Navigate Like a Pro
A 58-year-old male with no significant medical history presents for a health maintenance visit. He asks about prostate cancer screening. According to USPSTF guidelines, which approach best demonstrates appropriate shared decision-making for PSA screening?
A) Recommend against PSA screening due to potential harms outweighing benefits
B) Order PSA screening as part of routine preventive care for all men this age
C) Discuss individual risk factors, potential benefits and harms, and elicit patient preferences before deciding
D) Defer the decision to a urologist
E) Screen only if the patient has a family history of prostate cancer
Answer: C
Rationale: PSA screening is a USPSTF Grade C recommendation for men aged 55-69, meaning the net benefit is small and the decision should be individualized through shared decision-making that incorporates patient values and preferences.
You are analyzing colorectal cancer screening rates in your clinic's patient population. Your registry shows 800 patients aged 50-75 years. Of these, 520 are up-to-date with screening. What is the screening rate?
A) 35%
B) 45%
C) 55%
D) 65%
E) 75%
Answer: D
Rationale: Screening rate = (520/800) × 100 = 65%. This is a basic population health metric essential for monitoring preventive service delivery.
Which of the following best describes the primary focus of Systems-Based Practice (SBP) as an ACGME core competency?
A) Individual physician clinical knowledge and skills
B) Awareness of and responsiveness to the larger health care system context
C) Personal professionalism and ethical behavior
D) Communication skills with patients and families
E) Lifelong learning and self-assessment
Answer: B
Rationale: Systems-Based Practice specifically requires residents to demonstrate awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal care.
What distinguishes preventive medicine specialists from other medical specialties in terms of core competencies?
A) Focus exclusively on clinical preventive services
B) Integration of clinical preventive medicine and public health competencies
C) Emphasis on acute care management
D) Specialization in a single organ system
E) Focus on tertiary prevention only
Answer: B
Rationale: Preventive medicine uniquely integrates clinical preventive medicine competencies with public health competencies, enabling specialists to work at both individual patient and population levels.
A hospital system asks you to design a population health intervention to reduce cardiovascular disease mortality in a panel of 50,000 patients. Which intervention strategy has the strongest evidence for reducing population-level CVD mortality while addressing health equity?
A) Individual physician education on lipid management guidelines alone
B) Patient portal messaging about healthy lifestyle alone
C) Systematic registry-based identification and outreach to patients with uncontrolled hypertension and hyperlipidemia, combined with team-based care protocols
D) Community-wide media campaign about heart disease risk factors alone
E) Free gym memberships for all patients with CVD risk factors
Answer: C
Rationale: Systematic registry-based identification with proactive outreach and team-based care represents a comprehensive population health approach that addresses both patient-centered (L1a) and population-centered (L1b) navigation. This approach has evidence for improving outcomes and can address disparities through targeted outreach.
Which USPSTF recommendation grade indicates high certainty of substantial net benefit?
A) Grade A
B) Grade B
C) Grade C
D) Grade D
E) I Statement
Answer: A
Rationale: Grade A recommendations reflect high certainty of substantial net benefit. Grade B reflects moderate to high certainty of moderate net benefit.
You are the medical director of a community health center serving 15,000 patients. Your quality improvement data shows the following colorectal cancer screening rates by race/ethnicity:
Overall: 58%
Non-Hispanic White: 68%
Non-Hispanic Black: 42%
Hispanic: 45%
Asian: 52%
What is the most appropriate FIRST step in addressing these disparities?
A) Implement a mass media campaign about colorectal cancer
B) Conduct a root cause analysis to identify system barriers
C) Offer free colonoscopies to all minority patients
D) Hire more bilingual staff
E) Send reminder letters to all patients
Answer: B
Rationale: Before implementing interventions, conducting a root cause analysis helps identify specific system barriers (access, language, cultural factors, insurance coverage, etc.) contributing to disparities.
Research suggests that delivering all USPSTF Grade A and B recommendations to a panel of 2,500 patients would require approximately how much clinician time?
