USMLE | Social Sciences

Communication and interpersonal skills, including health literacy and numeracy, cultural competence

Patient interviewing, consultation, and interactions with the family (patient- centered communication skills)

• • fostering the relationship (eg, expressing interest)
  • information gathering (eg, exploring patient's reaction to illness) information provision (eg, providing information about working diagnosis) making decisions (eg, eliciting patient's perspectives)
  • supporting emotions (eg, effective discussion with difficult patients)
  • enabling patient behaviors (eg, education and counseling)

Use of an interpreter

Medical ethics and jurisprudence, include issues related to death and dying and palliative care

Consent/informed consent to treatment, permission to treat (full disclosure, risks and

benefits, placebos, alternative therapies, conflict of interest, and vulnerable populations)

Determination of medical decision-making capacity/informed refusal

Involuntary admission

Legal issues related to abuse (child, elder, and intimate partner)

• • child protective services, foster care, immunizations legal requirements for reporting

Birth-related issues

Death and dying and palliative care

• • life support
  • advance directive, health care proxy, advance care planning euthanasia and physician-assisted suicide
  • diagnosing death/determination of brain death pronouncing death
  • organ donation hospice
  • pain management, including ethical issues related to death and dying information sharing, counseling families
  • psychosocial and spiritual counseling, fear and loneliness

Physician-patient relationship (boundaries, confidentiality including HIPAA, privacy, truth- telling, other principles of medical ethics, eg, autonomy, justice, beneficence)

Impaired physician, including duty to report impaired physician

Negligence/malpractice, including duty to report negligence and malpractice Physician misconduct, including duty to report physician misconduct Referrals

Cultural issues not otherwise coded

Systems-based practice (including health systems, public health, community, schools) and patient safety (including basic concepts and terminology)

Complexity/systems thinking

Characteristics of a complex system and factors leading to complexity: how complexity leads to error

Sociotechnical systems: systems engineering; complexity theory; microsystems

Health care/organizational behavior and culture: environmental factors, workplace design and process; staffing; overcommitment, space, people, time, scheduling; standardization, reducing variance, simplification, metrics; safety culture; integration of care across settings; overutilization of resources (imaging studies, antibiotics, opioids); economic factors

Quality improvement

Improvement science principles

• • Variation and standardization: variation in process, practice; checklists, guidelines, and clinical pathways
  • Reliability

Specific models of quality improvement: model for improvement: plan-do-study-act (PDSA), plan-do-check-act (PDCA); Lean, including recognition and types of waste; Six Sigma

Quality measurement

• • Structure, process, outcome, and balancing measures
  • Measurement tools: run and control charts
  • Development and application of system and individual quality measures: core measures; physician quality report system (PQRS); event reporting system

Strategies to improve quality

• • Role of leadership
  • Principles of change management in quality improvement: specific strategies

Attributes of high-quality health care

• • High-value/cost-conscious care: overutilization of resources, including diagnostic testing, medications
  • Equitable care: access
  • Patient-centered care
  • Timely care

Patient Safety

Patient safety principles

• • Epidemiology of medical error
  • Error categorization/definition: active vs latent errors; Swiss cheese model of error;
  • preventable vs non-preventable; near miss events/safety hazards
  • Causes of error
  • Patient factors: understanding of medication use; health literacy; economic status;
  • cultural factors (eg, religion); failure to make appointments; socioeconomic status Physician factors: deficiency of knowledge; judgment errors; diagnostic errors; fatigue, sleep deprivation; bias – cognitive, availability, heuristic, anchoring, framing
  • Human factors (eg, cognitive, physical, environmental)
  • High reliability of organization (HRO) principles: change management and improvement science; conceptual models of improvement
  • Reporting and monitoring for errors: event reporting systems
  • Communication with patients after adverse events (disclosure/transparency)

Specific types of error

• • Transitions of care errors (eg, handoff communication including shift-to-shift, transfer, and discharge): handoffs and related communication; discontinuities; gaps; discharge; transfers
  • Medication errors
    • Ordering, transcribing, dispensing, administration (wrong quantity, wrong route, wrong drug)
    • Medication reconciliation
    • Mathematical error
  • Procedural errors
    • Universal protocol (time out); wrong patient; wrong site; wrong procedure
    • Retained foreign bodies
    • Injury to structures: paracentesis; bowel perforation; thoracentesis; pneumothorax; central venous/arterial line injuries; arterial puncture and bleeding and venous thrombosis; lumbar puncture bleeding; paralysis
    • Other errors: anesthesia-related errors; mathematical errors
  • Health care-associated infections: nosocomial infection – eg, surgical site, ventilator associated, catheter-related; handwashing procedures or inadequate number of handwashing stations; central line-associated blood stream infections; surgical site infections; catheter-associated urinary tract infections; ventilator-associated pneumonia
  • Documentation errors: electronic medical record (including voice-recognition software errors); record keeping; incorrect documentation (eg, wrong patient, wrong date, copying and pasting, pre-labeling)
  • Patient identification errors
    • Mislabeling: transfusion errors related to mislabeling
    • Verification/two identifiers: lack of dual validation, including verbal verification of lab results
  • Diagnostic errors: errors in diagnostic studies; misinterpretation
  • Monitoring errors
    • Cardiac monitoring/telemetry
    • Drug monitoring (warfarin, antibiotics)
  • Device-related errors
    • malfunction programming error incorrect use

Strategies to reduce error

• • Human factors engineering
    • Situational awareness
    • Hierarchy of effective interventions: forcing function; visual cues
  • Error analysis tools: error/near miss analysis; failure modes and effect analysis;
  • morbidity and mortality review; root cause analysis
  • Safety behavior and culture at the individual level: hierarchy of health care, flattening hierarchy, speak up to power; afraid to report, fear; psychological safety; closed-loop communication
  • Teamwork: principles of highly effective teams; case management; physician teams, physician-physician communication; interprofessional/intraprofessional teams; strategies for communication among teams, including system-provider communication, physician-physician communication (eg, consultations), interprofessional communication, provider-patient communication

Health care policy and economics

• • Health care policy
    • Health care disparities: race/ethnicity; numeracy/literacy; socioeconomic status
    • Access to care: critical access systems or hospitals
    • Social justice
  • Health care economics/Health care financing
    • Types of insurance: Medicare, Medicaid, private insurance, self-pay
    • Navigating the insurance system: deductibles/co-pays; in-/out-of-network; preferred providers
    • Reimbursement issues affecting safety and quality: emergency services – EMTALA;
    • pay-for-performance

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