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VCOM Professionalism and Ethics Exam 2 (Lec 12-23)
Terms in this set (248)
What does professionalism involve?
Respect for ____(peers, professors, staff, visitors, standardized patients, visiting lecturers, etc...)
Respect for ________ in Anatomy lab (they donated their most intimate possession, their body, for your education)
Respect for the _______ (even if you are frustrated by circumstances)
Respect for all __________ and family members
Respect for ________ (stand up if you are put in a morally challenging situation)
Remember to always act with ______
American Board of Internal Medicine (ABIM)
Professionalism Project identified elements of professional and unprofessional behavior. What were the ethical behaviors? (6)
• Altruism: what is in the best interest of patients, not self-interest
• Accountability: being accountable to both patients AND society
• Excellence: to exceed ordinary expectation
• Duty: a commitment to service. Being 'on call' and accepting inconvenience
• Honor and integrity: refusal to violate one's standard of behavior
• Respect for others: this is the essence of 'Humanism'
ABIM Unprofessional Behaviors? (7)
Abuse of power:
• When interacting with patients and colleagues (this can start in medical school)
• Bias and sexual harassment
• Breach of confidentiality
Arrogance: an offensive display of self-importance; superiority
Greed: inappropriate aspiration of fame, power or money
Misrepresentation: Lying and fraud
Impairment: inability to meet professional obligations (and not reporting physicians who are impaired)
Lack of conscientiousness: doing more than 'just the minimum'
Conflicts of interest: unethical collaboration with industry; acceptance of gifts; misuse of services (self-referral)
Residency selection is competitive. Does the difference between scores matter that much?
matters, but you need other things to pick a person because this isn't enough given sores can be so close to one another
Medical Student Performance Evaluation (MSPE)
The MSPE or 'Dean's letter' is a comprehensive report of...?
The MSPE includes all performance, academics, service and evaluations (are these good or bad?).
Compared to his or her peers
In 2002 the 'Dean's Letter' was redesigned, to ensure ________across all medical schools
-In _______ the AAMC introduced new recommendations for the MSPE
...the medical student's performance through the first 3 years of medical school
both good and bad instances/things
What rank of importance is the MSPE with citation for residency application?
Timeline of MSPE
The MSPE starts with the work you will do in Block 1!
VCOM has a standard of honesty and disclosure in the MSPE
Residency program directors rely on the MSPE to help choose a class
• In addition to GPA, Board Scores, Audition Rotations, Interviews, CV, Personal
The MSPE is completed after the completion of all 3rd year requirements (clerkship and academic)
• Does not include 4th year rotation information
When do MSPEs uploaded for places to access?
fall (September 29th) of 4th year
We can use your CV for the MSPE
A ______ ______ (_____) is an 'official' document that highlights the important milestones of your educational and professional background
It is essential for highlighting your
• Both for residency as well as obtaining any job afterwards
It can be necessary to schedule visiting _________
ERAS has a standard format for the CV, but you will need a formal CV for _______ and other meetings
Examples of who would review your CV: (4)
Curriculum Vitae (CV)
• Dean for the MSPE
•Residency Program Directors
• Physicians writing letters of recommendation
• You will want to use it as a source of information for applications and interviews
How can we let the school get to know us for a Dean Letter? (6)
1) community outreach
2) community service
3) intern opportunities
4) scholarly activities
5) club involvement
6) international missions
What are negative things that could end up on a deans letter? What can be on the letter with this?
*hint - Honors code violations
All infractions of the honor code are confidential to the students and the college
Serious honor code violations are a reason for dismissal, or they are required to be resolved prior to graduation
The student will expect to provide an explanation of any honor code violation at the time of their interview
Students must sign a release of information on an honor code violation to be provided to the residency program
How is the MSPE structured?
Section 1: Starts with comments from the Dean...Then identifying information from the registrar page
Section 2: academic performance in 1st and 2nd year
Section 3: clinical year evaluations (H, HP, or P)
Section 4: Campus engagement completed by student services
Appendix: professional characteristics (HCC infractions?) AND scattergram (students at VCOM aren't ranked)
What constitutes campus engagement for section 4 of the MSPE?
community and international outreach
additional awards and scholarships
The MSPE is not a letter of ______
It is based on _____ a reflection of your performance and activities.
While every opportunity is taken to advocate for you, your
___________ must speak for itself.
The final MSPE may contain both positive and negative aspects of your _____________
The MSPE is who's property?
*who can view it?
• You may view your MSPE in the Registrar's Office once it is complete (usually mid-September)
• You may NOT make copies or show it to anyone other than those involved in its writing
-Including advisors, mentors, and those writing letters of recommendation
What are the 4 reasons for insurance?
Life is uncertain
People desire to reduce risk
"Individuals purchase health insurance to protect themselves against the risk
of unforeseen and costly events"
Health care cost more than most people can afford
Health insurance is important for access why?
• Give one the ability to _______
• And the availability to...? (4)
• It is a key factor in accessing ____
• Facilities and health professionals
• Culturally competent
Who are uninsured?
Almost 50 million uninsured Americans in 2010, but cut to 27.5 million in 2019
What are the characteristics of uninsured people? (8)
• Working age (19 - 64)
• Employed full-time or part-time (Pre-Covid)
• Lower household income
• Closer to poverty level
• Less formal education
• Not married
• Blacks and Hispanics more likely to be uninsured
• More white's uninsured
How many uninsured people are eligible for assistance?
Many uninsured people are eligible for coverage.
______% for medicaid as adults
______% for medicaid as children
______% for Tax credits (if healthcare is through marketplace)
Given how many people are uninsured but are eligible for coverage, what should physicians do?
Assist patients to determine if they are eligible for coverage
Cost-sharing-requires policy holders to pay part of the bill
• Premium - annual amount paid for health insurance
• Deductibles - amount beneficiary must pay before insurance pays anything
• Co-payment - A set fee paid every time certain services are provided
• Co-insurance - After deductible, the percent the beneficiary pays
• Maximum out-of-pocket - maximum payment by beneficiary during plan year
Do co-payments count toward the deductible?
• Maybe, but most likely probably not
DO NOT ASSUME THEY DO -EVER
Do co-payments count toward the maximum out-of-pocket?
• Yes, but can very by plan
• Does not include premium payments
*for this class, assume YES
Who and What is covered?
_______ or _______ - the health insurance consumer
___________/________ services - - what insurance will pay for
Beneficiary or insured
Out-of-network providers - lack contracts and do not provide discounts
• Beneficiaries pay more
List of drugs that insurance companies prefer beneficiaries use (Casto & Forrestal, 2015)
Explain what is in the EOB report
EOB means explanation of Benefits
• Description of service
• Date of service
• Cost sharing
• Amount insurer pays
• Amount owed by beneficiary
IMPACT OF COST SHARING
• Cost-sharing is _______ - negatively impacts low-income individuals the most
• Cost-sharing contributes to _______
• Out-of-pocket spending reduces use of ...?
...appropriate and inappropriate health
VALUE-BASED INSURANCE DESIGN (VBID)
• Minimizes or eliminates out-of-pocket expenses for _____-_____ care
• High value services determined by _______-_______ analysis
• More clinically beneficial the ______ the out-of-pocket
• Cost sharing through higher cost-sharing would _______ low value care
• Absence or lowering of cost-sharing would ..?
• Value-based does not necessarily mean ______ expensive
• Value-based does not necessarily mean ______ utilization
..encourage use of high value care
What are the 4 key principles to VBID?
• Value equals clinical benefit for the money spent
• Health care services differ in benefits provided
• Value depends upon the individual who receives them
• Value depends on where the service is provided
______________ - a fee (often discounted) for providing a specific service
______________ - A fixed fee per member for a specific period (typically a month)
______________ - One payment for a defined period of care
______________ - one payment to cover a group of individuals for a defined time period
Payment methodology and risk bearing
• Payers want to shift risk to the _______
• _______ do not necessarily want to accept risk
• Different payment models place more or less ______ on providers
list services from low to high provider risk
Traditional fee-for- service
Issues with Fee-for-service payments
doesn't encourage what?
contributes to growth in health _________
cooperation among providers
Patient interactions with health insurance
When can reimbursement be denied? (6)
Insurance companies must have an ______ mechanism
• Being referred out-of-network
• Receiving a non-covered service
• Not obtaining required pre-authorizations
• Incorrect coding of medical records
• Being prescribed drugs not on the formulary
• Maybe the insurance just denies reimbursement
What are the 4 Managed Care Organizations ?
