2. YEAR 2 EXTRAS FROM BLOCK LEARNING OUTCOMES Flashcards
why is there a rising demand for healthcare?
due to the ageing population and elderly people being more at risk of more serious acute threats to health but also have more difficulty recovering from what younger people would regard as minor injuries
If a condition is incurable, should we offer the treatment to someone else?
just become a condition isnt curable doesnt mean it is untreatable.
Its important to stop viewing cure as the criterion of benefit and instead think about people’s health related QOL
what is macro level resource allocation?
Macroallocation decisions are made in government and policy arenas to allocate resources among competing needs
what is microlevel resource allocation?
decisions made about a particular patient or clinician
argue some reasons why age should be relevant to resource allocation decision making?
treatment and the care of older people is very costly
older people have lived a full life already unlike younger people
older people have been paying their taxes to finance the healthcare system all their life
older people are likely to be less responsive to treatment
a younger person will have a longer ‘rest of life’ than older people
argue some reasons why age should not be relevant to resource allocation decision making?
Just because older people have paid taxes does not make the NHS a savings club for healthcare - the NHS is part of a social insurance team
the costly bit is not the age but the end of life treatment
some elderly people will have suffered a lifetime of pain and disability so will not have had a ‘fair innings’
palliative care can be more expensive than therapeutic care
even though older people will have a shorter ‘rest of life’, you could argue that as you have less years left, each year of life becomes more precious
age along is not a good predictor of prognosis and decisions should be made based on biological not chronological age
making treatment decisions on the basis of age is discrimination which is against the law
what is the fair innings argument?
older people have has a full life already and younger people have not so its much fairer to divert resources from older to younger patients.
what did the Equality Act 2010 say?
protection must be offered for age, sex, race, gender reassignment status, disability, sexual orientation, marriage status and pregnancy
the relevance: it banned age discrimination against adults in the provision of services and public functions
what is direct age discrimination?
when a direct difference in treatment based on age cannot be justified. Is/was/could be treated in an infavourable way because of age
what is indirect age discrimination?
when a seemingly neutral provision/measure/practice has harmful repercussions on a person or group of persons
outline how you could argue that medical practice is age discriminating?
Doctors can withhold treatment that is likely to do more harm than good. The prevalence of impairments increases with age so older people are more likely to be excluded than younger people.
Nevertheless, wide individual variation exists in aging and many people in later life function physiologically within the normal range for people much younger.
what are the arguments for the use of QUALYs?
they provide the net benefit as they adress the primary purpose of healthcare which is about maximising healthcare - utilitarian theory
patients often say quantity and quality of life is what matters most
they are used widely by NICE
what are the arguments against the use of QUALYs?
• Measurements of output in units based on life years puts different values on individuals according to their life ecpectancy and thus citizens are no longer equal and older people are particularly disadvantaged
• It assumes that the value of life is determined by its length but the only person who can put a true value on life, is the person living it.
- They presume that given the choice a patient would prefer a shorter healthier life to a longer period of survival in a state of severe discomfort.
- Double jeopardy objection - those patients with pre-existing medical conditions will be treated much worse as it will reduce their overall quality of life
what are some relative measures of risk?
risk ratios and odds ratios (chances compared to another group)
what are some absolute measures of risk?
risks, odds, risk differences (the actual chances)
what did Benjamin Franklin say?
nothing can be certain except for death, taxes and scarcity of resources
what causes the scarcity in healthcare?
NHS budgetary restrictions
public expectations
ageing population = increasing demand
staffing levels
what is distributive justice?
distributing resources in a way that is fair and just
what is health economics?
the study of how society uses and allocates its limited resources to produce, distribute and consume health and healthcare
what is clinical and cost effectiveness?
when deciding a treatment it must permit the greatest health gain for the patient at the lowest cost possible
what is utilitarianisms view of rationing healthcare resources?
aims to maximise overall benefits at a societal lovel e.g. QUALYs
what is egalitarianisms view of rationing healthcare resources?
emphasises the equal moral status of individuals by trying to provide equal opportunity to have the basic goods in life e.g. using a lottery
what is prioritarianisms view of rationing healthcare resources?
attempts to help those considered worst off
what is the problem with utilitarianisms view of rationing healthcare resources?
there are unanswered questions on how best to quantify the QOL
what is the problem with egalitarianisms view of rationing healthcare resources?
insensitive to factors that are important e.g. patient need
what is the problem with prioritarianisms view of rationing healthcare resources?
ignores the prognostic differences
what is the rule of rescue?
the moral imperative to rescue identified individuals in immediate peril, regardless of cost
who are the buyers and sellers in the NHS market?
the clinical commissioning groups are the buyers
providers of care are the sellers
why is demand for healthcare always increasing?
because of the increasing population size, ageing population, multiple morbidities increasing
what is NICE’s recommendation for threshold of cost per QUALY?
