PublIc health

 Types of medical errors :

 Preventable medical errors : error involve the harm of patient by act of
commission or omission rather than the underlying disease → results of failure
to follow evidence based best practice guidelines. (e.g. missed hypothyroidism as a
cause of depression)
 Non preventable medical error : medical error that cannot prevented by
giving the curret state of medical knowledge e.g. allergy from a drug.
 Near miss : medical error that is recognized before any harm is done to the
patient (e.g. medical error but caught by pharmacist)
 Sentinel event : unexpected occurrence involving death or serious physical or
psychological injury (e.g. inpatient suicide) … require immediate investigation

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  Malpractice: it is a legal term not medical error, occur when lower than
standard of care medication given to the patient. (it is not a category of medical
error)

Biostatistics
 Mortality

 Case fatality rate: can be used as measure of severity of the disease. Calculated as
proportion fatal cases / total number of cases (fatal / all)
 Calculating probability:
- Independent event probability of getting all same result = multiply
- While probability of at least 1 event different = 1 – P
- Probability of getting 3 heads in row → 0.5 X 0.5 X 0.5 = 0.125 , the probability
that at least on of them is tail = 1 – 0.125
 What is meant by attack rate in case of outbreak investigation
- Number become ill / total number exposed to this risk
 How to calculate cumulative incidence:
- Total number of new cases of a disease over specific period divided by
number of people at risk (number of already diseased are not
included) at the beginning of the period
- N.B.  deaths are not considered under any cause (they are already included in
people at risk)
- N.B2  Time is not incorporated at the denominator, unlike incidence
 Incidence: number of new cases / population at risk over a period of time
Prevalence: point prevalence as opposed to period prevelance
Prevalence = incidence X duration of disease
 ↑↑ survival from a disease will ↑↑ prevelance with no effect on
incidence

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 Meaning of RRR → e.g. RRR = 50% means that a drug ↓↓ the incidence of disease
from 50% to 25%
 How to calculate NNT (number needed to treat):
 Number of patients needed to be treated to prevent an additional adverse event
 We use absolute risk reduction
 NNT= 1/ ARR
 The ideal NNT is 1 → all patients in treatment group will benefit from the
treatment , so NNT the lower, the better
 What is the meaning of odds ratio and How to calculate it ∷
 Odds of event = probability (not ratio) of the event happening / probability of
event not happening
 Used in case control studies, with outcome occurring based on exposure status.
 First do 2 X 2 table and take care
 ‫ = الطول‬outcome ‫ = العرض‬exposure

A B
C D
 Take care of the site of letters
 Calculate odds (probability) of event to occur → a/b (not a / (a+b)
 Odds of event not to occur → c / d
 For simplification  odds ratio = AD / BC
 When odds < 1 → risk of developing adverse effect is lesser in exposure than non
exposure
 How to calculate NNH (number needed to harm):
 Number of patients needed to be treated before an additional adverse event
occurs

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  Simply, we use absolute risk increase (attributable risk)
 To calculate absolute risk increase → you must calculate the absolute event rate in
both groups (number of adverse event / total number treated), and subtract both
numbers
 NNH = 1 / absolute risk increase (if NNH = 40, so we need to treat 40 patient
before we see additionl one adverse effect)

 How to calculate attributable risk percentage in the exposed (ARP exposed):

- It represents the excess risk in exposed population that can be explained by
exposure to the risk factor.
- ARPexposed = 100 X [(RR-1) / RR] = 100 X [(risk in
exposed – risk in unexposed) / risk in exposed]
- ARPexposed is related to the attributable risk (AR) which is simply the difference
between risk in the exposed and risk in the unexposed
 Measurement of central tendency
- Mean → average
- Median → order the set choose the number that divide the set into 2 equal
numbers
- Mode → the most frequent one, resistant to outliers
 Skewed distribution:
Always the median is in the middle
- positive skewed: mode < median < mean
- negative skewed: mode > median > mean
 Statistical significance tests:
- First determine the null value e.g. RR = 1.0

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 - If 95% CI contain null value → so P-value > 0.005 → statistical
insignificance
- If 95% CI Don’t contain null value → P-value < 0.005 → statistical significance
 Ecological study: when the frequency of a given character and outcome are studied
using population data not individual data, these studies geerate hypothesis
and associations but unable to make conclusions regarding individuals (ecological
fallacy)
 Cross over study:
- the patients serve as their own controls
- Cons: effects of onettt may carry oer and alter the effect o fthe subsequent
treatment → so washout phase with no drug is advised and it is long
enough