• Health Maintenance Organizations (HMO) • Exclusive Provider Organizations (EPO)
• Point-of-Service Plans (POS)
• Preferred Provider Organizations (PPO)
• Salaried or contracted providers • Negotiated (per capita) rates
• Coordinate and control services provided
• Use only their network of providers
• Established quality standards
• Self funded by employers or associations
• Most often no out-of-network options
• Primary care physicians serve as "gatekeepers"
• Aggressive review of medical necessity and utilization
• A network of providers
• Patients can go out of network, but pay more
• Providers accept discounted fees
• Patients choose HMO, PPO, FFS option at time of service
• Provider network
• Capitated payments
• Requires patients have a "gatekeeper" to control access
• Patients can go out-of-network, but pay more as providers paid fee-for-service
Mechanisms to manage care and control costs
__________ __________ - care is within accepted standards within the community
__________ __________ (whoever is at risk performs) - denies payments for services not deemed appropriate
__________ __________ - required before performing certain services
__________ and __________ opinions - required before performing certain services
__________ __________ - coordination of care for complex and high-cost cases
Second and third
Characteristics of _______ ______ ______ (______)
• Accountable Care Organization (ACO)
- 512 Medicare ACOs in 2021
• 12 million beneficiaries • Bundled payments
Advance Payment Models (APMS)
What organizations do the following?
• Group of providers responsible for patient outcomes and costs
• Receives fixed payment per enrollee
• Must demonstrate improvements in quality and costs
• Can share is costs savings
• Publicly reported results
Accountable Care Organizations
What is the ACO's responsibility for quality? (4)
• Patient/Caregiver Experience (8 measures)
- Examples: Timely care, shared decision making, provider communication
• Care Coordination/ Patient Safety (10 measures)
- Example: Screening for fall risk
• Preventive Health (8 measures)
- Examples: Colorectal and breast cancer screening
• At-risk populations (5 measures)
- Examples: Diabetes and hypertension control
ACOs can share in savings
_____% of 561 Medicare ACOs two-sided in 2018
• One-sided ACO = only shares if positive results
- One-sided share in up to 50% of savings
• Two-sided AC) = shares in positive and negative results
- Two-sided share in up to 60% of savings or losses
• One payment for an episode of care - examples? (3)
• Payment shared between?
• Payment tied to ?
• Reporting of quality_______
•An acute care stay
• Inpatient stay plus 90-day post-discharge
• All services following hospital discharge
What are these characteristics of?
• Processes to manage sickest patients
• Electronic medical records and communications with patients
• Strong hospital and physician relations
• Care coordinators at practice level
• Team approach to care
• Expanded office hours
Impact of Pay-for-performance hopsitals?
• Provide cost-effective quality care or be penalized
• Hospital Readmission Reduction Program
- Poor performers lose 3% of inpatient Medicare payments
• Hospital-acquired Conditions (HAC)
- Lowest quartile lose up to 1% of inpatient Medicare payments
Impact of pay-for-performance Physicians?
• Provide cost-effective quality care or be penalized
• Merit-based Incentive Payment System (MIPS)
-Use of electronic records
• High performers earn 4% to 12% more
• Poor performers pay for the high performers
the belief that one type of skin tone is superior or inferior to another within a racial group
prejudiced action against a group of people
the unjust or prejudicial treatment of different categories of people or things, especially on the grounds of race, age, or sex.
racism embedded in social institutions
biased thought based on flawed assumptions about a group of people
making assumptions and decisions based on inaccurate or faulty information and assumptions
the act of real estate agents directing prospective homeowners toward or away from certain neighborhoods based on their race
a set of attitudes, beliefs, and practices that are used to justify the belief that one racial category is somehow superior or inferior to others
Sometimes Overt, Sometimes Subtle, Continues to Plague U.S. Health Care
the practice of routinely refusing mortgages for households and business located in predominately minority communities
sedimentation of racial inequality
the intergenerational impact of de facto and de jure racism that limits the abilities of black people to accumulate wealth
oversimplified ideas about groups of people
the benefits people receive simply by being part of the dominant group
Who said it?
"People fail to get along because they fear each other; they fear each other because they don't know each other; they don't know each other because they have not communicated with each other."
We are all the same, but we are not all equal.
Explain balancing power with racial justice
• RacialJustice ≠ diversity
• Diversity = variety
Racial Justice ≠ Equality
• Equality = sameness
RacialJustice = equity
•Equity = fairness, justice
People get what they need
___________ are oversimplified ideas about groups of people, a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized groups.
____________ refers to thoughts and feelings, while discrimination refers to actions.
___________ refers to the belief that one race is inherently superior or inferior to other races.
7 Forms of Racism
• Representational Racism
• Ideological Racism
• Discursive Racism
• Interactional Racism
• Institutional Racism
• Structural Racism
• Systemic Racism
Microaggressions in Medicine
statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.
What is privilege
"Privilege exists when one group has something of value that is denied to others simply because of the groups they belong to, rather than because of anything they've done or failed to do. Access to• privilege doesn't determine one's outcomes, but it is definitely an asset that makes it more likely that whatever talent, ability, and aspirations a person with privilege has will result in something positive for them."
What does it mean to have privilege ?
It is defined as "unearned access to resources (social power) only readily available to some people as a result of their advantaged social group membership".
Determining who has privilege or disadvantage is complex because cultural, social, and historical changes affect which groups are privileged and which groups are not.
"the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."
What can we do to be aware of cultural competence and acceptance and equality?
• Culturally-Sensitive Education
• Listening and Adaptation
• Means and Ends
What does racial and ethnic disparities in health care originate from?
...from a multiple complex factors, discrimination in health care, genetics, unequal educational opportunity, income gaps, health care access disparities, cultural beliefs, and community systems. Easy solutions are not available, however there is a moral imperative that must be brought to bear to address these differences. Improving access to quality care, reforming the health care delivery system, improving cultural understanding, diversifying the health care workforce, and improving social influences of health are all worthy goals but more is needed.
Cultural and linguistic competence is...?
Cultural competency in health care is...?
...a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations
....the ability of healthcare providers and organizations to meet the cultural, social, and linguistic needs of their patients.
How is it shaped?
What must a culturally competent healthcare professional or institution take into account?
• Culture- encompasses a person's learned beliefs, thoughts, and behaviors, their values, customs, and traditions, their communication style, their views on relationships, and the different ways they interact with others.
• Culture is shaped by many things, including race, ethnicity, nationality, heritage, socioeconomic status, education, and other factors.
• all of these aspects of an individual to achieve cultural competence.
Distinct qualities, backgrounds, characteristics and beliefs which make us different from each other either as individuals or as groups.
An identified group of individuals of the same species who have identifiable biological traits passed from one generation to the next.
Careful - this may be touchy as it can be linked to stereotypes
A cultural, linguistic, religious, racial, or national heritage which identifies an individual with a group of individuals.
An identified group of individuals which has little power or representation in a given society.
The state of being male or female (typically used with reference to social and cultural differences rather than biological ones.)
a particular system of faith and worship
the length of time that a person has lived
A person's sexual identity in relation to the gender to which they are attracted. The fact of being heterosexual, homosexual or bisexual.
an individual's or family's economic or social position in relation to others based on income, education and occupation.
Mental and Physical Disabilities
A condition that impairs, interferes or limits a persons ability to engage in certain tasks or actions or participate in daily activities.
Military Personnel and Family
A person's serving predominantly full time in the United States Armed Forces and their families who live in military environments that often have their own unique subculture and lifestyle apart from the general population.
Why does cultural competence in healthcare matter?
• Improve patient care and satisfaction
• Decrease malpractice risks and insurance costs
• Experience operational efficiency
• Increase compliance with state and federal regulations
• Overall, reduce health disparities among populations
What is the relevance of cultural competency in Health Care?
*Ability to interact effectively with people of different cultures
*This skill set allows one to increase their appreciation and understanding of differences without bias between groups of individuals.
*Application of this skill allows the health care provider to interact successfully and appropriately to provide needed health care to all identified groups of individuals.
*Being culturally competent is an "ongoing process". As the world progresses and becomes more diverse, we as health care providers, must do likewise.
It is projected that people of color will account for over ______ (_____%) of the population in 2050, with the largest growth occurring among ________.
half (52%); Hispanics
Define Health Care Disparities
Why do they occur?
Health and health care disparities refer to differences in health and health care between groups that are closely linked with social, economic, and/or environmental disadvantage.