20,000 -30,000
what is Alan Williams principles to guiding rationing?
to treat equals equally and with dignity
to meet peoples needs for healthcare as efficienctly as possible by imposing the least sacrifice on others
to minimise inequalities in the lifetime health of the population
what are guidelines?
systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances
NICE clinical guidelines are recommendations on how healthcare and other professionals should care for people with specific conditions.
why are clinical guidelines important?
they ensure doctors provide evidence based care, improve cost effectiveness, provide a practical and ethical framework for decision making and enhance the appropriateness of practice
what are some problems with clinical guidelines?
there are conflicting guidelines for patients with multiple morbidities
medicien is rapidly developing so guidelines can quickly go out f date
failure to understand or agree with responsibility for using the guidelines
lack of knowledge that the guidelienes exist
what is biographical disruption?
the way in which a life-threatening illness breaks an individual’s social/cultural experience by threatening self-identity.
what are some of the impacts of having a chronic illness?
loss of control and person power and self esteem loss of independance loss or change of role in family/work loss of financial security loss or change of future plans loss of identity
what is the house of care model?
a framework for a coordinated service model that enables patients with long-term conditions and clinicians to work together to determine and shape the support needed to enable them to live well with their condition.
who rations health care?
central government decides NHS funding and this is divided amongst the 4 national constituent parts of te NHS. Its allocated by CCGs on the basis of population weighted by need.
what is the hippocratic tradition?
requires doctors to maximise benefits of care for the patient regardless of opportunity cost
what is ‘need’ for healthcare? and how is this different from ‘demand’?
a need for medical care exists when there is an effect and acceptable treatment or cure
demand is when an individual considers they have a need and wishes to recieve care
what was the sugary drinks tax?
an effective public health measure where a 20% tax on sugary drinks was used to try to reduce the number of obese adults
what is prognosis?
an assessment of the future course and outcome of a patients disease, based on knowledge of the course of the disease together with the persons general health, age and sex.
what are prognostic factors?
characteristics of the patient that can be used to predict outcomes more accuretaley
e.g. demographics, disease specifics and co-morbidities
what are risk factors?
patient characteristics associated with the development of the disease in the first place.
what is consequentialism?
whether an act is morally right depends only on consequences
what are some forms of consequentialism?
utrilitarianism rule consequentialism state consequentialism ethical egoism ethical altruism etc
what is clinical reasoning?
the ability to sort through a cluster of features presented by a patient and accurate asian a diagnostic label with the development of an appropriate treatment strategy as an end goal
what are some consequences of a poor doctor-patient realationship?
complaints inaccurate diagnoses less recognition of ICE non adherence with care or treatment decreased patient satisfaction
What did William Osler say about person centred medicine?
The good physician treats the disease, the great physician treats the person who has the disease
what are the 6 elements of person centred care?
understanding individuals preferences empathy shared goal setting and decision making active listening open ended questions and reflective conversations involvements of family and friends
what is a doctor patient relationship?
A consensual relationship in which the patient knowingly seeks the physicians assistance and in which the physician knowingly accepts the person as a patient
outline the development of the doctor patent relationship
paternalistic model where active doctor and passive compliant patient
mead and bowers model of patient cent redness
what is microeconomics?
the study of how individuals and companies make decisions to allocate scarce resources
what is macroeconomics?
the study of an economy as a whole.
what is medical pluralism?
the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness
what is inequality?
the phenomenon of unequal and/or unjust distribution of resources and opportunities among members of a given society
what is equity
“providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status i.e. everyone should have equal opportunity to healthcare
what is ethical reasoning?
a skill enabling you to better argue to a position you can justify and to evaluate the views and arguments of other people.
what is ethics?
is the study of what makes an action wrong or right.
what is meta-ethics?
study of the meaning of moral concepts i.e. what does right mean
what is normative ethics?
the study of the means of deciding what is right or wrong aka. Moral theory.
what is applied ethics?
the application of moral theory to real world cases
what are the 4 types of moral theory?
consequentialism
deontoloy
virtue
utilitarianism
what is consequentialism?
– rightness is judged by desirability of the consequences of that action
what is deontology?
actions are right if they conform to a system or rules or regulations
what is virtue ethics?
the right act is the one which a virtuous person would perform in the circumstances
what is utilitarianism?
whats the four principle approach to ethics?
- Beneficience – a practitioner should act in the best interests of the patient
- Non-maleficience – a practitioner should ensure no further harm comes to the patient
- Autonomy – the competent patient has the right to make their own decisions regarding their own healthcare. This involves acting with understanding, freely from the will of others and in accordance with your own values.
- Justice – law/resource management etc
why is autonomy important?
it generally leads to better outcomes as patient is more likely to trust thr doctor and stick to the regimen (consequentialism)
its a requirement (deontology)
a virtuous person would allow an individual to be self-determinant (virtue)
When doctors act in the patients best interests they are activng in ways that will have an overall net benefit for the patient (beneficience).
Sometimes the treatment will have side effects (goes against non-maleficence) but its deemed to be in the best interests of the patient because of the net positive effect
what might make ethical decisions hard?