 Difference between case-control study & retrospective cohort study:

 Case (diseased) control (non diseased) recruitment not recruit about risk
stratification which is cohort, so first of all select subject according to disease not
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 risk exposure, also cases and controls are matched, the subject selection don’t
depend on exposure

 How to calculate the ris & relative risk:

- Risk: probability of developing a disease over the study period → number of
diseased / total number of subjects in the same group
- Relative risk: comparing the risks between 2 groups → risk among diseases /
risk among control
 rate of increase of disease :Number of new cases per year – (death / cure)
divided by total population

Choosing statistical test


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 Chi-square test:
- Need two categorical variables (both dependent and independent)
 Analysis of Variance (ANOVA):
- Used to compare ≥ 2groups of quantitative variables (by comparing means in
them)
 Importance of two sample t-test:
- Used if the dependent variable is quantitative one (≥ 2 population → use ANOVA)
- Used to determine if the means of 2 populations are equal or not
- The basic requirements → mean values, sample variances, sample sizes
- Calculate t statistic → P-value if <0.005 → reject the null hypothesis and the two
means are from different populations, and the 2 means are statistically significant

 Accumulation effect: it means that effect of exposure to risk factors or risk

reductions depend on the duration, intensity of the exposure so long term exposure
may be necessary before effect appear, this is relevant with antioxidant use,
smoking in lung cancer
 Describe confounders and how to overcome its occurance:
- Confounders: when there is perceived association between an exposure and
outcome explained by confounding variable associated with both.
- The best decision is matching, during study design enumerate all confounders and
stratify the patients according to, or choose cases & control matched together by
same confounders.

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 Effect modification:
- effect modification appear when external variable affect the previous
association when stratified against(outcome is modified by another variable), so
effect modifier; initially there is association and after stratification there is
also difference measures of association either positive or negative

 Difference between confounders and effect modification:

- So confounders and effect modifiers can be easily differentiated by
effect of stratification, in confounders → no association after
association, effect modifiers → modify the association
 Different types of bias:

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- Recall bias: result from inaccurate recall of past exposure; mostly occur in
retrospective studies (as case control study). this bias type is reduced by
prospective studies
- Observer bias (expectancy bias):
o occur when the investigator (observer) misclassify data due to preconceived
expectations or prior knowledge about the study
o this important when the outcomes are subjective (radio, patho
interpretation)
o this bias can be reduced by blinded study in which the observers are
unaware of study details, and multiple observers encode and verify the
recorded data
- Observer bias effect (Hawthorne effect): tendency of the study subjects to
change his behavior as a result of awareness that they are being studied, common
in behavioral outcomes / changes → affect the validity of the study
o Study subjects can be kept unaware that they are being studied, but this can
occasionally pose ethical problems
- Lead time bias: should be considered when evaluating any screening test.
o Lead time → time between initial detection of the disase and specific
outcome / end-point
o Lead time bias is apparent ↑↑ in survival time among patients undergoing
screening when they actually have unchanged prognosis, this only occur
because The diseases is detected earlier
o To detect the effectiveness, you should follow up the patients for longer
periods than the apparent ↑↑ in survival an compare mortality.

- Attrition bias (form of selection bias): occur in prospective studies, when

there are 2 groups. With loss to follow up mainly occur in one group lead to
affection of the results between the 2 groups. When the lost patient occur
randomly (occur relatively ) in the 2 groups, no bias formed

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 What is the difference between sample mean & population mean, how to calculate
variance in both:
- When applying rules of normal distribution curve, mean is the average of results
of the sample, while SD is the distribution of results around that mean
- When 95% lies between ± 1.96 SD → I mean that 95% of result lies between
(mean± 1.96 * SD)

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 - But this rule cannot be applied on distribution of the population, as the sample
mean is different from the true population mean (the variability between
sample means)
- So how to calculate variability around the unknown true population mean?? It is
by usage of standard error (SE) =
SD/√n (n is size of sample)
e.g. (sample mean ± 2 * SE) means
that I am sure by 95% that the true
population mean lies at this range
→ meaning of confidence interval
- So confidence interval of mean =
mean ± [z-score] * SE (SD/√n)
- Sample size (n), SD of the sample
determines the magnitude of
variability due to sampling. So ↑↑
sample size → narrower & precise
CI, ↑↑ SD → ↑↑ SE → wider CI
 Remember that above 2 SD → there
is only 2.5% of sample size, while 5%
are lie outside the 2 SD