Disparities occur in healthcare because of "differences that occur by gender, race or ethnicity, age, education or income, disability, geographic location, or sexual orientation."
Woman are more likely than men to have ______ conditions, but men die from them more.
Health Care Disparities Examples: Sexual Orientation/ LGBTQ+
Unique health challenges?
Gay/ Bisexual men and HIV?
HIV prevalence in trans females?
Routine care for lesbian/bisexual women?
LGBT youth and abuse?
Health Disparities linked to social stigma, discrimination and denial of civil and human rights.
Health issues: psychiatric, substance abuse, suicide
Environmental factors: victimization, violence
Unique health challenges: access to care, insurance
Gay and bisexual men=more than half of new HIV infections in US each year
HIV prevalence in transgendered females exceeds 25% nationwide
Lesbian/bisexual women receive less routine care than other women, including breast and cervical cancer screenings
Approx 30% of LGBT youth report physical abuse by family members due to sexual orientation or gender identity/expression
Health Disparities Examples: Race and Ethnicity (CHART)
what are they caused by?
minority populations usually have higher rates of?
What did the Chronic Disease Death Rates by Race and Ethnicity chart show?
Health disparities between different racial or ethnic groups are caused by differences in genetic factors, environments or health behaviors, and also other factors such as systemic racism and bias.
Minority populations often have higher rates of chronic disease. The chart shows below shows how death rates for diabetes, heart disease and cancer can vary widely by racial and ethnic groups.
The chart shows that:
1) Black/African American, American Indians and Hispanic groups are more likely to die of diabetes
2) Black/African Americans and White groups have higher death rates for heart disease and cancer
3) For all three diseases, Black/African Americans have the highest death rates while Asian/Pacific Islanders have the lowest
Health Disparities Examples: Race and Ethnicity
Most people who got COVID were white, but primarily black patients died from it. This shows a significant current health disparity
Health Disparities Examples: Income or Education
Groups with low incomes?
Higher income groups?
What did the US Obesity Rates and Income Chart show?
Groups with the lowest income and education levels also have the lowest health status. Groups with higher income are more able to access medical care and health information.
Higher income groups are also more able to take part in healthy behaviors such as exercise and eating well. The chart below shows how income is related to people's perceptions of their health status.
The chart below shows five income levels and the percent of obese people in those income levels. Obesity among the poorest group is twice the level of the richest group.
The less money people have, the more calories (or less nutrient dense food) they eat
Health Disparities Examples: Disability Status
Disabilities, whether present or acquired at birth or developed later in life, can manifest into?
People with disabilities represent about _____ percent of the U.S. population (Brault, 2012).
There is ample evidence to suggest that people with disabilities are at increased relative risk for?
People with disabilities also report higher rates of what?
physical, cognitive, or mental health- related impairments, which can affect health outcomes.
poor well-being, but this population has been overlooked.
obesity, lack of physical activity, smoking, and three to four times the rate of cardiovascular disease versus people without disabilities
Health Disparities Examples: Geographic Location
The Appalachian Region Commission Studies have identified what? (7)
1) Higher rates of Cancer, in particular cervical cancer
2) Higher rates of Heart Disease
3) Higher rates of premature infant
4) Higher rates of lung disease
5) People living at or below poverty level
6) Poor access to medical services
7) High school drop - out or non- completion
Complex Causes of Healthcare Disparities
Social Determinants of Health (______ Contributor)?
Racial or ethnic bias (______ Contributor)
Health ________ or _______
______ and ______ barriers
Number of providers (_____ contributor)?
Lack of _____ of health care providers
Quality of _____
Lack of ______ across providers
Major - socioeconomic status, education, physical environment, social support, access,
Major - clinical uncertainty when interacting with patients of another racial or ethnic group
infrastructure or coverage
Major - Physicians are less likely to locate in areas where greater poverty exists
How Does Cultural Incompetence Lead to Healthcare Disparities?
i.e. providers and trust
Providers may unintentionally provide lower expectations for patients who are in disadvantaged positions and therefore influence patient health outcomes
Providers may employ stereotypes when under time constraints resulting in poor patient communication
Patient may mistrust medical profession → leading to poor adherence → resulting in provider cynicism toward the patient → thereby provider offers patient fewer services (repeat)
What can be done to stop incompetence and health disparities? (7 steps)
1) Identify and verify a healthcare disparity which is problematic based on accepted medical and scientific standards.
2) Define those healthcare disparities which have a realistic solution and the intervention utilized to address the problem has a clear outcome measure.
3) Increase community awareness of disparities.
4) Set priorities among disparities.
5) Articulate valid reasons to expend resources to reduce and eliminate priority disparities.
6) Implement universal and targeted intervention programs.
7) Aim to achieve a faster rate of improvement among vulnerable groups.
Medical Student Cultural Competence - What skills should you develop to be Culturally Competent? (7)
1) Develop knowledge of diversity as it relates to disease processes
2) Be able to obtained a culturally competent history and physical
3) Learn sources of information regarding cultural diversity
4) Develop understanding of personal biases through
5) Be able to conduct culturally competent patient education
6) Be able to develop culturally competent treatment plans
7) Understand epidemiological data relevant to practicing culturally sensitive medicine
What are the Best practices for students to become culturally competent?
Learn the language or colloquialisms
Use a worldview approach (assumptions about reality)
Use caution in eliciting help from family/friends in interpretation
Know customs (eye contact, touching, asking questions, space, time)
Ask questions—don't assume
Small talk, self-disclosure
Use the formal name when unsure
Don't ask "do you understand?", repeat in own words
How to Support Diversity in the Health Professions? (3)
1) Medical Outreach: International/Appalachian Outreach
2) Get involved in student organizations:
Student National Medical Association
American Medical Women's Association
Hispanic Community Medical Outreach
PRIDE in Healthcare
3 )AMA and AOA recommend getting involved in programs encouraging interest in medicine among minorities and low income youth
What can we do as a health care system to promote cultural competency? (10)
1) Provide training to increase cultural awareness, knowledge, and skills
2) Provide interpreter services
3) Recruit and retain minority staff
4) Coordinate with traditional healers
5) Use community health workers
6) Incorporate culture-specific attitudes and values into health promotion tools
7) Include family and community members in health care decision making
8) Locate clinics in geographic areas that are easily accessible for certain populations
9) Expand hours of operation
10) Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials
Define Gender (W.H.O. def)
"Gender - refers to the socially constructed characteristics of women and men - such as norms, roles and relationships of and between groups of women and men. It varies from society to society and can be changed. While most people are born either male or female, they are taught appropriate norms and behaviors - including how they should interact with others of the same or opposite sex within households, communities and work places. When individuals or groups do not "fit" established gender norms they often face stigma, discriminatory practices or social exclusion - all of which adversely affect health. It is important to be sensitive to different identities that do not necessarily fit into binary male or female sex categories."
1) Sexual Orientation
2) Gender Identity
3) Gender Expression
1) A person's EMOTIONAL &/or PHYSICAL ATTRACTION to people of the same gender &/or a different gender
• Most people identify themselves as lesbian, gay, bisexual, or heterosexual, but there are many other terms that people use to describe their sexual orientation
2) An individual's INTERNAL SENSE OF GENDER, which may or may not be the same as one's gender assigned at birth
3) Way in which an individual OUTWARDLY presents their gender, through how they choose to speak, dress, or generally conduct themselves socially.
(The way one expresses their gender is NOT always indicative of their gender identity)
Meaning of LGBTQ+
(L) Lesbian: a woman who is attracted to other women
(G) Gay: a man who is attracted to other men
(B) Bisexual: someone attracted to people of either gender
(T) Transgender: when one's biological sex and gender-identity
do not match
(Q) Queer: individuals who don't identify as straight or who have non-binary gender identity
(+) inclusive of all identities
Fluidity of Terminology
• It is important to remember that the terminology itself is fluid.
• Terms are not static and can vary in different cultures.
• With identity terminology, trust the person who is using the term and their definition of it.
having a gender identity that matches one's assigned sex
A general term used for a variety of conditions in which a person is born with reproductive or sexual anatomy that doesn't seem to fit the typical definitions of female or male.
Anyone who does not fit neatly into a gender role. Sometimes this is used to suggest that there is something wrong with people who do not fit gender roles. There is not.
An umbrella term derived from a contraction of "transgender" or "transsexual". The asterisk is a "wildcard" that stands for the multitude of ways that trans
people identify. The prefix "trans" can mean beyond, across, between, through, transcending, or changing. Many trans
people have a gender identity that is different from the one they were assigned at birth. Some people identify as trans* if their gender expression is different than what is expected for their gender.