It can be difficult to assess best interests when the patient cannot communicate, when youre trying to weigh up conflicted goods. When your own values might disrtort what you think is in the best interest of the patient, when you disagree with the patient etc.
what makes an argument valid?
valid if the conclusion follows logically from the premises.
what makes an argument sound?
if the conclusion follows logically from the premises AND the premises are infact true
what id ad hominem?
– irrelevantly attacking the person instead of addressing someones argument e.g. not listening to a woman who stands against abortion because you know she had abortions herself
what is an argument from authority?
agreeing with a particular view because the person who said it occupies a place of authority
what is begging the question?
when an arguments premises assume the truth of the conclusion rather than supporting it e.g. tom wants to convince james chocolate is healthy so his argument is that cjocolate grows on trees so it must be healthy even though there is no proof that something is good for you just because it grows on trees
what is the straw man fallacy?
misrepresenting someones argument to make it easier to attack e.g. telling someone who wants to legalise cannabis that we should not because legalising drugs is dangerous even though the original argument was about cannabis specifically, not just drugs generally.`
what is sensitivity?
– the ability of a test to correctly identify patients with a disease (true positives / all diseased individuals)
what is specificity?
the ability of a test to correctly identify people without the disease (true positives / all non-diseased individuals)
what does high sensitivity mean?
fewer false negative results so its used to rule out conditions
what does high specificity mean?
reduces false positives so usually used to rule in conditions
what is a positive predictive value?
proportion of positive tests that are correct (true positives / test positives)
what is a negative predictive value?
proportion of negative tests that are correct (true negatives / test negatives)
what is screening?
Screening is the systematic application of a test or inquiry to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventative action, amongst persons who have not sought medical attention on account of symptoms of that disorder.
what are the Wilson criteria for screening?
- The condition sought should be an important health problem
- There should be an accepted treatment for patients with recognized disease
- Facilities for diagnosis and treatment should be available
- There should be a recognizable latent or early symptomatic stage
- There should be a suitable test or examination
- The test should be acceptable to the population
- The natural history of the condition, includng development from latent to declared disease should be adequately understood
- There should be an agreed policy on whom to treat as patients
- The cost of case-finding should be economically balanced in relation to possible expenditure on medical care as a whole
- Case finding should be a continuing process and not a once and for all project
what makes screening effective?
effective it needs to be able to recognize a high proportion of disease in its preclinical state, be safe, be cost effective, lead to demonstrated improved health outcomes and be widely available.
what are some barriers to screening?
fear, stigma, moving address so not getting updates, language barriers, people thinking they need symptoms first, not knowing how to book an appointment, embarrassment, lack of transport, misconceptions, childcare to worry about
describe the disability caused by incontinece?
People worry about coughing and sneezing, worry about their incontinence worsening as they age, worry about smelling of urine, worry about a sex life, limit their choice of clothing and have a desire for normality
People may also feel a loss of dependency, loss of control and may develop problems with their body image.
what is stigma?
an identifying mark or characteristic that can be a specific diagnostic sign of a disease
what is the process of stigma?
: labelling -> stereotyping -> othering -> stigmatisation -> discrimination
what is discreditable stigma?
keeping stigmatised conditions hidden except to close friends and family
what is discrediting stigma?
when a stigmatising conition cannot be hidden
what is felt stigma?
a sense of fear and shame due to one’s condition
what is enacted stigma?
discrimination by others
what is internalising?
absorbing the social views of being lower status and the impact on personal beleifs and behaviours
what is passing?
passing oneself off without acknowledging symptoms e.g. hiding yourself – can come at a very high psychological cost
what is covering?
not disclosing e.g. wearing cream to hide eczema
what is withdrawal in terms of stigma?
socially acknowledging a symptom but withdrawing from generally expected social interactions and relationships
e.g. social isolation is common amongst incontinence sufferers leaving them with feelings of hopelessness, sadness, and shame. The stigma attached to this condition is often worse than the actual symptoms.
how can stigma affect healthcare?
Fear of stigma may act as a barrier to seek medical care
Concerns about confidentiality
In some cultures stigma attached to HIV contributes to lack of medical care
describe the impact of chronic dialysis on patients?
Those on dialysis have lower levels of physical activity, diminished health questionnaire results compared with the general population.
it takes a long time out of the day
may be difficult to get to the dialysis unit
can limit freedom of movement
what is opportunity cost?
represent the potential benefits that an individual misses out on when choosing one alternative over another
how is NHS funded?
tax finance, national insurance and user charges
what is rationing?
when someone is denied/not offered an intervention that everyone agrees would do them good and they would like to have
Why should smokers receive treatment even if the smoking has ‘caused’ their helth condition?
Its not the role of the doctors to decide who is more deserving of a treatment
The patient may have little/no control over their smoking habits
Even if patients did have control they are no less deserving
Decision should be made on ground of clinical need
They may not be aware that they have contributed to their own ill health
They have paid taxes
what is confidentiality?
the principle of not divulging or disclosing information about patients to others