 Sensitivity & specificity:

 The above mentioned curve can
measure sensitivity & specificity but
cannot measure predictive values as
it depend on the prevalence
 They are intrinsic test parameters
and don’t depend on population or
prevalence
 Screening test must have high
sensitivity
 Specificity must be high in
confirmatory testing
 Highly sensitive test → “if
negative∷ no disease∷ rule out
diagnosis” so very low False
negative, so high ability to ability to identify those who are diseased [TP /
(TP+FN)]
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  Highly specific test → “if positive∷ have the disease∷ rule in diagnosis”
so very high true negative & low false positive [TN / (TN+FP)]
 PPV & NPV:
 Predictive values are depend on specificity, sensitivity and also prevalence (as
the PPV depend on the population, and how the test affect the population)
 ↑↑ prevalence of the disease (pretest probability) → ↑↑PPV & ↓↓ NPV
 PPV → it answer the following question; if the test is positive, how many patient
of them have the disease, it affected by prevalence & pretest probability of the
disease
 Predictive values are of rime important to physicians because patients more often
present with positive /negative tests rather than defined diseases

 Type I, Type II errors:

- α value typically = 0.05, it is the P-value, not directly affected by sample size
- β value related to study power (power = 1 - β):
o ↑↑ sample size → ↑↑ study power (ability of the study to detect difference
when there is true difference)
o ↓↓ sample size → ↓↓ power → ↑↑ β → type II error

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 Reliability & accuracy:
- PRrecision (Reliabilty) → Repeat exam show the same results (Reproductive)
- Accuracy (Validity) → if compare to the gold standard test, it have equivalent
result (measure what is supposed to measure)
- Poor accuracy or prescision can limit (low) the specificity and sensitivity of the
tests if results from health and diseased are so close

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 Ethics
 Patient confidentiality must be respected at all levels, in medical and non-medical
situations, with colleagues or not, even telling your colleague that someone is your
patient. If you want to talk with another doctor in the hospital, make sure that you
use private area (even in the hospital)
 Physicians should always provide the life threatening therapy to minor in emergency
regardless of parents’ wishes
 Effective discharge planning:
- During hospitalization, social worker can contact the involved family members
and assess whether there are any social factors affecting the patient’s ability to
return home and develop strategy for effective discharge
- It needs the interdisciplinary collaboration among the social workers, nurse, and
physician.
- You should take into account the cognitive status, activity, family support
 What is the best communication model developed in medical practice:
- Communication error (vague, unclear commands) are one of the most common
factors involved in malpractice claims of medical errors\
- The best approach is closed loop communication → the doctor transmit the
message to nurse, the nurse should repeat the message again in clear sentnces,
the doctor should confirm with yes
 Certification of disability:
- Disability is insurance with financial support, certification of disability must be
signed by the physician before the benefit is granted
- Take care of possible malingering, exaggeration to obtain benefits
- You must take detailed History, examination, testing to assess the
condition and don’t depend on the previously signed one

 Assessment of decision-making capacity of the patient:

- If the patient refuse treatment from life threatening condition, assess the
patient’s capacity to make her own decisions → if it is good → respect

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 How to deal with patient in acute intoxication:
- patient autonomy for deciding treatment & management must be in a decision
making capacity → i.e. patient must communicate a choice, understand
information given, appreciate consequences.
- Intoxicated patients or blunted patients have temporarily lack capacity so
1) Never let the patient leave the ED as it may endanger his life
2) Keep the patient and reassess him when he is clinically sober as reassess his
descicion making capacity
3) After the patient gain the capacity, if he refuse the treatment → discharge the
patient
 Release of medical information:
- HIPAA state that release of medical info must be done only after verbal or
(better) written authorization for relase of information the family member.
- This authorization must be privately discussed, preferred to be written.
- If the patient is incapacitated (ori ED situation); only basic information can be
shared (like; the patient is stable now)
 How to reduce the “wrong site surgery” error:
- Causes by failure to mark the site, emergency operations, poor communication,
surgeon fatigue
- To reduce this most frequent error → marking the operative site,
independent verification
- Independent verification of the patient, site, procedure mustbe done independely
by 2 HCW, also use of surgical timeout is important
 It is the patient right to refuse receive diagnostic information and must be
respected by the doctor, the physician must communicate with the patient why he
ask this
 What is the appropriate decision if there is medical error occur (regardless
presence of harm)
- Full disclosure of the medical error should occur in timely manner → associated
with neutral - positive effect on patient relationship