1. "Male to female"; a person who was assigned male at birth and identifies as a woman
2. Some trans* people use "MTF" to describe their medical transition goals; they want their body to lose some "male-typical" sex characteristics and gain some "female-typical" sex characteristics.
1. "Female to male"; a person who was assigned female at birth and
identifies as a woman.
identifies as a man.
2. Some trans* people use "FTM" to describe their medical transition
goals; they want their body to lose some "female-typical" sex characteristics and gain some "male-typical" sex characteristics.
Having two parts. Some societies such as ours tend recognize just 2 genders, male and female
A person whose gender identity does not fit the strict man/woman dichotomy.
Some non-binary people feel that their gender identity is between a man and woman, is simultaneously fully man and fully woman, changes from man to woman and back, is a separate entity without connection to man or woman, is similar to either man or woman but is not quite either, is entirely neutral, or does not exist at all.
A term for LGBTQ members of the Native American community, first coined in 1990 by a Native American group in Winnipeg. The term references a tradition common to several tribes, where some individuals possessed and manifested a balance of both feminine and masculine energies, making them inherently sacred people.
How does Stigma and Discrimination affect the LGBTQ+ community's health?
Stigma can act on multiple levels to create both personal and structural barriers to accessing care.
Barriers may be reinforced for LGBTQ+ people who belong to more than one marginalized and stigmatized group (race, ethnicity, or SES), or who simply express themselves in ways that differ from accepted norms.
This "accumulated stigma" leads to both medical and behavioral health disparities.
LGBTQ+ people experience a higher prevalence of...?
LGBTQ+ health disparities largely track to long history of...?
Stigma and discrimination - direct and indirect effects?
Despite the existence of discrimination and disparities, a sizable _________ of LGBTQ+ people live healthy, productive lives that are integrated into the activities and professions of general society.
...of a range of medical and behavioral health issues.
....societal stigma and discrimination directed at sexual and gender minorities.
• Directly: Bias by health care professionals, violence fueled by hatred of LGBTQ+ people, and policies that deny health insurance coverage to same-sex partners
• Indirectly: Discriminatory actions toward LGBTQ+ people around the world creating a negative environment for LGBTQ+ individuals wherever they may reside.
For LGBTQ+ individuals, there is an increased risk for what?
Delayed or refusal of healthcare impact?
• Increase risk for depression, anxiety, suicide attempts, and substance use disorders
• LGBTQ+ youth are 4x as likely to attempt suicide
• 19% of transgender individuals reported being refused care because of their
• Fears or concerns over disclosing sexual identity and lack of culturally competent providers
Barriers of Insurance for LGBTQ+ members
Wording excludes coverage outside of standard care (hormones, surgery, definition of family)
Lack of providers' knowledge of social issues surrounding the LGBT community, or lack of desire in treating this particular population.
LGBTQ+ in the elderly in understanding barriers
Limited social support systems
Discrimination in assisted living facilities in dealing with homophobia/ transphobia
SSand pension plans often exclude a partner from being on a significant others plan if marriage is not legally recognized.
SOCIAL DETERMINANTS OF LGBTQ+ HEALTH
Social determinates of health refer to economic & social conditions that influence individual and group differences in health status (e.g. social & economic resources such as housing education, employment, and health care; government & institutional policies)
Social determinates of health are often linked to stigma & discrimination. Examples in clude:
Schools that do not include sexual orientation & gender identity/expression protections in their anti-bullying programs can leave LGBT youth vulnerable to verbal & physical harassment, which is associated with depression, suicidality, & risk for HIV & other STIs.
Employment discrimination against transgender people can cause many to go without health care & can lead some to engage in the sex trade as a means of survival, putting them at risk for multiple health issues.
Unequal access to health care is of critical importance to all LGBTQ+ people, particularly those who are poor &/or living with HIV/AIDS
Beyond insuranceissues, many LGBTQ+ people continue to lack access to providers who are knowledgeable about their unique health needs or who understand how to address them with cultural sensitivity.
Creating affirmative and inclusive clinical environments
The environment of care can affect one's overall health care experience begins well before a patient greets a clinician in the exam room.
What makes for a gender affirming environment ? (7)
1) Have reading materials in your lobby areas that are encouraging of all patient types
2) Single occupancy restrooms
3) Call patients by their preferred names
4) Allow patients to determine who can visit and who cannot (family member, friend, or other individual)
5) Have patient intakes that ask:
• Assigned Sex at Birth
•Current Gender Identity
6) EMR flags/tags indicating transgender patient
7) Have clinical policies that help train staff on ways to best work with those whom are different than themselves
What are the 4 conceptual Frameworks for understanding LGBTQ+ HEALTH-
People have different health care needs at different life stages.
Ex. LBGTQ+ youth may have concerns related to coming out to their families, while older LGBTQ+ adults may have concerns about loneliness & living without extended families.
Characteristics of the social environment, including family, other relationships, the community, culture, and general society, can affect an individual's behavior and well-being. How does the social context of people's lives influence their health?
Sexual and gender minorities (like other minority groups) experience chronic stress arising from social stigmatization and manifested in both external and internal processes. Lack of social tolerance of homosexual behavior may result in stress-related disorders, such as depression, for LGBTQ+ people, especially in those who feel the need to be covert about their sexual orientation or gender identity.
Social, racial/ethnic, religious, economic, cultural and other factors-in addition to sexual orientation and gender minority status-influence the identities, health, and lived experiences of LGBTQ+ people. Clinicians may need to explore and understand the role and intersection of different identities and other factors in their patient's lives.
Intersectionality was coined in the late 1980s by _______ _______, a legal scholar and civil rights activist. She introduced the term as a way to ...?
help highlight the fact that some individuals experience multiple or compound types of oppression and discrimination, because of the diversity in their identities.
What does intersectionality inform us ?
that we cannot just discuss separate categories of diversity and not address that they are also interdependent.
What is diversity ?
It is a broad concept that refers to the variety of group experiences that result from the social structure of society. It is influenced by social constructs such as but not limited to race, gender, age, class, nationality, sexual orientation, religion, region of origin, and so on...
based on the definition of diversity, how can we interpret intersectionality?
And so intersectionality is the intersecting of our diverse social constructs. And these social constructs are what help us formulate our identities.
And our identities are what drive our sense of SELF...Our Value Systems...AND how we see ourselves and the world around us.
It is important to always keep an open mind; and to remember that people are more than just what we see on the outside.
When viewed by an intersectional lens we can start to get more of an understanding about a person.
We can start to see the intersecting lanes and gain a better understanding of what might be some obstacles or disadvantages that a person is facing. And when we can do that we can start to help someone on a deeper level.
Intersectionality and Health Care?
The extent to which identity formation is creating emotional, physical, or social distress is a consideration for health care providers. Using a client-centered approach is one method to examine this.
The provider's self-awareness is equally as important as understanding the many facets of the LGBTQ+ individual.
The provider should strive to have an awareness of the potential range of identities and that these identities come together to create a unique experience for the patient.
The provider should seek to understand, explore, and listen to the patient's meaning, perspective, and impact of these identities.
Having self-awareness allows the provider to incorporate how their own views impact and set expectations of who their patients are and should be. Further understanding of the social, psychological, and identity issues of the patient provides a rich opportunity to support patient engagement and positive mental and health outcomes.
What policy does VCOM have for equal opportunity policies according to the national standards?
Equal Opportunity Policy (Statement)
If you have a discrimination issue, what VCOM policy helps you?
Acts of Discrimination, Harassment and Violence Policy by VCOM
What constitutes discrimination?
Discrimination is an act of making distinctions between people based on the person belonging to or being from a certain group such as religion, race, ethnicity, sexual orientation, disability or other categories to which they are perceived to belong.
VCOM had adopted a zero-tolerance to inappropriate behavior exhibited as an act of discrimination
What Constitutes Harassment?
Commonly understood as offensive behavior that demeans, humiliates, embarrasses, annoys, intimidates, alarms or threatens someone and is characteristically identified as being unacceptable in terms of social and moral reasonableness.
VCOM has zero tolerance for harassment, whether based on a protected classification or not.
What is always considered unacceptable behavior?
This includes physical contact through any act of violence, physical control, and/or intimidation through threat of violence.
_________ ______ includes unwanted sexual contact through intimidation, physical control, and extends to an act of sexual contact with a person who is incapacitated to the point of being unable to voice consent or their lack of consent.