A) 2-3 hours per day
B) 4-5 hours per day
C) 7-8 hours per day
D) 10-12 hours per day
E) 1 hour per week
Answer: C
Rationale: Studies have shown that delivering all USPSTF A and B recommendations would require 7-8 hours per day, which exceeds available time in traditional primary care, necessitating system-level solutions.
A health system is considering implementing a patient navigation program to improve cancer screening rates among underserved populations. Which navigation model has the strongest evidence for improving health service utilization?
A) Lay person-led navigation only
B) Health professional-led navigation only
C) Team-based navigation combining lay and professional navigators
D) Self-navigation with online resources
E) Physician-only navigation
Answer: C
Rationale: Evidence suggests that team-based system navigation may result in slightly more appropriate health service utilization compared to baseline or usual care.Team-based models that combine lay navigators with health professionals leverage the strengths of both approaches.
A residency program director wants to implement an effective curriculum for teaching systems-based practice. Based on educational research, which approach has been shown to significantly improve residents' understanding of SBP concepts?
A) Lecture-based didactics only
B) Self-directed reading assignments only
C) Teamwork competition model with problem-solving activities and practical application
D) Watching educational videos only
E) Annual competency testing without instruction
Answer: C
Rationale: Studies have demonstrated that active learning approaches using teamwork competition models with practical problem-solving significantly improve residents' understanding of SBP, with post-intervention knowledge increasing from 33% to 85%. This approach is more effective than passive learning methods.
A 52-year-old woman presents for her annual visit. She is eligible for multiple preventive services: colorectal cancer screening, mammography, lipid screening, diabetes screening, and depression screening. She has 12 minutes remaining in her visit and states she feels "overwhelmed by all the tests doctors want me to get."
Which strategy best demonstrates patient-centered system navigation (SBP2.L1a)?
A) Order all tests today without discussion to ensure completion
B) Prioritize the most important services, use brief SDM for top priorities, and schedule follow-up for remaining services
C) Tell the patient she must complete all tests or she's non-compliant
D) Refer her to a preventive medicine specialist
E) Cancel the visit and reschedule when she has more time
Answer: B
Rationale: This approach demonstrates patient-centered navigation by prioritizing services, using time-efficient SDM, and creating a realistic plan that respects both evidence and patient preferences.
Which population-based intervention has the strongest evidence for improving colorectal cancer screening rates among underserved populations?
A) Individual physician education alone
B) Patient portal messaging
C) Systematic registry-based identification with proactive outreach and patient navigation
D) Community-wide media campaigns alone
E) Waiting for patients to request screening
Answer: C
Rationale: Registry-based identification combined with proactive outreach and patient navigation has strong evidence for improving screening rates and reducing disparities in preventive services delivery.
What is the current USPSTF recommendation grade for lung cancer screening in adults aged 50-80 years with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years?
A) Grade A
B) Grade B
C) Grade C
D) Grade D
E) I Statement
Answer: B
Rationale: The USPSTF gives lung cancer screening with low-dose CT a Grade B recommendation for this population, indicating moderate certainty of moderate net benefit.
Which population-based intervention using health information technology has been shown in randomized trials to significantly increase comprehensive cancer screening rates in high-risk patients?
A) Automated email reminders only
B) Patient portal messaging only
C) IT-enabled patient navigation with registry-based identification and outreach
D) Electronic health record alerts to physicians only
E) Social media campaigns
Answer: C
Rationale: A randomized clinical trial demonstrated that patient navigation using a population-based IT system significantly increases screening rates for breast, cervical, and colorectal cancer in patients at high risk for nonadherence. The intervention combined registry-based identification with active navigation.
A residency program director is developing a curriculum to teach cost-effective clinical decision making as part of systems-based practice competency. According to surveys of both residency program directors and managed care medical directors, which statement best reflects the importance of this competency?
A) Cost-effective decision making is valued only by managed care medical directors, not academic residency directors
B) Cost-effective clinical decision making is equally highly valued by both residency directors and MCO medical directors
C) Cost-effective decision making should be taught only in business school, not medical training
D) Residency directors consider cost-effectiveness less important than MCO medical directors
E) Cost-effectiveness training is not relevant to current medical practice
Answer: B
Rationale: Research examining perspectives of residency program directors and managed care medical directors found that cost-effective clinical decision making was as highly valued by residency directors as by medical directors. Despite potentially disparate perspectives on the future practice of medicine, these two groups were remarkably similar in their views of the importance of specific tasks to effective practice, including cost-effective decision making.