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 - The disclosure should include apology for what occurred
 Discharge checklist:
- Transition from the hospital to outpatient is high risk for the patients, so the
most effective strategy for decreasing the adverse outcome and avoid
readmission in discharge checklist
- It is different from discharge summary which is written by the hospital and
directed to other outpatient physician and written in difficult technical language
- Discharge list should e written in appropriate language and take patient education
and literacy into account, it huld include:
1) Detailed instructions about medications
2) Follow up appointments
3) Any medication changes
 Advance directive:
- Advance care planning should begin by conversation between the physician and
patient in outpatient care
- As a part of admission process (either emergency / ward) → hospital should
inquire about the advance directive in the event that the patient become unable to
make decisions
- Advance directive are consists of : living will: patient’s end of life wishes about
resuscitation, intubation … etc. health care proxy: allow the patient to
designate individual to take the decisions according to living will
 Sequence of patients’ informed consent / making medical decisions:
1) The best, is from patient himself
2) Advance directives, health care proxy
3) Family member (act as surrogate decision maker)
4) If no family member, person who care about and knows the patients’ wishes → if
there is struggle between family member → ethical committee → last resort, court
 All adolescent visits should include an opportunity to interview the patient alone to
discuss topics such as drugs, alcohol, tobacco and sexual activity
 If you suspect child abuse, take History with open ended questions then ask
specific questions, the next step usually to interview the child alone and properly
examine him and take detailed history … if suspect abuse call child protective
services immediately

 How to deal with recurrent same medical error:

- The best approach is root cause analysis → to identify what, how, ehy an
undesirable outcome occurred

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 - The first step usually to collect data by interviewing multiple staff members about
the events → after gathering informations, key solution may be important after
determine the cause
 Transcription errors are preventive medical error, largely reduced by educations to
reduce use of abbreviations and avoid trailing zero e.g. use “2 mg not 2.0 mg”
 What is the proper response to history of sexual abuse:
- 2 things must occur simultaneously, empathy and support
- First, acknowledge the sexual abuse (this help the patient fell that she is
understood better)
- Second; gently ask the patient if she would like to discuss it further (if the patient
not ready to discuss that → convey willingness to discuss it when the patient is
ready)
 What is the proper managemt of an emergency case with NO money:
- According to Law EMTALA, three primary requirements in hospitals that provide
emergency services.
1) Provide appropriate screening medical exam to anyone who comes to ED
seeking medical care
2) Stabilize & treat the emergency situation
3) Not transfer an individual with emergency medical condition that has not been
stabilized
 Medical history taking, should start wiith open ended questions that make the
patient answer and describe the condition in his own word without any interference
from the doctor
 Types of prevention in heath
care:
- Health promotion → Process
of enabling people to ↑↑
control over their health and
its determinants, it is type of
primary prevention
 Never be judgmental when
taking with patient, always show
empathy, acknowledge, maintain
confidentiality and autonomy

 Taking sexual history:

- Physicians should obtain sexual history during patients’ initial visit, routine
preventive screen and any suspected STI.
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 - Maintain neutral, open, non judgmental discussion and try to put the patient at
ease when talking about sexual history
- Don’t leave anything for assumptions even sexual partner, remember be neutral
and direct
 Intimate partner violence (IPV):
- Many women don’t seek medical assisstanc ein case of IPV due to feeling of
shame, fear of partner retaliation, no alternative … etc.
- Best approach of these victims is supportive, open ended inquiry,
identification of safety plans ,
- Physicians should not confront the patient in direct way instead you must assess
immediate and future safety of all patients

 Hospital ethical committee → only consulted when the clinician is confronted

with ethically difficult situation
 Parent’s wish when against the child best interest → the physician should discuss
with the parent’s the consequences, court order may be needed or involvement of
child protection agency
 About accepting gifts:
- It is unethical to accept gifts of significant monetary value , so many
hospitals implement no-gift rule or 10$ or less.
- Expensive gifts may influence the physician’s professional judgment
- Accepting low monetary value gi→ appropriate
 How to deliver bad news:

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 Contact precautions with infectious diseases:
- Standard precautions (for all patients) → handwashing, proper disposal +
- Suspected C.difficile  handwashing by soap & water as alcohol don’t kill
the spores
- Contaminated secretions  gown for any patient contact, non-sterile gloves
- Dedicated devices as BP cuff …
- Simple facemask → for infections transpmitted by droplets >5μ for 6 – 10 ft.

