POM Final

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jknell
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205281
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POM Final
Updated:
2013-03-06 00:15:35
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POM
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POM
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  1. Pediatric Growth and Development
    -Brain is not fully developed at birth --> environmental influence on synaptic connections

    -Brain peaks at 3 years

    -Bowlby's theory of attachment: we form early stable relationships with primary caregivers

    • Erikson Psychosocial Stages of Development:
    • 1. 0-1: trust
    • 2. 1-3: autonomy
    • 3. 3-6: initiative
    • 4. 6-12: industry
    • 5. Adolescence: identity
    • 6. Early Adult: intimacy
    • 7. Mid Adult: generativity
    • 8. Late Adult: integrity

    • HEADSS
    • -Home
    • -Education
    • -Activities
    • -Drugs
    • -Sex
    • -Suicide
  2. Medical Errors
    ~150,000 deaths/year due to medical error

    Pyramid of systems (sharp end physician, blunt end policies and support staff)

    Swiss cheese model for errors

    • Solutions to Medical Errors
    • -checklists
    • -no ego
    • -carefully design system
    • -redundancy
    • -standardization

    • Error disclosure team:
    • -interact with family
    • -honest but compassionate
    • -trained to break bad news
    • -allow family to be angry (catharsis)
    • --> vs old model where doctors not allowed to inform patients about what happened

    • Cases:
    • 1. Malignant hypertension
    • -unfamiliar with machine
    • -overworked
    • -alarm disabled
    • -drug not available

    • 2. Mismatched transfusion
    • -untrained employee covering position
    • -similar labels
    • -nurse couldn't contact superior
  3. Health Systems
    Pre-1940s: fee for service, mostly solo practice

    WWII: private insurance (BS/BX, Medicare and Medicaid)

    Controlling Medicare/aid expenditures (sustainable growth rate, limit increase in total payments, typically overridden by congress)

    PPO: contracted list of MDs/Hospitals, lower deductibles and copays when in network

    HMO: care paid for only when MDs/Hospitals under contract, referrals must be authorized, minimal copays

    Point of Service: HMO + PPO use of out of network with high copays and deductibles

    High Deductible Health Plans: consumer directed, high deductibles, consumers discipline market

    • ACA:
    • 1. Individual Mandate (individuals required to purchase insurance starting in 2014)
    • 2. Health Benefit Exchanges (marketplace to provide consumers with info to chose among plans)
    • 3. Changes to Private Insurance
    • -can't deny based on health status/gender
    • -caps annual spending, no lifetime limits
    • -until 26
    • 4. Employer mandates (must pay fees if don't offer coverage)
    • 5. Medicare reform (covers donut holes, increase payments in underserved areas, includes adults without children)
  4. Legal Issues
    • Negligence:
    • 1. duty
    • 2. breach of duty
    • 3. breach caused
    • 4. damage

    • Informed Consent:
    • -discuss risks and benefits of each dx or tx
    • -professional centered and patient centered

    • Emergency Tx Exception:
    • -don't need informed consent if patient unconscious or lacks capacity

    • Conflict of Interest:
    • -antikickback statute
    • -Stark self-referral prohibitions
    • -false claims act

    • Advanced Directives:
    • -Living will
    • -Health care proxy/DPOA

    • Oral Directives:
    • -terry schiavo
    • -controversial, differ by state

    • Liscensure:
    • -determined by Board of Medical Examiners or Medical Licensing Board
    • -also has the power to discipline practicioners
    • -USMLE tests
  5. Healthcare Costs
    Healthcare costs have been rising (18% of GDP)

    Cost increases could be due to increased price or quantity or both

    • Cost Control Strategies:
    • -control fees and provider incomes
    • -cut prices of drugs and supplies
    • -reduce administrative waste
    • -eliminate interventions of no benefits
    • -replace with cheaper technologies
    • -increase preventative services
  6. Motivational Interviewing
    "RULE"

    • R: Resist the righting reflex
    • U: understand pt's motivations (ask why and how they want to change)
    • L: listen to patient
    • E: empower patient (be specific)
  7. Nutrition


    • Saturated fat: increases xol and TGs (increases risk for CVD)
    • -limit dietary fat to less than 30% of daily calories

    • History
    • -meals and snacks
    • -meals away from home
    • -types of eating places
    • -how much fruit
    • -how much veggies (most US folate deficient)
    • -high fiber breakfast cereal
    • -red meat
    • -chicken/turkey
    • -fish/shellfish
    • -hours of TV/day (snacking)
    • -dairy products
    • -desserts and sweets
    • -juice (associated with childhood obesity)

    • Fats:
    • -vitamins AKED
    • -xol/steroid synthesis
    • -20-35% of calories
    • -monounsaturated (avocado, olive oil)
    • -polyunsaturated (omega 3 and 6, 1:4)
    • -transfat (margarine, chips) --> insulin resistance, heart disease

    • Glycemic Index
    • -how quickly blood sugar rises
    • -fruits have high GI

    • Glycemic Load
    • -GI taking into account amount of food eaten

    • Fiber
    • -soluble and insoluble
    • -lowers LDL, increase satiety, speed passage of food/waste

    • Proteins
    • -NAs, PM, hormones, NTs, plasma prots
    • -essential AAs
    • -excess intake big problem in US

    • When to screen nutrition
    • -new patient
    • -BMI <19, >25
    • -waist circumference >40" (men), >35" (women)
    • -dx
    • -pertinent ROS

    • Mediterranean Diet
    • -plant based
    • -olive oil as primary fat source
    • -mod to high fish
    • -low to mod wine
    • -low red meat
    • -50-70% lower risk of heart disease

    • DASH diet
    • -dietary approach to stop HTN
    • -high in fruits and veggies, low fat dairy
    • -controlled calories
    • -lower BP/lipids --> lower CVD
  8. Mindfulness
    • Mindfulness-based stress reduction
    • -structured group program
    • -alleviate suffering from physical, psychosomatic and psych disorders

    Can improve burnout, depersonalization, empathy, mood disturbance in PCPs

    • Mindfulness: moment to moment non-judgemental awareness
    • -paying attention

    • Evidence based mindfulness effects:
    • -insomnia
    • -failed back surgery syndrome
    • -smoking
    • -obesity (decrease weight, binge eating)
    • -PMS
    • -hot flashes in menopause
    • -better immune fxn
    • -psych

    • BREATHE
    • -B: breathe
    • -R: realistic goals
    • -E: every day events (notice them)
    • -A: acts of kidness
    • -T: turn negative thoughts into positive
    • -H: honor your strengths
    • -E: end each day with gratitude

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