A 52-year-old woman presents for her annual visit. She is eligible for multiple preventive services: colorectal cancer screening, mammography, lipid screening, diabetes screening, and depression screening. She has 12 minutes remaining in her visit and states she feels "overwhelmed by all the tests doctors want me to get."
To make this visit more efficient, which system-level intervention could have been implemented beforehand?
A) Sending patient decision aids prior to the visit
B) Requiring the patient to watch educational videos
C) Scheduling a 2-hour appointment
D) Having the patient see multiple specialists
E) Eliminating preventive services from annual visits
Answer: A
Rationale: Sending patient decision aids before visits increases efficiency by preparing patients for SDM discussions, allowing more productive use of limited visit time.
You are the medical director of a community health center serving 15,000 patients. Your quality improvement data shows the following colorectal cancer screening rates by race/ethnicity:
Overall: 58%
Non-Hispanic White: 68%
Non-Hispanic Black: 42%
Hispanic: 45%
Asian: 52%
How would you measure the success of your disparity reduction intervention over 12 months?
A) Overall screening rate only
B) Number of colonoscopies performed
C) Screening rates stratified by race/ethnicity with focus on reducing gaps
D) Patient satisfaction scores
E) Number of reminder letters sent
Answer: C
Rationale: To assess disparity reduction, you must measure screening rates stratified by race/ethnicity and track whether gaps between groups are narrowing, not just overall rates.
According to recent literature on evolving the SBP competency, which of the following is NOT one of the five priority focus areas for advancing systems-based practice in graduate medical education?
A) Comprehensive systems-based learning content
B) Professional development continuum across training stages
C) Individual physician autonomy in practice decisions
D) Clinical learning environments where SBP is practiced
E) Professional identity as systems citizens
Answer: C
Rationale: The five priority areas are: comprehensive learning content, professional development continuum, teaching and assessment methods, clinical learning environments, and professional identity as systems citizens. Individual autonomy without systems awareness contradicts the SBP competency.
Which institutional-level factor has been identified as most critical for facilitating patient-centered care and care coordination at the health system level?
A) Increasing the number of specialists
B) Optimization of IT infrastructure to enhance provider-provider and provider-patient communication
C) Reducing appointment times
D) Eliminating team-based care models
E) Focusing exclusively on acute care services
Answer: B
Rationale: Health systems analysis has identified IT infrastructure optimization for communication as a critical facilitator, along with institutional prioritization of patient-centered care manifest in performance feedback and shared values.
Residency program directors engaged in introducing new curricula to address population health identified 26 managed care tasks requiring new training. Which of the following tasks was ranked THIRD in priority by both residency program directors AND managed care medical directors?
A) Practice profiling and referral management
B) Competence with respect to practice guidelines
C) Acting on ethical principles to resolve conflicts when a patient needs procedures not covered by an MCO
D) Disease management and prevention
E) Gatekeeping skills
Answer: C
Rationale: Tasks associated with ethics and managed care were third in priority for both groups, with MCO medical directors placing slightly more importance on them than their academic counterparts. This finding may be surprising to some, but demonstrates the consistency of views between residency directors and managed care medical directors regarding the importance of ethical competencies in systems-based practice.
A 68-year-old patient with heart failure, chronic kidney disease, and Parkinson disease receives conflicting recommendations: the cardiologist recommends fluid restriction, while the nephrologist recommends adequate hydration. Which approach best demonstrates person-centered care planning (PCCP) for patients with multiple chronic conditions?