What does sexual violence encompass?
Sexual violence encompasses several categories including rape, sodomy, and sexual assault by a person or with an object and includes the crimes of dating violence, domestic violence, sexual assault, and stalking.
What is sexual assault?
Sexual assault for purposes of this policy is any type of sexual contact or sexual behavior that occurs without the explicit consent of the recipient.
Title IX Brief History? (5 points)
1) TITLE IX OF THE EDUCATION AMENDMENT OF 1972 (amended the Higher Education Act of 1965) and states "NO PERSON IN THE UNITED STATES SHALL, ON THE BASIS OF SEX, BE EXCLUDED FROM PARTICIPATION IN, BE DENIED THE BENEFITS OF, OR BE SUBJECTED TO DISCRIMINATION UNDER ANY EDUCATION PROGRAM OR ACTIVITY RECEIVING FEDERAL ASSISTANCE."
2) When TITLE IX was signed in 1972, the purpose was focused on equity and access for female student, particularly as it pertained to athletics, financial aid, and admissions.
3) Over the years this was expanded to include protections against sexual harassment and sexual violence, as well as gender discrimination against transgender students and pregnant students.
4) Title IX is a living and breathing document, with currently, over 20 suggested amendments to the law.
5) New requirements have been added in recent years to ensure that colleges prevent, respond to, and remedy sexual misconduct.
The Clery Act
The CLERY ACT requires institutions of higher education to report crime statistics, notify the campus community of threats, and compile and distribute (or post) an annual campus security report to the campus community, prospective students, and employees.
The CLERY ACT was created after ..?
1992- amended to require ...?
1998- amended and renamed the ...? Increased the categories of reportable crimes.
2000- amended to require institutions to provide information on the state's public ...?
...a student named Jeanne Clery was raped and murdered in her dorm room by a fellow student at Lehigh Univ. in 1986.
....the development and implementation of policies and procedures to protect the rights of sexual assault survivors.
....Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act
...sex offender registry and allowed the disclosure of registered sex offender information without violating privacy laws.
2008- after the 2007 Virginia Tech shootings...?
2013- amended again as part of the reauthorization of what Act? What does it incorporate? Increased reportable crimes including ....? What else did it increase?
...the Clery Act was included within the new Higher Education Opportunity Act of 1965 and amended to include new regulations re: emergency notifications and response, timely warnings, missing student notification, fire safety reporting, and hate crime reporting.
Violence Against Women Act (VAWA) which incorporated provisions of the Campus Sexual Violence Elimination
domestic violence, dating violence, sexual assault, and stalking. Also increased the rights of victims.
2016 - following the Penn State sex abuse scandal of young boys sexually abused over several years. What happened as a result?
2019, following the investigation of the case of Larry Nassar at Michigan state, ...?
Many ____ were filed at the state level by Institutions of Higher Education as they believed the states were moving the responsibilities of the courts (in deciding guilt) to the colleges and universities.
The Department of Education conducted the most extensive investigation ever conducted. Penn State was also fined 2.4 million dollars
2019, following the investigation of the case of Larry Nassar at Michigan state, the University was fined 4.5 million dollars, the largest ever Clery Act penalty. During the 2018 - 2019 period several states' higher education accrediting bodies along with the Dept. of Education, increased their reporting requirements on sexual crimes.
...the University was fined 4.5 million dollars, the largest ever Clery Act penalty. During the 2018 - 2019 period several states' higher education accrediting bodies along with the
Department of Education (DoE) Title IX Final Rule vs clercy act
burden on who?
Contains many of the policies, definitions and provisions of the Clery Act, however the process and procedures for
reporting have been changed and are now specifically limited.
The new rule specifically places undue burden on the victims as well as institutions.
Many appeals to the new rule have already been filed.
VCOM Policy on Sexual Harassment - How is this one policy with two procedures?
VCOM'S Policy on Discrimination, Harassment and Violence is much broader than the federal laws, incorporating them and prohibiting unprofessional and unethical conduct not covered by constitutional protections but expected of a physician.
Cases of alleged sexual harassment will proceed under the procedures set out in the Title IX Final Rule. All other cases of alleged Discrimination, Violence, and Harassment violations of the VCOM Policy will proceed under the College's procedures for the Discrimination, Harassment and Violence Review Committee.
As future Physicians you are held to a higher standard; by VCOM and by Medical Boards in the future.
SEXUAL HARASSMENT (Dept. of Ed TITLE IX Final Rule)Conduct on the basis of sex that satisfies one or more of the following: (3)
1) An employee of the recipient conditioning the provision of an aid, benefit, or service of the recipient on an individual's participation in unwelcome sexual contact; or
2) Unwelcome conduct determined by a reasonable person to be so severe, pervasive and objectively offensive that it effectively denies a person equal access to the recipient's education program or activity; or
3) Sexual assault, dating violence, domestic violence, or stalking
VCOM Policy on Sexual Harassment - SEXUAL HARASSMENT (TITLE IX) is conduct on the basis of sex satisfying one or more below: (3)
1) An employee of an institution conditioning the provision of an aid, benefit, or service of the institution on an individual's participation in unwelcome sexual contact.
2) Unwelcome conduct determined by a reasonable person to be so severe, pervasive, and/or objectively offensive that it effectively denies a person equal access to the institution's educational programs or activities.
3) Sexual assault which includes dating violence, domestic violence, and stalking.
What are 3 things we need to consider for the Final Rule issue?
1) The conduct complained of must have taken place against a person in an educational program or activity of VCOM in the Unite States.
2) For purposes of Title IX the "education program or activity" includes when the sexual harassment has occurred in an educational program, event, or in a facility owned by VCOM or where VCOM had substantial control over the location and the respondent.
3) These limitations do not apply to VCOM policies.
How does VCOM define consent?
• Consent is informed-
• Consent is an affirmative
(Yes means Yes and No means No)
• Consent if knowing and unambiguous, and
• Consent is a conscious decision
where each participant engages in mutually agreed-upon sexual activity.
________ is voluntary and given without coercion, force, threats, or intimidation. Consent means a positive cooperation with an intent to engage in the act in an exercise of free will.
Even though consent does not necessarily need to be verbal, relying purely on non-verbal communication can lead to _________. A spoken agreement is the most clearly indicated form of consent.
Consent is not to be inferred from silence, passivity, lack of resistance or a lack of an active response alone.
Assuming that consent was given by the absence of a "_____" is wrong.
Consent and Incapacitation
Consent cannot be given when a person is incapacitated.
A person cannot consent if they are unconscious or coming in and out of consciousness.
A person cannot consent if they are under the threat of violence, bodily injury or other forms of coercion.
A person cannot consent if their understanding of the act is affected by a physical or mental impairment.
Consent must be given with rational and reasonable judgment, so if the individual were physically incapacitated from the consumption of alcohol or other drugs, unconscious, or any other kind of inability, consent cannot be obtained.
Age of Consent
The age at which an individual can legally consent to sexual intercourse under any circumstance.
1) Minimum age of victim- the age below which an individual cannot consent to sexual intercourse under any circumstance.
2) The age set by the state, including definitions and defenses regarding statutory rape.
How can one prevent Sexual Violence? (4)
Prevention occurs by reducing vulnerability.
Sexual predators generally prey upon vulnerable people.
What makes someone vulnerable?
1) Being alone (hiking or biking alone in remote places, walking on city streets alone at night, etc.) Perpetrators avoid crowds.
2) Intoxication or drugs makes one more vulnerable. Charges for having sex with an incapacitated person are frequent.
3) Assure there is a designated driver you to take you home if you are drinking.
4) Never accept a drink from a stranger that may have added drugs.
What things to avoid in order to avoid being accused of sexual violence? (vulnerabilities and consent)
1) To avoid being accused of being a perpetrator, if a person you are accompanying becomes intoxicated or incapacitated to the point they are unable to comprehend and voice consent, or their lack of consent to sexual advances, they are considered vulnerable.
2) In this case, sexual advances should be avoided as they may be unwanted.
3) Mutual consent requires both persons to be capable of comprehending and voicing consent. VCOM will support the decision of the courts or authorities.
4) Women may be charged (just as men are) of unwanted sexual activity when incapacitated, even though more infrequent.
Sexual Harassment Grievance Process (5 steps)
1) Any person may report sexual harassment, whether or not they are the alleged victim.
2) The filing of a Formal Complaint with the Title IX Coordinator triggers the required response and investigation by the College.
