Block 9 Flashcards
What is evidence-based decision making (EBDM)?
Process for identifying and using most up-to-date (and relevant) evidence to inform decisions for individual patient problems.
What does EBDM involve?
Patient preferences, available resources, research evidence, clinical expertise.
Why is decision making in medicine important?
Doctors make decisions constantly, which affect patients, families, and society. Understanding decision making and the role of evidence can improve medical practice.
Why do we need EBDM?
Limited time to read, inadequacy of ‘traditional’ sources of information, disparity between diagnostic skills and up-to-date knowledge.
What are the different types of research studies and when are they each appropriate for decisions?
Cohort studies - Prognosis, cause; Case-control studies - Cause; Randomised controlled trials - Treatment interventions, benefits and harm, cost-effectiveness; Qualitative approaches - Patients and/or practitioners perspectives; Diagnostic and screening studies - Identification; Systematic reviews - Summary of evidence for a specific question.
What is the process of EBDM?
- Converting the need for information into an answerable question. 2. Identifying the best evidence to answer that question. 3. Critically appraising the evidence for its validity, impact, and applicability. 4. Integrating the critical appraisal with clinical expertise and the patient’s unique circumstances. 5. Evaluating our effectiveness and efficiency in carrying out the previous steps and seeking ways to improve.
What are the 4 steps in the approach to smoking cessation?
- Health education and general information to enhance motivation for quitting (light smokers). 2. Brief advice from a health professional to quit smoking (light smokers). 3. Advice, nicotine replacement, follow-up by a specialist (moderately motivated, medium dependence smokers). 4. Specialised counselling rooms and agencies working with group sessions (high-dependent smokers).
What is antibiotic resistance?
Bacteria change so antibiotics no longer work in people who need them to treat infections.
What are the reasons for the widespread use of antibiotics?
Increase in global availability; uncontrolled sale in many low or middle-income countries.
What are some of the causes of antibiotic resistance?
Use in livestock for growth promotion; releasing antibiotics into the environment during pharmaceutical manufacturing; volume of antibiotic prescriptions; missing doses when taking antibiotics; inappropriate prescribing of antibiotics.
How can antibiotic resistance be prevented?
Using antibiotics only when prescribed by a doctor; completing the full prescription; never sharing antibiotics or using leftover prescriptions; only prescribing antibiotics when they are needed; using the right antibiotics to treat the illness.
Which factors influence infection?
Infectious agents, environment, mode of transmission, portal of entry, host factors.
What are the most important infectious diseases in the UK?
Diphtheria, Haemophilus influenzae, measles, mumps, poliomyelitis, rubella, pneumococcal disease, tetanus, whooping cough.
What are the most important infectious diseases in developing countries?
Pneumonia, chronic diarrhoea, malaria, HIV/AIDS.
What is surveillance?
Systematic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken.
What is the purpose of surveillance?
Serve as an early warning system for impending public health emergencies; document the impact of an intervention; monitor and clarify the epidemiology of health problems.
Which infectious diseases are becoming more common in the UK and why?
Hospital acquired infections e.g. MRSA, STIs, mumps.
Which infectious diseases are associated with exposure to health care?
Nosocomial infections; more common examples - UTI, pneumonia, lower respiratory tract infections, surgical wounds, septicaemia; less common but more dangerous - Chicken pox, TB, legionella, MRSA.
What can be done to reduce the risk of nosocomial infections?
Prevention - Hand washing, infection control programs, advisory service, surveillance; detection, investigation and control of outbreaks; policies and procedures to prevent and control infection.
What is global health?
Health of the global population; improving health and achieving equality in health for all people worldwide.
What is international health?
Health defined by geography, problems, instruments, and a recipient and donor relationship.
What are the major functions of global health?
To provide health-related public goods; manage cross-national externalities; mobilise global solidarity; convene stakeholders to reach consensus.
What is the motivation for global health?
Increased awareness of global health disparities; enthusiasm to make a difference across international boundaries.
What is the ‘90/10 gap’?
Less than 10% of worldwide resources devoted to health research were put towards health in developing countries, where over 90% of all preventable deaths worldwide occurred.
What is the solution for this gap?
Regulation of the quality of imported food, medicines, and goods; timely access to information about infectious diseases; procurement of sufficient vaccine and drug supplies.
What impact has travel and migration had on diseases seen in the UK?
Help spread infectious diseases; transmission of behaviour and culture increases risk of non-communicable diseases; may introduce diseases to new populations.
What is WHO’s definition of environment, in relation to health?
All physical, chemical and biological factors external to a person, and all related behaviours.
