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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

Copyright © 2015 by the Federation of State Medical Boards of the United States, Inc. (FSMB) and the National Board of Medical Examiners® (NBME®). All rights reserved. Printed in the United States of America. The United States Medical Licensing Examination® (USMLE®) is a joint program of the FSMB and the NBME.