3) Title IX Coordinators on each VCOM Campus is the Campus Director of Human Resources. Also, reports of discrimination, harassment, or violence can be made to the Associate Deans for Student Services .
4) The issue will be brought to the attention of the Campus Dean as the person who has authority to institute corrective measures for the College.
5) The President and Provost also has authority over all campuses to institute corrective measures but is generally used only in appeals.
SEXUAL HARASSMENT GRIEVANCE PROCESS
• The Title IX Coordinator will meet confidentiality with the complainant (alleged victim) to:
1) Discuss availability of supportive measures
2) Consider the complainant's wishes with regard to supportive measures
3) Inform the complainant of the availability of supportive measures with or without filing a formal complaint
4) Explain the process for filing a formal complaint.
Supportive measures for Sexual Harassment?
What may these measure include?
Measures designed to restore or preserve equal access to the College's education program or activity without unreasonably burdening the other party, including measures designed to protect the safety of all parties or the College's educational environment, or to deter sexual harassment.
The measures may include counseling, extensions of deadlines or other course-related adjustments, modifications of work or class schedules, campus escort services, mutual restrictions on contact between the parties, leaves of absence and other similar measures.
In Sexual Harassment cases, the recipient must dismiss the formal complaint if the conduct alleged in the formal complaint: (3)
1) Would not constitute sexual harassment even if proved; or
2) Did not occur in the recipient's education program or activity; or
3) Did not occur against a person in the United States.
No one may intimidate, threaten, coerce, or discriminate against any individual for the purpose of interfering with any right or privilege secured by Title IX or any VCOM policy, or because the individual has made a report or complaint, testified, participated or refused to participate in any manner in an investigation, proceeding, or hearing under Title IX or any VCOM policy. Acts of ___________ are also considered unethical and unprofessional calling for review by the ______.
Professional and Ethical Standards Board (PESB)
Title IX Final Rule and Confidentiality?
As far as practical, and as allowed by law, the proceedings under the Title IX Final Rule and the VCOM Policy on Discrimination, Harassment, and Violence shall be kept confidential.
What is expected of a physician and a medical student as a future physician in regards to Sexual Harassment? (2)
1) Mandatory Reporters- all VCOM employees and students are considered mandatory reporters and MUST report an act of violence/sexual violence toward another student or employee that they witness to the Director of Human Resources or member of administration. Witnesses are also encouraged to report such acts to the local police using 911.
2) In the future, as a Physician you will also expected to report acts of violence / sexual violence. The patient has privacy rights according to HIPAA, and the reporting must only occur if the person agrees to the disclosure OR if the person is not of age OR if the Physician believes the person is in imminent danger.
Anonymous reporting of Sexual Harassment and VCOM (4)
(1) VCOM recognizes that the mandatory reporting policy may at times be a deterrent to a victim or observer reporting an act of violence/sexual violence.
(2) If a student is hesitant to report such an act but wishes to discuss it, VCOM requests that the student or employee call the Director of Human Resources or Associate Dean.
(3) In this case the caller may initiate the call anonymously. All reports of violence which become known to VCOM will be investigated.
(4) Evidence must exist and become known during the investigation verifying the violence took place in the case of anonymous reporting before the College may pursue the report further.
Mandatory Reporting of Sexual Harassment as a Physician in regards to confidentiality
Because of confidentiality restraints of the doctor- patient relationship, physicians who have patients who are clearly victims of sexual violence are often conflicted as whether to report the abuse or not. Most states have, by statute, made physicians mandatory reporters for instances of abuse to children, dependent adults and the elderly. However, very few have mandated this for competent adults. In the absence of a statutory mandate, or a consent from the adult patient, reporting would, unfortunately, be a HIPAA violation and, likely, a professional ethics violation.
Some states have mandatory reporting for certain types of injuries.
Virginia-? wounds fro guns, knives, Knuckles, nun chuck, throwing stars and similar.
wounds fro guns, knives, Knuckles, nun chuck, throwing stars and similar.
Avoiding Possible Allegations of Sexual Violence and Ethical violations in the Workplace (3)
1) Atmosphere of Political Correctness - need appropriate distance, have presence of staff when examining opp. sex, and be sensitive to appearance with hugging/kissing other people around.
2) The overly friendly or sexually forward patient - immediately and politely deflect with statements and don't embarrass the patient.
3) Romantic relationships - refer to another physician not in your office, and don't go with married patients, or staff or minors
Modern day mindfulness is considered what?
_____ _____-_____ founded the 1st mindfulness-based treatment approach - the...?
Ancient Eastern medication practices
considered a secular practice inspired by 2600 year old Buddhist teachings
Jon Kabat-Zinn; Mindfulness-Based Stress Reduction (MBSR)
What is mindfulness according to Jon Kabat-Zinn?
"paying attention in a particular way; on purpose, in the present moment, and non-judgmentally."
Don't be judgemental of yourself as it is not helpful for where you are going and where you are. Live in the moment.
Mindfulness is defined as...?
It is important to distinguish mindfulness as both a ______ (i.e.?) and ______ (i.e?)
...awareness that arises through intentionally attending in an open, caring, and nonjudgmental way.
process (mindful practice) and outcome (mindful awareness)
_______ _________ is the art of knowing what you are experiencing, as you are experiencing it
Seeing clearly and accepting what is here and now - what are the 3 things that follow under this?
It involves simply observing your _________ self without trying to get more of what one wants (pleasure, security), or pushing away what one doesn't want (e.g., fear, anger, shame)
feelings, thoughts, perceptions
Mindful awareness Cont.
Patterns of behavior are _________ & result in living on _________
Awareness involves distinguishing between _______ and ________ tendencies
People can develop insight from being aware of their internal experiences and ultimately make more ___________ choices
Ability to sustain __________ and switch focus of attention
crucial for effective _________ building with patients
beneficial and un-beneficial
Jon Kabat-Zinn describes several insights into the nature of things that can develop through mindful awareness and create positive change - what are the 3 mentioned?
1. Everything is impermanent
2. Suffering arises out of greed, hatred, and delusion
3. Everything is connected, nothing is separate
Research has shown mindfulness can have positive effects on the Brain and Body. What are these effects?
emotion regulation, working memory, cognitive control, attention, activation in specific somatic maps of the body, cortical thickening in specific regions
symptom reduction, greater physical well-being, immune function enhancement, epigenetic up and down regulation of gene activity*
What are the 10 benefits of meditation?
1) reduced stress
2) controls anxiety
3) promotes emotional health
4) enhances self-awareness
5) Lengthens attention span
6) fights addictions
7) reduce age related memory loss
8) improves sleep
9) helps control pain
10) decreases blood pressure
Mindfulness and Medicine
Studies show benefits for patients with acute and chronic diseases such as: (5)
___________ used successfully in treatment and prevention of high blood pressure, heart disease, migraine headaches, & autoimmune diseases (e.g. diabetes and arthritis)
Proven helpful to _____ obsessive thinking, anxiety, depression, and hostility
Chronic pain, cancer, cardiovascular disorders, epilepsy, HIV/AIDS
Self-care is critical for health care professionals to have the strength and clarity to ________ for others.
Up to ____% of physicians and nearly ____% of 3rd year medical students report symptoms of burnout.*
_________ associated with poorer quality of care and lower quality of life.
Mindfulness may help with ...?
...stress management, emotion regulation, energy level, empathy, and ability to be fully present for both good and bad daily life experiences.
Burnout is defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment.
We are addicted to thinking—takes away vital energy that could be better used elsewhere.
Burnout and Quality of Care
Physician burnout has been associated with what 7 things?
1) Higher levels of depersonalization resulting in lower patient satisfaction
2) Longer post discharge recovery time
3) Increase in medical errors
4) Reduced standards for patient care
5) Increased physician and medical staff turnover rates
6) Workplace productivity and efficiency
7) Physician depression, exhaustion, substance abuse and suicidal ideation
Which physicians are the most burned out? (3)
Which are least? (3)
3) Physical Medicine and Rehabilitation
1) Public Health and Preventative Medicine
Self-Care for Students and Physicians
Mindfulness increases _____-______ and the ability to recognize how our own thoughts, feelings, perceptions may be impacting personal & professional _________
Dr. _____ _____(among others) states
"A key goal of mindfulness training is to help physicians stay connected with their patients and practice deliberately on a moment-to-moment basis."