 Difference between physician fatigue and burnout

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 - Burnout → emotional exhaustion, ↓↓ sense of personal accomplishment which
lead to medical errors, but here errors result from lack of concern and callousness
toward patients
- Fatigue → sleep deprivation which may lead to forgetting do job.
o ≥ 17 hours of wakefulness, impairment of cognitive performance as those
who are seen in alcohol intoxication
 Dealing with low level literate patient:
- These patients always have lower quality of medical care, as they fail to
understand both written & spoken language and medical device.
- Detecting those patients is difficult as they are always ashame, should be very
suspicious
- The physician should have alternative modes of learning those
patients like videos or drawing is the best ones
 Normal stages of grief in terminal illness:
- not all patients will pass thorugh all of them
- if denial is significant (interfere with care) → should be confronted

 what are the leading causes of death in adolescents:

1) accidents
2) homicides
3) suicide
 assessment of medication-related falls in elderly:
- the most modifiable risk factors for falls is review of medications , remove any
drug which is no longer be necessary
- also review any new drugs. Other factors reduce risk of falls in adults; exercise ,
balance and gait training are helpfl
 Calling the patient by his first / surname:
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 - to build good relationships with the patients → first impressions are important
- initially, asking the patients for their preferred names at the initial
encounters
- especially in older patients, call them y their surnae & addressed by Ms. / Mr. to
show respect
- by time, after building strong relationship; many patients will prefer to be
addressed by their frst name. however it is always the patient who must
take the lead to lower level of formality.
 What are the requirements of hospice care:
- The physician must substantiate a prognosis of ≤ 6 months with documentation of
irreversible decline in clinical and functional status

 Reporting impaired colleagues:

- We are ethically, legally obligated to report impaired colleagues in a timely
manner.
- Most hospitals and state medical boards have regulations require physicans to
report impaired colleagues, usually done anonymously.
- If there is any impairment physicians in non emergency situation (not in
night shift) → contact physician health program, if not possible / not exist
call state licensing board and they are responsible to gather all facts and
arrange for assessment
- If there is any impairment physicians in emergency situation (on night shift)
→ you are obligated to report immediately, contact the immediate supervisor
 What is the best intervention to reduce mortality in diabetic patient:
- Smoking is the single most preventable cause of death & disease in US (in almost
all patients)
- Risk of MI-associated mortality is reduced immediately after smoking cessation,
but it may take years to return to its baseline
 Patient hand-off / sign-out ‫تسليم النباطشيات‬
- Patients are at higher risk of adverse outcomes when physicians don’t
communicate well during transitions.
- Communication failure during hand-off process→ adverse effects

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 - To reduce these risks, structured handoffs that include key elements have been
shown to reduce adverse effects
- Key element e.g. systemic procedure for sign-out, checklists of tasks that need to
be completed, standardization approach, don’t overwhelm with many details
rather be systematic
 Developmental mile stones in toddlers:

 What are circumstances in which minors (<18 y) can provide their own consent

 The first principle in medical practice;

first, do not harm, before prescribing
any treatment or procedure, the
advantages must outweight the risks

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 What is the proper response in the following situation:
“if one’s physician disagree with another’s practices & physicians”
- If the practice within the standard of care → never criticize the physician in
front of the patient
- If the practice is grossly negligent or treatment far outside the standard
of care (dangerous)→ the doctor should be criticized
- Privately discuss the patient with the referring physician to understand the
reason for his medications and explain the change

“non adherent to anti diabetic management as she feels good”

- Always begin by acknowledging that it is difficult to take medications daily for a
silent disease (normalizing her difficutly of non-adherence)
- Then, start open ended exploration about the reasons of her non-adherence
- Then followed by non-judgmental exploration of the patient’s understanding
of illness
- Never criticize the patient behavior or knowledge

“please, don’t tell my father about his cancer diagnosis”

- Every patient have the right to refuse receival of medical information as well as
he is intact
- Certain cultures view that withholding medical information is
appropriate (with beneficence > autonomy)
- The physician rule is to respect these cultural beliefs about the patient, but
emphasis is paced on family making health care decisions for the patient
alone as well as he is competent

“adolescent don’t take his insulin regularly”

- Adolescence involve developmental separation form parental figures to find one’s
society and taking responsibilities for ones health
- Factors associated with better treatment adherence → close peers with
complementary behavioral practices, positive family functioning, physician
empathy
- These changes occur in adolescence may be due to immaturation of prefrontal
cortex which is completely developed at 3rd decade of life, so they less able to
weigh risks & benefits of their decisions

