable for ruling out disease and indicates a low false-negative rate. Used for screening in diseases with low prevalence. = 1 – false-negative rate SNOUT = SeNsitivity rules OUT .

Used as a confirmatory test after a positive screening test. high threshold). high false negative rate. • Value approaching 1 is desirable for ruling in disease and indicates a low false-positive rate. confirm with Western blot (specific. • Specificity = TN / (TN + FP) Specific tests are used to rule conditions in (“SpIN”). • SPIN = SPecificity rules IN.Specificity • Proportion of all people without disease who test negative. • Example: HIV testing. low threshold). high false-positive rate. . Screen with ELISA (sensitive.

Positive predictive value (PPV) • Proportion of positive test results that are true positive. • (Note: If the prevalence of a disease in a population is low. • Positive predictive value = TP /(TP + FP) • Probability that person actually has the disease given a positive test result. even tests with high specificity or high sensitivity will have low positive predictive values!)) .

.Negative predictive value (NPV) • Proportion of negative test results that are true negative. • Negative predictive value = TN / (TN + FN) • Probability that person actually is disease free given a negative test result.

. the lower the positive predictive value. even if the test’s sensitivity and specificity are high! • Remember there can’t be many true-positives if there aren’t many patients.• The lower the prevalence of a disease.


Odds ratio vs. relative risk Odds Ratio for Case Control Studies: .

Relative risk (RR) Relative risk (RR) for cohort studies .

Attributable risk .

↓precision= Random Error ↓ Accuracy= Systemic Errors .


• In statistics, bias refers to any part of the study that may inadvertently favor one outcome or result over another. • Bias is often unintentional, but has the potential to invalidate conclusions. It is possible to detect certain forms of bias by analyzing the study in question.

• Can occur when one variable is closely related to another. If the researcher does not appreciate the relationship, the incorrect variable may be measured. • Example: A scientist notes that certain people stand outside every day during their breaks at work. He also notices that these same people often develop lung cancer. He collects data and finds that the more time one spends standing outside during work breaks, the more likely one is to develop lung cancer. He concludes that being outside causes lung cancer. In reality, of course, the people who stand outside a lot develop lung cancer because they smoke.


FORMS OF DISEASE PREVENTION • Public health officials try to limit disease through primary. Primary Disease Prevention • Primary disease prevention is a method used to stop the disease before it starts. . a cervical cancer vaccine has been developed that prevents infection of certain serotypes of human papillomavirus (HPV). • Recently. or tertiary prevention. secondary. For example. vaccination is used to build immunologic resistance and thus limit the infectivity and spread of a disease. thereby reducing the rates of cervical cancer.

g.• Other vaccines (e. tetanus.. pneumococcal. . diphtheria. mumps-measlesrubella) fall under the heading of primary disease prevention because these interventions occur before the host has become diseased.


colonoscopy for the detection of colon cancers. which detect HPV viral DNA. .Secondary Disease Prevention • Secondary disease prevention is the detection of the disease early in its course to reduce the associated morbidity and mortality. • Examples of secondary disease prevention include cervical cancer screening through Pap smears. • Early detection can reduce the morbidity and mortality of the disease and also prevent epidemics. and mammogram screening for the detection of breast cancers.

but may result in many false-positives. sensitivity rules people in). • Sensitivity is defined as the number or percentage of disease-positive individuals who have a positive test result. but have a falsely positive test result). . • Because screening methods err on the side of including individuals with disease (remember.• Disease screening tests usually are very sensitive to retain a high true-positive rate. it may include falsepositives (individuals who do not have the disease.

Tertiary Disease Prevention
• Tertiary disease prevention aims to reduce the disability or morbidity resulting from disease. Examples include exogenous insulin for diabetes and surgical treatment of cancers. • Tertiary disease prevention aims to treat the disease through available medical or surgical management.