Mindfulness and the Clinician
How can mindfulness help you be a better clinician? (7)
J CARE PQ
1) Be more Attentive—focus on patient needs
2) Have Compassion—for self and patient
3) Show Empathy—understanding others' feeling
4) Help build Rapport with patient
5) Improve Patient Compliance
6) Improve Quality of Care (decreased medical errors)
7) Suspend Judgement
Mindfulness-based stress reduction (MBSR)
1st and most popular; intensive 8-week program includes both formal and informal mindfulness practices & didactics
now used in both healthy populations and variety of clinical populations. It was first developed as an alternative treatment for difficult cases---refractory pain and anxiety treated in early MBSR.
Mindfulness-based cognitive therapy (MBCT)
8-week program aimed at treating depression, particularly relapse prevention
Similar to MBSR; varies in terms of mindfulness techniques
developed by experts in treatment of depression: John Teasdale, Mark Williams, and Zindel Segal (Dr. Kabat-Zinn). It is a manualized approach combining MBSR and CBT. Didactics include more on understanding depression.
Acceptance and commitment therapy (ACT)
Conducted individually; helps reduce avoidant coping styles
developed in late 1980s by Steven Hayes, Kelly Wilson, and Kirk Strohsal. Used in treatment of depression, OCD behaviors, psychosis, phobias, smoking cessation, and many more. Also used in healthy populations to deal with things like workplace stress. Applies acceptance & mindfulness strategies along with commitment to values and behavioral change strategies to increase psychological flexibility.
Dialectical behavior therapy (DBT)
Helps improve emotion regulation, distress tolerance, and ability to be mindful of others and their environment
developed by Marsha Linehan (1993) to treat Borderline Personality Disorder.
Currently adapted to a range of disorders including mood disorders, eating disorders, sexual trauma survivors, and patients exhibiting signs of suicidal & self-harm behavior. Elements of acceptance and change; teaches mindfulness skills geared toward balance & integration of opposing ideas.
Ways of intentionally pursuing Mindful Awareness
1) _____ ______ - systematic meditation practices that cultivate mindfulness skills (brief or intensive)
2) _____ ______ - application of mindfulness skills in everyday life; generalize what is learned in formal practice
1) formal practice
*sitting meditation, body scan, mindful yoga
2) informal practice
*mindful reading, mindful driving, a clinical encounter, grooming
Mindfulness techniques - Formal Practice (6) examples
1.Sitting Meditation (Breath-Counting) Meditation & Deep Breathing
Sitting meditation ?
Focus is on the breath. Tune into sensations of breath entering nose or mouth, or rise and fall of abdomen. Note sensory experiences as they arise--hearing, reactions (e.g. enjoying a thought, urge to scratch an itch), then bring attention back to breathing
Breath-counting: count each exhale; note when mind wanders then simply start over & return to counting exhales
Deep breathing: use of 4 senses
How does one practice deep breathing?
1) find a comfortable place
2) take a deep breathe through nose, hold for 2 sec, and exhale through mouth. Repeat this during the following steps
3) Take notice of what you can SEE around you
4) Take notice of what you can HEAR around you
5) Take notice of what you can SMELL/TASTE around you
6) Take notice of what you can FEEL around you
Focus is on ...?
Make a list and read aloud to see what feels right or ________
Common mantras: "one", "OM" (pronounced aum-traditional mantra)
How do you say a mantra?
Be aware of each ________ and bring attention back if mind ________
...a word, syllable, or phrase of choice repeated over and over
Say mantra silently or aloud
What does it help develop?
Increases body sensations to?
Usually practiced how?
Focuses attention SLOWLY and deliberately to where?
Notice what things ??? and then let them go
Helps develop mind-body connection
Increases bodily sensations related to stress, pain, and other forms discomfort
Usually practiced lying down with arms by sides, palms up, and legs hip-width apart
...on each part of the body from head-to-toe or vice versa
Notice sensations, emotions, thoughts, then let them go and return to exercise
Usually about 1 min between areas of body (30-45min) OR 10 min total
Mentally note what?
Pay attention to sensations of ..?
What's an alternative method to this?
What is the goal?
Focus is on the act of walking
Mentally note "lifting", "stepping", "placing" as they happen naturally
Pay attention to sensations in feet and lower legs
Alternative way is to count steps with breathing ("in...2...3, out...2...3)
Remember goal is not to get somewhere or exercise; it is to develop mindfulness
Pay attention to what?
Notice what things ?
Observe what process?
When does it work best?
Pay attention to each aspect of the eating experience
Notice colors, shapes, smells as well as intentions and desire to begin eating
Observe process of chewing and swallowing; silently label to help maintain focus or use non-dominant hand
Works best when eating alone
Mindful Yoga - what is it?
Practice on own requires what?
What does this practice do?
Practicing mindfulness skills while practicing yoga
Notice feelings, areas of tension, judgments, comparisons with others, etc. and gently let them go
Practice on own requires intention to be mindful while going through poses
Helps calm the mind, cultivate kindness for the body and awareness of the body's capabilities
5-3-1 Daily practice to reduce burnout
Mediate for 5 minutes.
Identify 3 good things that happened.
Do 1 act of kindness.
HIPAA or HIPPA?
What does it stand for ?
Health Insurance Portability and Accountability Act
In accordance with HIPAA:
1) Only access what information?
2) Only tell others what information?
1) info that you need to know to do your job
2) what they need to know to do their job.
"Carilion takes its obligation to protect patient privacy very seriously. We find out about patient privacy concerns in two primary ways. Individuals may raise specific concerns, or Carilion may proactively monitor a high-profile patient's medical record.
In the wake of a recent high profile event in our region, we learned that 14 employees accessed patient medical records without a legitimate patient-care need. Based on the findings of our internal investigation, appropriate actions have been taken with each employee, up to and including termination. Eleven of the employees were based in the New River Valley, while three were based in Roanoke."
Students are part of the problem with Confidentiality
One study found that _______% of US medical schools "reported incidents of students posting unprofessional content online"
______% of the incidents involved violations of patient confidentiality
About ______% of posting violated HIPAA
What is the ultimate goal with HIPAA training ?
No HIPAA violations - ever
Introduced by? why?
When was it enacted?
Required Congress to pass regulations by when?
Who was to develop regulations if Congress did not?
Senators Kennedy and Kassebaum to:
• need standards to protect the privacy of patient records and
• streamlining of billing and reimbursement processes
August 21, 1996
August 21, 1999
Department of Health and Human Services
HIPAA History Cont.
Did congress act?
When was HIPAA effective?
When was it implemented?
April 14, 2001
April 14, 2003
(2 years to integrate the law into their system)
Title II - Preventing Healthcare Fraud and Abuse, Administrative Simplification, and Medical Liabillity Reform
What were the 3 administrative simplification that were noted as the issues?
_____________ - PHI is not available or disclosed to unauthorized persons or processes
_____________ - PHI is not altered or destroyed in an unauthorized manner
_____________ - PHI is accessible and usable upon demand by an authorized person
"A major goal of the Privacy Rule is to assure that individuals' health information is properly _________ while allowing the flow of health information needed to _______ and ______ high quality health care and to protect the public's health and ______ ______"
Summarize into 3 points
Protected; Promote and Provide; well being
1) individuals health info is properly protected
2) we need flow of info to provide quality health care
3) need to protect the public's well-being
What is affected by the Privacy Rule?
Does format matter?
• Any identifiable health information • Protected health information (PHI)
• Any format - doesn't matter if electronic, oral, or paper or other
What is "individually identifiable information (or PHI)?
• information, including demographic data that relates to an individuals:
past, present or future physical or mental condition;
provision of care;
past, present or future payment for health care;
OR for which there is reasonable basis to believe can be used to identify the
What are examples of PHI?
• Treatment plans
What are the two groups that are held to the standards and are covered by HIPAA?
1) Covered entities - the healthcare providers
2) Business Associates - provide services to healthcare providers
Privacy Rule Principle
When can one disclose protected health information (PHI)?
What is it a good idea to do to make sure that you don't get in trouble for sharing PHI?
• As Privacy Rule Permits
• As Authorized by patient or patient's representative
get authorization in WRITING
What are the appropriate disclosure that the Privacy Rule Permits? (5)
• Patient or authorized representative
• Other health care providers involved in treatment/referral
• Obtain reimbursement
• Health care entities for operations (Quality assurance and case management, Credentialing and accreditation,Training of student and residents).