What is an outbreak?
Sudden increase in occurrences of a disease in a community that has never experienced the disease before.
What is an epidemic?
Occurrence of a group of illnesses of similar nature and derived from a common source, in excess of what would be normally expected.
What is a pandemic?
Worldwide epidemic; outbreak -> epidemic -> pandemic.
How can we prevent epidemics?
Insure poor countries against the threat of a pandemic; funds and international responders sent to countries with outbreaks; development of vaccines.
What is the role of WHO in public health?
Providing leadership on health matters; shaping the research agenda; setting norms and standards; providing technical support.
What general intervention strategies are possible for HIV/AIDS?
Introduction of blood donor screening; promotion and distribution of condoms; peer education for high-risk groups; promotion of safer sexual behaviour.
What are the determinants of effective outcomes of intervention?
Economics; priorities; setting.
What are the current problems and issues?
Africa struggles against debt, trade restrictions, and inadequate aid provisions.
What are the public health objectives of vaccination?
To reduce mortality and morbidity from vaccine-preventable infections; to prevent outbreaks and epidemics; to generate herd immunity.
What factors influence the utility of immunisation/vaccination as an approach to disease prevention?
Disease burden; risk of exposure to the disease; age, health status, vaccination history.
What is required for a disease to be eradicated using vaccination?
Where no other reservoirs of the infection exist; where consequences of infection are very high; where scientific and political prioritisation exists.
Give examples of diseases that have been eradicated?
Smallpox, Polio.
What is herd immunity?
Level of immunity in the population which protects the whole population; provides indirect protection to unvaccinated.
What is R0?
Basic reproduction rate; the average number of individuals directly infected by an infectious case.
What factors affect R0?
The rate of contacts in the host population; the probability of infection being transmitted during contact; the duration of infectiousness.
What is effective reproduction rate (R)?
Estimates the average number of secondary cases per infectious case in a population made up of both susceptible and non-susceptible hosts.
What is the equation for effective reproduction rate?
R = R0 x (fraction of the host population which is susceptible).
What is the equation for herd immunity?
H = (R0 - 1) / R0.
What is a susceptible population?
Any person who is not immune to a particular pathogen.
What is WHO’s role in vaccination?
Makes recommendations for countries on vaccination policy; supports less able countries with vaccination strategy implementation.
List some international immunisation programmes.
Expanded programme on Immunisation (EPI); Global Polio Eradication Initiative (GPEI); Global Alliance for Vaccines and Immunisation (GAVI).
How are new vaccination programmes implemented?
Who - To protect vulnerable; How - Pilots, phased introduction; When - Greatest impact on disease burden.
What is shared decision making and why is it important?
Conversation between patient and their health care professional to reach a health care choice together; important when there are multiple reasonable options.
What are the pros of vaccination?
Can save life; ingredients are safe; adverse reactions are rare; herd immunity; economic benefits for society.
What are the cons of vaccination?
Can cause serious side effects; contain harmful ingredients; government intervention in personal medical choices.
What factors influence decision making?
Lifestyle; perception of health; beliefs about childhood diseases.
What is the population vs individual interest debate?
For the individual - Protection by ‘herd immunity’ may be safest option; for the community - Avoidance of vaccination diminishes herd immunity.
Which websites can be used to find out if a person needs travel vaccines?
NHS fitfortravel; The National Travel Health Network and Centre (NaTHNaC).
What are some of the free and private travel vaccines available?
Free - Diphtheria, polio, tetanus; Private - Hepatitis B, Japanese encephalitis.
What factors should be considered when deciding to get travel vaccinations?
The country or countries you’re visiting; when you’re travelling; your age and health.
What are the 5 most common cancers (incidence) in adult men and women in the UK?
- Breast/prostate 2. Lung 3. Bowel 4. Melanoma 5. Non-Hodgkin Lymphoma.
What are the 5 most common causes of cancer mortality for adult men and women combined in the UK?
- Lung 2. Bowel 3. Prostate/breast 4. Pancreas 5. Oesophagus.
What are the most common cancers in children?
Leukemias.
What is the most common cause of cancer mortality in children?
Brain, CNS and intracranial tumours.
What are the 5 most common causes of cancer mortality for adult men and women combined in the UK?
- Lung
- Bowel
- Prostate/breast
- Pancreas
- Oesophagus
What are the most common cancers in children?
Leukemias
What is the most common cause of cancer mortality in children?
Brain, CNS and intracranial tumours
How do the patterns of cancer in the UK differ from that seen in a developing country?