Medical Surveillance
• The effort to continuously monitor and detect the occurrence of healthrelated events is known as medical surveillance. Through medical surveillance, it is possible to determine the incidence rate of disease (the rate of new disease in a given period), the number of deaths resulting from the disease (case fatality), the mortality rate (combination of incidence rate and case fatality), rate ratios (a ratio of the incidence rates of two different groups, resulting in a comparison of the rate of disease occurrence), and mortality patterns. Figures 2-10, 2-11, and 2-12 show examples of incidence rates, mortality rates or patterns, and rate ratios, respectively.

• Example of age-adjusted incidences rates. Age-adjusted incidence rates of the leading cancers in men and women in the United States from 1996–2000.

Age-adjusted total mortality rates by calendar year and race in the United States.• Example of age-adjusted total mortality rates. . 1980–2001.

. Schematic representation of black-to-white incidence rate ratio for cancers of the lung and bladder in the United States.• Example of incidence rate ratio.



Statistics MEASURES OF CENTRAL TENDENCY AND STATISTICAL DISTRIBUTION: • Distribution is a term used to describe the frequency of observations in a population or data set as plotted on a graph. • Distribution of a set of observations is defined by the measures of central tendency: .

however. may not be an appropriate measure of central tendency for skewed distributions or in data sets which contain outliers.Mean (arithmetic mean. . or average) • is the most common measure of central tendency. It represents the ratio between the sum of all individual observations (ΣX) over the number of observations (n): M = ΣX / n • The mean.

• Arrange the data in an increasing order. . or the point at which half of the observations are smaller and half are larger. • The median is often a more appropriate measure of central tendency for skewed distributions or in situations with large outliers.Median (middle observation) • represents the 50th percentile of a distribution.

the median may also be used for categorical data as well. and is commonly used for a large number of observations to identify the value that occurs most frequently.Mode • represents the most common value in a distribution. All three are used for continuous data. .

” or “bellshaped. Terms that describe the curves created include: • GAUSSIAN: Also known as a “normal. These curves may indicate symmetric or asymmetric distribution of observations. .FREQUENCY CURVE • A frequency curve may be produced from the data set. It indicates symmetric distribution of the observations. (mean = median = mode) • BIMODAL: The curve produces two “peaks” due to two separate areas of increased frequency of data in the population or data set.” curve.

(B) Positively skewed.Mean < median Mean < mode Mean > median Mean > mode • Shapes of common distributions of observations. (C and D) Symmetric. . (A) Negatively skewed.

Follow the tail • Positive skew: Asymmetric curve with the tail on the right side of the graph. It indicates a large number of outlying values. – Mean > median – Mean > mode • Negative skew: Asymmetric curve with the tail on the left side of the graph. It indicates a small number of outlying values. – Mean < median – Mean < mode .

differentiated by how the statement is framed: • Null hypothesis (H0): A statement that suggests that there is no difference. • In medicine. H0 is tested for possible rejection under the assumption that the hypothesis is true.STATISTICAL HYPOTHESIS • A statistical hypothesis is a formal statement regarding the expected outcome of an experiment. this normally relates to disease and risk factors. or association between two or more variables. There are two major types of hypothesis. .

• An example of a null hypothesis is.” • Alternative hypothesis (H1): A statement that suggests that there is an association between two or more variables. An example of an alternative (H1) hypothesis is. the observations are the result of a real effect. “Increased sodium intake leads to increased blood pressure.” . “There is no association between sodium intake and hypertension. and contrary to the null hypothesis.

which means that there is a less than 5% chance of making a type I error. – The normal accepted α is usually < 0. which is defined as the probability of making a type I error.Type I Error (α) • Type I error results when one states or determines that there is an effect or difference when in reality one does not exist. Stated another way. denoted as the Greek letter α. Type I error is also known as a “false-positive. . or that the data will show something that is not really there.” – This error is a preset level of significance. the alternative hypothesis is accepted when in actuality the null hypothesis is correct.5.

the null hypothesis is accepted when in actuality the alternative hypothesis is correct.” . Type II error is also known as “false-negative.Type II Error (β) • Type II error results when one states or determines that there is not an effect or difference when in reality one does exist. In other words.