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 “ senior attending order a wrong drug to the patient”
- As art of education process it is essential to understand the clinical
reasoning behind the team member decisions, as it is the best interest for
both junior & senior staff
- So respectfully discuss the issue directly and ask why the decision
was made, don’t order the medication until you ask him

“I need more pain medication”

- First, revise his previous prescriptions using state based online prescription drug
monitoring programs , it will clarify which drugs, by whom and any suspected
abuse will appear
- The most appropriate actions are to validate the patient’s concern about pain
control, engage in non-judgmental & collaborative discussion of how he is
using medication

“non-English speaking patient and need informed consent”

- The best is providing medically trained interpreters, they are trained and know
medical terms and can easily explain the procedure to the patients.
- Begin by screening test to assess language proficiency; “how well do you spek
English∷ not at all, not well, well, very well” → language interprter is
needed when the answer is not well or no answer
- Using bilingual friend or family member is inappropriate as it will break the
confidentiality and they are generally not trained and not knowing the medical
terms

“The patient is deaf”

- Just like limited English proficiency, deaf patients require either American sign
language fluent provider or qualified sign language interpreter, if not available,
remote video interpreting services should be offered
- If urgent situation need communication, use any communication available
including family, drawing and writing

“the intern should take informed consent about procedure he didn’t know about”
- Informed consent is not a paper needed to be signed, it is a dialogue between the
provider and patient about the procedure
- The doctor must inform the patient about risk, benefits, alternative treatment
- The ideal physician who take informed consent is the one who will do the
procedure

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 “you are an attractive doctor, I wish to go for date with you”
- Romantic and sexual relationships with current patients are always unethical
due to potential interference with the physician role as a doctor
- Romantic relationships between doctors (non-psychiatrists)– patients (after
termination the doctor patient relationship) may be acceptable, but it is
not the role

“I use weight loss herbal preparations, they are good”

- Although FDA regulate the use of herbal medications, they contain toxic
ingredients that may cause adverse effects and dangerous drug interactions
- The patient should be counseled regarding the risks of using unregulated
supplements and by the help of physician they should prepare plan for safer
behavior to lose weight

“different religion, but pray for me in the OR”

- You as a doctor should respect the beliefs of your patient even it is totally different
from yours
- In the interests of doing no harm, the physician should agree at least in a generic
sense, to keep the patient in their thoughts / prayers
- In non-emergency cases, chaplain is a very crucial person for religious
patients especially in advnce directive & DNR orders

“I always skip the dose of cortisol, double the dose as needed”

- Patient misunderstanding of medication use can resut in medication error and in
serious cases can lead to toxicity
- The physician should educate this patient about the risk associated
with irregular dosing (not only write the dose)

“terminate the pregnancy as soon as possible”

- Physicians are not required to provide medical services that are against their
personal / moral beliefs
- First, establish patient-physician relationship, start neutral non judgmental
discussion with the patients and alternatives.
- Second, if the patient insists, the physician should respect patient autonomy and
he is obligated to refer the patient to another service provider.

“write an antibiotic to me, i am your friend”

- Treatment of friends and family should be limited to emergency situations
when no other physician is available

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 - Before helping your friend, consider ethical issues. There are potential problems
that results from inadequate assessment.

“I need antibiotic for my common cold”

- This problem of prescribing un-necessary antibiotic is common
- The best approach is (patient centered approach) → educate the patient
about the adverse effects of antibiotics and lack of efficacy and provide another
options for treating the conditions, this should be done with empathic, non-
judgmental fashion

“I want my fallopian tubes get ligated”

- Every individual has autonomy over his body including reproductive organs
- Although, the physician should encourage the patient to discuss the decision
with her husband, his consent is useless.
- So consent must be taken from the patient alone after discussing with her the
different options

Some points about insurance :

 Each person should have monthly premium (‫ )قسط شهري‬to cover the insurance
plans, but expenditures are usually higher than those premium 
 So health insurance try to ↓↓ expenditures to be lower than premiums by 1)
patient share of cost for the services they receive (copayment, deductibles) 2)
limiting range of services the patient receive
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 Health maintenance organization (HMO) plan:
o Low monthly premium, low copayments, low cost for the patients ‫تأمين صحي‬
‫مصري اصيل‬
o It reduce utilisations by some conditions:
1) Confiding patients to a limited panel of providers (cannot go outside it)
2) Specialized consultation need referral from primary care provider
3) Any service don’t meet EBM → denied by health insurance

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