Mortality is higher in UK (29%)
What is the role of legal and lifestyle changes in reducing incidence and mortality of cancer?
Prevention - Legal and lifestyle changes, vaccinations
Screening - Early detection and diagnosis
Disease management - Improving treatments and quality of life
What is meant by difficult (or bad) news?
Bad/difficult news is defined as any news that drastically and negatively alters the patient’s (or their relatives) view of his or her future
What factors can affect the impact of news on a patient?
Institutionalised beliefs, personality types, gender, culture/race, religion, patients knowledge, relatives
What anxieties might health care professionals have about breaking bad news?
Uncertainty about the patient’s expectations
Fear of destroying the patient’s hope
Fear of their own inadequacy in the face of controlling disease
Not feeling prepared to manage the patients anticipated emotional reactions
Embarrassment at having previously painted too optimistic a picture for the patient
What is the ABCDE method of breaking bad news?
A - Advanced preparation
B - Building a relationship
C - Communicate well
D - Deal with patient reactions
E - Encourage and validate emotions
What is the SPIKES method of breaking bad news?
S - Setting up
P - Perception
I - Invitation
K - Knowledge
E - Emotions
S - Strategy and summary
What emotions may a patient feel when they receive difficult news?
Grief, distress, denial, anger, agitated/restless
How can cancer change partner relationships?
Change in roles
Change in responsibilities
Change in physical needs
Change in emotional needs
Change in sexuality and intimacy
Change in future plans
What were the conclusions and consequences of the Eurocare-II report?
Despite limitations of the methodology, cancer survival in the UK in the 1980-90s was one of the worst in Europe
Expert advisory group formed to the chief medical officer in 1995 which generated the Calman-Hine report
What were the conclusions and consequences of the Calman-Hine report (1995)?
Examined cancer services in the UK, and proposed a restructuring of cancer services to achieve a more equitable level of access to high levels of expertise throughout the country.
All patients to have access to a uniformly high quality of care
Public and professional education to recognise early symptoms of cancer
Patients, families and carers should be given clear information about treatment options and outcomes
The development of cancer services should be patient centred
Primary care to be central to cancer care
The psychosocial needs of cancer sufferers and carers to be recognised
What are the Calman-Hine solutions?
There should be 3 levels of care:
Primary care
Cancer units serving district general hospitals - Treat common cancers, diagnostic procedures, common surgery, non-complex chemo
Cancer centres (populations in excess of 1 million) - Treat rare cancers, radiotherapy, complex chemo
Key to managing patients would be the MDT
What is a national service framework?
Set national standards and define service models for a service or care group
Put in place programs to support implementation
Establish performance measures against which progress within agreed timescales would be measured
What are the main aims of the NHS cancer plan (2000)?
Save more lives
Ensure people with cancer get the right professional support, care and treatments
Tackle the inequalities in health e.g. unskilled workers are 2x more likely to die from cancer as professionals
Build for the future - Investment in cancer workforce, strong research, preparation for the genetics revolution
What are the 6 key areas for action in the cancer reform strategy (2007)?
Prevention - Smoking, obesity, alcohol etc
Diagnosing cancer earlier - Screening
Ensuring better treatment - Reduced waiting times, increase in radiotherapy capacity, new cancer drugs be referred to NICE, chemotherapy audits
Living with and beyond cancer - National cancer survivorship initiative
Reducing cancer inequalities
Delivering care in the most appropriate setting - Locally where possible, services should be centralised where necessary
Which cancers are screened for?
Cervical, breast and bowel
What is the national cancer survivorship initiative?
Partnership with cancer charities, clinicians and patients, considered a range of approaches to improving services and support available for cancer survivors
What were the main outcomes from ‘Improving outcomes: A strategy for cancer (2011)’?
Prevention and early diagnosis - Focus on lifestyle factors, screening, diagnostic tests
Quality of life and patient experience - Patient experience surveys, more 1-1 support roles, risk stratified pathway of care, following assessment and care planning
Better treatments - Cancer drugs fund, reducing variation in radiotherapy, reaffirmed MDTs and national audits
Reducing inequalities
What are some of the inequalities experienced amongst cancer patients?
White cancer patients report a more positive experience than other ethnic groups
Younger people are the least positive about their experience, particularly around understanding completely what was wrong with them
Men are generally more positive about their care than women, particularly around staff and staff working together
Non-heterosexual patients reported less positive experience, especially in relation to communication and being treated with respect and dignity
People with rarer forms of cancer in general reported a poorer experience of their treatment and care than people with more common forms of cancer
What are the outcomes from the independent cancer taskforce (2015)?