. there is power in numbers. The power is calculated by subtracting the type II error (β) from 1. Power = 1 − β • Power is increased by sample size.Power • Power is the probability of rejecting the null hypothesis when it is in fact false. • The power can be manipulated based on sample size as well as the difference in compliance between sample groups.

the standard error of the mean (SEM) is used to estimate the standard deviation of error in that particular method. from the central tendency. • describe the spread of values within a particular distribution. is a statistical measurement that is used to describe the deviation. within a statistical distribution. • All forms of measurement have some inherent error. or variance.STANDARD DEVIATION VERSUS ERROR • S. or mean. .D. For this reason.

. medium. and three standard deviations (light.7%. this accounts for about 68% of the set (dark red). For the normal distribution. and dark red) account for about 99.• Standard deviation: Dark red is less than one standard deviation from the mean. while two standard deviations from the mean (medium and dark red) account for about 95%.

What percentage of people would be expected to have systolic blood pressure at or above 140 mm Hg? • (A) 1.0% • (E) 64.5% • (D) 34. Systolic blood pressure is normally distributed with a mean of 120 mm Hg and a standard deviation of 10.5% • (C) 13.2% .• 1.9% • (B) 2.


2. In a population of 500 people. how many would be expected to have systolic blood pressure between 110 mm Hg and 120 mm Hg? • (A) 80 • (B) 100 • (C) 125 • (D) 170 • (E) 250 .

. • Systolic blood pressure between 110-120 mmHg is one standard deviation below the mean.Answer • Systolic blood pressure of 140 mmHg is 2 standard deviations above the mean (120 mmHg).35% plus about 0.50% of the people will have blood pressure of 140 mmHg and above. The area under the curve between 2 and 3 standard deviations above the mean is about 2. The percentage of people in this area on a normal curve is 34%. a total of about 2. Thus. 34% of 500 people. Thus. will have systolic blood pressure in the range of 110-120 mmHg. or 170 people.15% (everything above 3 standard deviations).

. • The confidence interval (CI) can be determined by using both the standard deviation and the SEM. and can be used with any population parameter.96σ • If the CI includes zero. there is no difference between the variables).e. with upper and lower limit values known as confidence limits. CI = mean ± 1.Confidence Intervals • Confidence intervals essentially provide a range..96 (SEM) or CI = mean ± 1. the null hypothesis is accepted (i.

. if a number falls between the upper and lower limits of a 95% confidence interval. there is a difference. Thus. • Knowing the CI is important because it gives an estimate of how likely it is that a value is true. between the variables).• If the CI does not contain zero.. or association. the null hypothesis is rejected and the alternative hypothesis is accepted (i.e. one can be confident that the data are correct 95% of the time.

• Example: Imagine a study in which a group of people in a certain town have their blood pressure measured several times over the course of a year (independent samples taken repeatedly from the same population). . • The results of the blood pressure measurements would be reported by giving a range. It is best to express this range as a CI because it tells readers that a value falling within that range was similar to the blood pressure of 95% of the patient population.


Since a correlation coefficient (r) cannot be more than +1 the only possible answer is + 0. scores increase). as parental income increases. .60.answer • The correlation between parental income and USMLE Step 1 scores as shown by these data is positive (+) (i.e..

the t distribution becomes increasingly spread out.t-TEST. which involves degrees of freedom (df). . • The t distribution can be determined using a mathematical equation and correlated to a P value using the appropriate table. • For groups with a large df value. This test is based on the t distribution. • As the df decreases. AND CHI-SQUARE (Χ2) t-Test: • The t-test is used to determine the difference between the mean values of two groups of observations. ANOVA. the t distribution is indistinguishable from the normal distribution.

.• A t-test would be useful when comparing the means of two groups (placebo versus treatment) to see if a statistical significance exists between the mean clinical outcomes of the two groups.