A) Follow the cardiologist's recommendation since heart failure is most life-threatening
B) Implement the 4M's framework (What Matters, Medication, Mentation, Mobility) to center the patient's goals and facilitate interdisciplinary team coordination
C) Refer the patient to a third specialist to break the tie
D) Allow the patient to choose without clinical guidance
E) Alternate between recommendations on different days
Answer: B
Rationale: The 4M's framework for age-friendly health systems aligns with person-centered care planning by centering patient goals and emphasizing that clinical decisions require consideration of what matters most to the patient. Coordination and communication across care teams are essential to addressing a patient's multiple, complex, and sometimes contradicting needs. This approach facilitates goal identification by interdisciplinary teams to foster person-centered care planning.
A screening test has 95% sensitivity and 90% specificity. The disease prevalence in the screened population is 5%. What is the approximate positive predictive value (PPV)?
A) 12%
B) 22%
C) 33%
D) 45%
E) 95%
Answer: C
Rationale: Positive Predictive Value (PPV) answers the question: "If my patient tests positive, what is the probability they actually have the disease?"
PPV = True Positives / (True Positives + False Positives)
Step 1: Start with disease prevalence (5%)
In a population of 1,000 people with 5% prevalence:
People WITH disease = 1,000 × 0.05 = 50
People WITHOUT disease = 1,000 × 0.95 = 950
Step 2: Apply sensitivity (95%) to those WITH disease
Sensitivity tells us how many diseased people test positive
True Positives (TP) = 50 × 0.95 = 47.5 (round to 48)
False Negatives (FN) = 50 × 0.05 = 2.5 (round to 2)
Step 3: Apply specificity (90%) to those WITHOUT disease
Specificity tells us how many healthy people test negative
True Negatives (TN) = 950 × 0.90 = 855
False Positives (FP) = 950 × 0.10 = 95
Step 4: Calculate PPV
PPV = TP / (TP + FP) = 48 / (48 + 95) = 48 / 143 = 0.336 or approximately 33%
Research examining healthcare team members' perspectives on systems-based practice competency has identified three major resident roles. Which of the following is NOT one of these consensus roles?
A) Resident as Self-Manager
B) Resident as Team Collaborator
C) Resident as Patient Advocate
D) Resident as Independent Decision-Maker
E) All of the above are consensus roles
Answer: D
Rationale: Multidisciplinary stakeholder analysis identified three major resident roles in SBP: Self-Manager, Team Collaborator, and Patient Advocate. The concept of "Independent Decision-Maker" contradicts the collaborative, systems-oriented nature of SBP. Notably, some ACGME-emphasized concepts like cost-benefit analysis were absent from healthcare team-generated priorities, highlighting gaps between formal definitions and practical expectations.
A health system is implementing person-centered care planning (PCCP) for patients with multiple chronic conditions. Which combination of strategies has the strongest evidence for overcoming barriers to PCCP implementation?
A) Increasing appointment times only
B) Hiring more physicians without workflow changes
C) Multidisciplinary team-based care, digital health solutions, workflow changes, and value-based payment models
D) Eliminating care coordination to reduce complexity
E) Focusing exclusively on acute care management
Answer: C
Rationale: Person-centered care planning for patients with multiple chronic conditions requires multidisciplinary team-based care and care coordination, digital health solutions, workflow changes, and value-based payment models that support comprehensive coordination of medical and social services. Barriers to implementing PCCP include time constraints, inadequate payment, and workforce availability and competencies. Promising solutions include the combination of multidisciplinary teams, digital health technologies, workflow changes, payment policies, and goal alignment.
An institution with 115 ACGME-accredited residency and fellowship programs serving 1,327 trainees implements a systems-wide curriculum to facilitate teaching and assessment of PBLI and SBP competencies. After two years, what outcome would indicate successful implementation?
A) 100% of programs report perfect competency in all trainees
B) A 35% increase in program directors' ability to provide written documentation of competence in SBP
C) Elimination of all quality improvement projects
D) Decreased emphasis on patient outcomes
E) Reduction in trainee participation in systems improvement
Answer: B
Rationale: An institution-wide curriculum implementation study revealed a 35% increase in program directors' ability to provide written documentation of competence in SBP between 2005 and 2007, along with a 13% increase in perceived ability to measure competency in SBP. Nearly 70% of programs had trainees participating in QI projects. These outcomes demonstrate successful implementation of systems-based practice curricula.