Spearhead a radical upgrade in prevention and public health
Drive a national ambition to achieve earlier diagnosis
Establish patient experience as being on a par with clinical effectiveness and safety
Transform our approach to support people living with and beyond cancer
Make the necessary investments required to deliver a modern high-quality service
Overhaul process for commissioning, accountability and provision
What is body image?
Perceptions, thoughts, and behaviours related to one’s appearance
The body is a bearer of values and a means of representing our identity to others - It shows who we are to others
What is biographical distribution?
Chronic illness leads to a loss of confidence in the body
From this follows a loss of confidence in social interaction or self-identity
Give examples of diseases/symptoms/treatments/side-effects which affect body image?
Scars
Prosthetic device - leg
Mastectomy
Impact on sexuality - Function, pain, appearance
Stoma
Hair loss
Weight loss/weight gain
What is the importance of hair?
An important site for individual and group identity
A way of ‘doing gender’ - A symbol of femininity? Hair loss not so bad for men
Stigma - Patients have some choice as to whether they will be stigmatised
Patient control of their status as sick - Can be managed through ‘normal’ appearance (wigs, beanies, scarves)
What are the functions of the clinical record?
Support patient care
Improve future patient care
Social purposes at the request of patients
Medico-legal document
What should be recorded in a clinical record?
Presenting symptoms and reasons for seeking health care
Relevant clinical findings
Diagnosis and important differentials
Options for care and treatment
Risk and benefits of care and treatment
Decisions about care and treatment
Action taken and outcomes
What are the differences between paper and electronic records?
Paper - Continuous, portable, writer identified, legibility issues, must be dated and signed
Electronic - Problem orientated, searchable, structured, safer prescribing, clinical decision support software
What is the use of records in audit, research and management?
Support clinical audit
Facilitates clinical governance
Facilitates risk management
Support clinical research
What is duty of care?
Legal obligation which is imposed on an individual requiring adherence to a standard of reasonable care while performing any acts that could foreseeably harm others
What is negligence?
Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances
You have to make decisions that adheres to your duty of care as a doctor and could not be considered negligent
What are the 4 ethical principles?
Beneficence - Duty to do good
Non-maleficence - Duty to not cause harm
Autonomy - Patient has the right to make their own decision
Justice - Fair, equitable treatment for all
What are the ethical theories?
Consequentialism - The correct moral response is related to the outcome or consequence of the act
Deontology - Places value on the intentions of the individual and focuses on rules, obligations and duties
Virtue ethics - Right living is derived from the moral character of the agent
How do you evaluate an argument?
- Get clear on the logical form of the argument
- Query - Valid and sound
Why might an argument be invalid?
- Different premises may express different concepts
- Confusing necessary with sufficient, and vice-versa
- Insensitive to the way in which claims are qualified
- Argument begs the question
Why might an argument be unsound?
Argument is invalid
Argument is valid but one or more premise is false - Makes a false/controversial
moral/empirical claim
An unsound argument doesn’t mean there will be an unsound conclusion
What should be avoided in arguments?
Straw man fallacy - Simply ignoring the person’s actual position and substituting it for a distorted, exaggerated or misrepresented version of that position
Ab hominems - Directed against a person rather than the position they are maintaining
Appealing to emotion
Begging the question
Argument from fallacy - Conclusion must be false because the premises are false
(not necessarily)
What is a moral argument?
Seek to support a moral claim of some kind
Argument need not succeed but to be an argument it must at least provide some
supporting reasons for the claim in question
What is a deductive argument?
Purely logic
This means this, therefore this means this
What is an inductive argument?
Making an argument based on observation, more probable conclusions (seeing is believing but you may not have seen everything)
What are MDTs in cancer care and why are they needed?
Modern management of cancer - Involved many disciplines, surgical and non- surgical, oncology
Allied health professionals e.g. nurses, physiotherapists, speech therapists, etc
Delivery of cancer care is often fragmented over several hospital sites - Need to
streamline and co-ordinate various components of care
Probably better outcomes for patients managed in MDTs
Who is in a cancer MDT (core)?
- Physicians
Surgeons
Oncologist
Radiologist
Histopathologist
Specialist nurses
MDT co-ordinator
Who is in a cancer MDT (extended)?
Physiotherapist
Dietician
Palliative care
Chaplin
What are the functions of MDTs in cancer care?
Discuss every new diagnosis of cancer within their site
Decide on a management plan for every patient
Inform primary care of that plan
Designate a key worker for that patient
Develop referral, diagnosis and treatment guidelines for their tumour sites
Audit