• Which of the following statistical tests is most appropriately used to evaluate differences between initial body weight and final body weight for each woman on a protein-sparing diet? • (A) Paired t-test • (B) Analysis of variance • (C) Chi-square test • (D) Correlation • (E) Independent t-test .

This is an example of a paired t-test because the same women are examined on two different occasions.• The t-test is used to examine differences between means of two samples. .

ANOVA • ANOVA = ANalysis Of VAriance of three or more variables. • ANOVA is used to determine the statistical difference between the means of three or more groups of observations. .

. The percentage of survivors versus controls can be compared using this test. • An example of the chi-square test is a clinical trial comparing a 28-day survival or treatment group versus a control group.Chi-Square (χ2) • Chi-square is used to determine the statistical difference between two or more percentages or proportions of categorical outcomes (not mean values).

• Which of the following statistical tests is most appropriately used to evaluate the difference in the percentage of women who lose weight on a protein-sparing diet versus the percentage who lose weight on a high-protein diet? • (A) Paired t-test • (B) Analysis of variance • (C) Chi-square test • (D) Correlation • (E) Independent t-test .

the percentage of women who lose weight on a protein-sparing diet versus the percentage of women who lose weight on a high-protein diet.• The chi-square test is used to examine differences between frequencies in a samplein this case. .

and values approaching −1 indicate an inverse relationship. It indicates the strength and direction of a linear relationship (correlation) between two or more different and independent variables. indicate a strong correlation between the variables. • Values approaching 1.Correlation Coefficient • The correlation coefficient (r) is a numerical value that always falls between 1 and −1. . A value of 0 indicates no correlation.

as explained by the fitted model.• The coefficient of determination (R2) is the proportion of variability (or sum of squares) in a data set that is accounted for by a statistical model. It helps to determine whether a linear relationship exists between the response variable and the “regressors. .” • If R2 = 1 → there is a linear relationship. using regression analysis. • If R2 = 0 → there is no linear relationship between the response variable and regressors.

12 hypertensive patients are given the new drug and 10 hypertensive patients are given a placebo. The dependent variable in this study is • (A) the experimenter's bias • (B) giving the patients the drug • (C) giving the patients a placebo • (D) the patients' blood pressure following treatment with the drug or placebo • (E) the daily variability in the patients' blood pressure before the drug treatment .• In a study to determine the usefulness of a new antihypertensive medication.

In this case.• Ans-D. The dependent variable is a measure of the outcome of an experiment. In this case. giving the patient a drug or placebo is the independent variable . blood pressure following treatment with the drug or placebo is the dependent variable. • The independent variable is a characteristic that an experimenter examines to see if it changes the outcome.



Generally disappears around 3–4 months. • Moro: Infant spreads. • Palmar: Infant grasps objects that come in contact with the palm.REFLEXES OF THE NEWBORN • Infants exhibit characteristic reflexes at birth that fade and then vanish at certain points in development. persists in certain conditions. • Rooting: Nipple seeking. persists in certain neurologic conditions. • Babinski: Toes fan upward upon plantar stimulation. such as cerebral palsy. then unspreads the arms when startled. . Generally disappears around three months. Generally disappears around 12–14 months. Generally disappears around 2–3 months.

psychologist Harry F. Major effects of long-term infant deprivation: • Illness: Increased vulnerability to physical ailments.INFANT DEPRIVATION • History. • Wordless: Language deficiencies. . • Mistrust: Difficulty in forming emotional bonds. • Floppy: Decreased muscle tone. In the 1950s. sense of abandonment. Harlow demonstrated that rhesus monkeys deprived of affection and physical contact developed abnormally. Later studies have suggested the existence of a similar phenomenon in humans: Long-term infant deprivation results in multiple long-term sequelae.

