POM Final

-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

~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

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)

• 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

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

"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)

• 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

• 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