• Informally if individual has opportunity to agree or object (Facility directories and Family members)
Privacy Rule Requirements - one must disclose PHI when? (12)
HRT GLOW PADDLe
• As required by law (statute, regulation, court order)
• Public health activities
• Victims of abuse, neglect or domestic violence
• Health oversight activities
• Judicial and administrative hearings
• Law enforcement purposes
• Decedents (funeral directors, coroners)
• Organ, eye, tissue donation
• Serious threat to health or safety
• Essential government functions
• Workers' Compensation (as required by law)
What does the Privacy Rule Prohibit?
the disclosure of PHI except as defined in the Privacy Rule or authorized in writing by the individual or his/her representative.
HIPAA is a floor and not a ceiling, so one should also be cautious of the _______'s more restrictive privacy laws if applicable
Covered Entity Responsibilities
• Disclose ________ necessary to complete the task
Covered entities protect PHI by:
• _______ policies and procedures
• Designated privacy _______
• Annual education
• Business Associate ________ with covered entities
• Reasonable efforts to protect PHI: (6?)
What can one provide each patient with for this?
• Limiting access to electronic records
• Auditing those who access electronic records
• Shredding of documents
• Conducting audits and surveys of physical security of PHI.
• Fax cover sheets
a "Notice of Privacy Practices"
Inspect and obtain copies of _____ ______.
_______ information the patient believes is incorrect subject to organizational
Accounting of disclosures other than for treatment, payment or healthcare operations.
• What are the reports required by state and federal laws ?
• funeral homes
• communicable diseases
• vital statistics
Patient Rights Cont.
• To request restrictions on what information is provided to others - exception ???
• To request that confidential communications are provided by a particular
means or location - exception ???
if patient pays cash then information cannot be released to the insurance company.
Exceptions to Patient Rights
• Copies may be denied if likely to endanger the ______ or ______ _____ of the individual or another person.
• Amendments may be ______
life; Physical Safety
If a patient's amendment was denied, what must be in writing about the denial? (2)
• The reason for the denial
• Directions for filing a complaint
What else do covered entities do?
They discipline those who violate policy via? (4)
• Oral warning with retraining
• Written warning with more retraining
• Referral to law enforcement
What can the government do regarding disciplining due to HIPAA violation?
• ________ (minor things)
- $100 per incident not to exceed $25,000 for identical violations per year
• ________ (major things)
- Up to $___________ and 1 year for knowingly and improperly obtaining or disclosing PHI
- Up to $__________ and _____ years if the offense is committed under false pretenses
- Up to $__________ and _____ years for obtaining or disclosing PHI with the intention to sell it or use it for malicious purposes.
DO NOT Recommendations:
• Access PHI for which you have no legitimate ________ to access.
• Discuss PHI in ________ places such as elevators, bathrooms, lobbies, etc.
• Share or use someone else's ________.
• Store PHI on your _______ unless approved by covered entity.
DO NOT Recommendations: (cont.)
• Throw PHI in _______ trash cans.
• Leave PHI in a place that can be accessed or seen by the ______
• Use _______ ______ to discuss patient information. (hint - internet)
• Access what records in personal connections?
regular (there are special ones with locks for this)
your records or those of your family members or friends (a lot of hospitals have rules to not let you look at your own records, even though it is not a violation of HIPAA)
• Access records for which you have a ________ need.
• Share PHI with who?
• Discuss PHI in _______ places.
• Verify that you can share _______ with someone, such as a family member, by asking the patient or by reviewing their written _______ or asking for the password/code assigned by the covered entity if there is one.
• Follow all the covered entities IT policies and procedures.
those who need to know.
A covered entity (i.e. physician/student) may not use or disclose PHI, unless? (2)
1) the Privacy Rule permits or requires
2) the individual who is the subject of the information (or the individual's personal representative) authorizes in writing.
Secrecy; the state of having the dissemination of certain information restricted
Ethical Duty as a student/physician?
Hippocratic oath and osteopathic oath both say to respect patient confidentiality
AMA Code of Ethics also says a physicians may not reveal the confidences entrusted to him of medical attendacne unless he is required by law or if necessary to protect the individaul's or the community's welfare
So, HONOR PRINCIPLE OF AUTONOMY and confidentiality tied to it
What are the 8 reasons for maintaining confidentiality ?
1) Shows respect for patients.
2) Patients want to control access to sensitive information
3) Patients expect physicians to maintain confidentiality.
4) Encourages people to seek medical care
5) Encourages patients to discuss issues
6) Complete information results in better treatment
7) Prevents discrimination and stigmatization.
8) Health care providers liable for breaches
What about Waivers of Confidentiality?
• Waivers of Confidentiality DO NOT grant ________ permission
• What are the 3 Waivers that address using PHI ?
(these tend to be in order to provide specific info)
-Care and treatment
-Health care operations
When must confidentiality be breached in accordance to HIPAA? (the 3 focused on)
1) As required by law (statue, regulation, court order)
2) Victims of abuse, neglect or domestic violence
3) Serious threat to health or safety
• Public health activities
• Health oversight activities
• Judicial and administrative proceedings
• Law enforcement purposes.
• Decedents (funeral directors, coroners)
• Organ, eye and tissue donation
• Essential government functions
• Workers' Compensation (as required by law)
Confidentialities may need to be breached to do what 2 things?
Protect third-parties from violence
To protect others from the spread of disease
Tarasoff v. Regents of the University of California (1969)
• Therapist determines "boyfriend" will harm her
• Therapist and two colleagues decide to commit patient
• UC attorney warns Tarasoff cannot be informed
• Boyfriend could not be in held for treatment and Tatiana Tarasoff killed 10/27/1969
Confidentiality may be breached when ALL of the following conditions are met: (6)
1) "Potential harm to identifiable third parties is serious.
2) The likelihood of harm is high.
3) No less invasive alternative means for warning or protecting those at risk.
4) Individual at risk can take steps to avoid harm.
5) Harm to the patient is minimized and acceptable.
6) Disclosure should be limited to information essential to the intended purpose, and only those persons who need to know should receive information.
When MUST confidentiality be breached?
• Infectious diseases -Lyme disease, tuberculosis, MRSA, HIV and gonorrhea to the health department.
• Conditions that impair driving - epilepsy
• Injuries caused by weapons or crime
When do you have to breach confidentiality?
• ______ states - suspected child abuse or neglect
• ______ states - suspected elder neglect
• ______ states - suspected domestic violence to the appropriate agency.
• ______ states, -to report impaired health care providers.
What are the 3 purposes of having a medical record?
• Enhance patient well-being
• Provide quality care
• Justify payment for services provided
What things are documented in the medical record that are important? (5) *note there are more noted in the NCQA
1) Significant illnesses and medical conditions
2) Medication allergies, adverse reactions
3) Past medical history: serious accidents, operations and illnesses
4) Working diagnosis
5) Treatment plans
What are the 3 risks to omitting information?
Is omitting information always possible?
1) May compromise CARE
2) Important clinical information will not be available in an EMERGENCY.
3) Appropriate documentation is required for REIMBURSEMENT
In many organizations testing/results can only be ordered/received by computer so omitting potentially sensitive information is not possible.
For some patients, a breach of confidentiality is more ______ than bad care, and this is why they don't want all info on a medical record.
Many patients choose to withhold what kind of information?
What information should they not withhold?
Information regarding INACTIVE problems
Information regarding ACTIVE problems
Middle Ground for not wanting a medical record
• Exclude historical information not _______
• Keep separate secure _____ with the other information
• Patient should put what 3 things on the medical record?
• Joint decision and should _____ by patient to not share
• Treatments and medications
• Information related to current treatment
What are the 5 requirements for consent for release of information?
1) Written, signed and dated by the requestor
5) Right to revoke
GINA stands for ?
Genetic Information Nondiscrimination Act (est. 2008)
GINA - encompasses what types of genetic information?
"Information about an individual's genetic tests;
Information about the genetic test of a family member;
Family medical history;
Requests for and receipt of genetic services by an individual or a family member; and
Genetic information about a fetus carried by an individual or family member or of an embryo legally held by an individual or family member using assisted reproductive technology."
What 2 things does GINA prohibit?
1) Using genetic information for:
- Employment decisions such as hiring , firing, promotion, job duties, etc
2) Employer acquisition of genetic information
- i.e. Family medical history during employment medical exam
When does GINA allow sharing of genetic information? (6)
• Employee or family member with written request
• Research compliant with federal regulations
• Court order
• Government agents investigating GINA compliance
• Certification for Family and Medical Leave Act/state leave laws
• Public health agency for contagious diseases threatening public health
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