. infant’s dependence on mother)..g. • Withdrawn: Defi cient socialization skills. • Anaclitic depression: Relating to one person’s physical and emotional dependence on another person (e. failure to thrive.• Thin: Weight loss.

and in severe cases. Deprivation for longer than six months can lead to irreversible changes. unresponsiveness. unstimulating institutional environments. a Hungarian. . death. to refer to the deteriorated psychological and physical health of infants who are separated from their caregivers and placed in cold.• The term “anaclitic” depression was used by Renee Spitz.American psychoanalyst. such as withdrawn state. failure to thrive.

caregivers may commit neglect by failing to provide for a child’s basic needs.CHILD ABUSE • Abuse of children by caregivers can be physical. or sexual. In addition. and safety. . emotional. such as food. physical and sexual abuse are covered in Table 2-5. clothing.


DEVELOPMENTAL MILESTONES • Developmental milestones are skill sets (described in Tables 2-6. Variation among normal children can be considerable. . 2-7. and 2-8) acquired by children at certain ages and are useful for determining whether a child is progressing at the expected rate.



• In general. and pronation precedes supination. and from proximal to distal. grasp precedes release. . Ulnar precedes radial. motor development proceeds cephalocaudally. from medial to lateral.

and variation may be considerable. . emotional differentiation proceeds as follows: • Excitement → distress or delight at 2–3 weeks • Distress → fear/anxiety and anger by 2–3 months • Delight → joy and affection by 2–3 months.• In general. • Normal children progress at different rates.

or time from sleep onset to morning awakening.NORMAL CHANGES OF AGING • As adults move from early to late adulthood. The sleep period. longer refractory periods. does not decrease. • Sexual changes (male): Slower erection and ejaculation. • Sleep pattern changes: Decreased rapid eye movement (REM) and slowwave sleep. . However. and dryness. thinning. • Sexual changes (female): Vaginal shortening. and increased sleep latency. certain patterns of physiologic and psychological change are notable. true sleep time does decrease due to increased awakening during the night.


• Certain medical conditions become more common: Heart disease. . • Psychiatric problems. some cancers. hypertension. cataracts. • Thinking becomes less theoretical and more practical. are more common. arthritis. such as depression. • Higher suicide rate.

.g. rape] • and various forms of personal loss may also experience these stages..) Although this order is typical.NORMAL GRIEF • Elisabeth Kübler-Ross defi ned the stages of grief in her landmark book. some individuals experience these stages in a different sequence. On Death and Dying. More than one stage may be present at a given time. and not all individuals experience all fi ve stages. (Victims of physical or psychological trauma [e.

It is important for physicians to see the anger as normal and to not personalize it. or caregivers. One might understand the situation intellectually without experiencing the full emotional and psychological impact. . • Anger: Anger and resentfulness are experienced and possibly expressed toward the departed. family and friends.• Denial: The reality of the loss is denied initially in an attempt to avoid emotional distress.

"I miss my loved one. Anger – "Why me? It's not fair!". the individual recognizes that denial cannot continue. why bother with anything?". the individual may become silent.". "I can't fight it. the dying person begins to understand the certainty of death.. "How can this happen to me?". Bargaining – "Just let me live to see my children graduate. "I'll do anything for a few more years." The third stage involves the hope that the individual can somehow postpone or delay death. What's the point?".. It is not recommended to attempt to cheer up an individual who is in this stage. the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. "Who is to blame?" Once in the second stage. I may as well prepare for it. Any individual that symbolizes life or energy is subject to projected resentment and jealousy. not to me.". It is an important time for grieving that must be processed. but if I could just have more time. This feeling is generally replaced with heightened awareness of positions and individuals that will be left behind after death." Denial is usually only a temporary defense for the individual. "This can't be happening.. refuse visitors and spend much of the time crying and grieving. the person is very difficult to care for due to misplaced feelings of rage and envy.". "I will give my life savings if.. Psychologically.". why go on?" During the fourth stage. This process allows the dying person to disconnect oneself from things of love and affection. "I understand I will die.• • • • • Denial – "I feel fine.. "I'm going to die. Usually. the individual begins to come to terms with his mortality or that of his loved one.. Because of anger." Depression – "I'm so sad. Acceptance – "It's going to be okay. the individual is saying." In this last stage. . Because of this.

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