Block 9 H+S Flashcards
Why is knowing about decision making in medicine important?
- doctors make decisions very often
- need to know the effect their decision has on patients and their families
- An understanding of it can help improve medical practice
What is the nature of decisions in medicine?
- They’re complex
- doctors generally use process of hypothetic-deductive reasoning
- Research evidence can help inform decision making
What goes into evidence based decisions?
- Evidence from research
- Patient preferences
- Clinical expertise
- Available resources
Why do we need Evidence based decision making?
- Increasing medical knowledge
- Limited time to read
- Textbooks etc. often out of date
- Disparity between diagnostic skills and clinical judgement
What is in the chain of infection?
- host
- infectious agent
- reservoir/ environment
- portal of entry
- mode of transmission
What are the different types of research studies and when are each appropriate?
-Cohort studies- prognosis and cause
-Case control studies- cause
-Randomised control trials- treatments, interventions, benefits/ harm, cost effectiveness
-Qualitative approaches- patient perspectives
Systematic reviews- summary of evidence for a specific question
What is the process of evidence based decision making?
- converting need for information into an answerable question
- identifying the best evidence to answer that question
- critically appraise the evidence for validity, impact etc.
- Integrating the critical appraisal with clinical expertise and patient circumstances
What are the reasons for widespread use of antibiotics?
- Increase in global availability
- Uncontrolled sale in many low/ middle income countries
What are some of the causes of antibiotic resistance?
- Use in livestock for growth promotion
- Volume of antibiotics prescribed
- Inappropriate prescribing of antibiotics
- Missing doses/ not finishing dose
- Releasing antibiotics into environment when manufacturing
How can we prevent antibiotic resistance?
- Only taking them when prescribed by doctor
- Completing full prescription
- Not sharing antibiotics
- Only prescribing when needed
- Using more specific antibiotics
What factors influence infection?
- Infectious agents- ability to reproduce, survival, infectivity etc.
- Mode of transmission
- Environment
- Portal of entry- mouth, nose, ears etc.
- Host factors- nutrition, age, smoking etc.
What are the most important infectious diseases in UK?
- Diptheria
- Haemophilus influenza
- Measles
- Mumps
- Poliomyelitis
- Rubella
- Pneumococcal disease
- Tetanus
- Whooping cough
What are the most important infectious diseases in developing countries?
- Pneumonia
- chronic diarrhoea
- Malaria
- HIV
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?
- Early warning system for impending public health emergencies
- Document the impact of an intervention or track progress towards a goal
- Monitor and clarify the epidemiology of health problems so can prioritise.
Which infectious diseases are associated with exposure to healthcare?
Nosocomial infections:
- UTI
- Pneumonia
- Lower respiratory infections
- Septicaemia
- MRSA
How can we reduce risk of nosocomial infections?
- Prevention- handwashing, surveillance, sterilisation of instruments
- Detection, investigation and control of outbreaks
- Policies 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
- Emphasises transnational health issues, determinants and solutions
What is international health?
Health defined by geography (poor nations), problems (infections, water, sanitation), instruments and a donor- recipient relationship
What are the major functions of global health?
-To provide health-related public goods - research, standards, guidelines
- To manage cross-national externalities through epidemiological surveillance,
information sharing, and coordination
- To mobilise global solidarity for populations facing deprivation and disasters
- To convene stakeholders to reach consensus on key issues, setting priorities,
negotiating rules, facilitating mutual accountability, and advocating for health in other policy-making arenas
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, manufactured goods, and inputs
- Getting timely access to information about the global spread of infectious diseases
- Procurement of sufficient vaccine and drug supplies in a pandemic
- Ensuring a sufficient corps of well-trained health personnel
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 a diseases to a new population - Widespread and deadly effects
- More in contact with animals - Increase in animal diseases (zoonosis)
- Migrants may bring diseases to countries that have not been exposed
What is WHOs definition of environment, in relation to health?
- All the physical, chemical and biological factors external to a person, and all the related behaviours
- Environmental health consists of preventing or controlling disease, injury, and disability related to the interactions between people and their environment
What is an outbreak?
Sudden increase in occurrences of a disease in a community, which has never experienced the disease before or when causes of the disease occur in numbers greater than expected in a defined area
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 in a community or region
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 country with outbreak to reduce human
suffering
- Development of vaccines
- Fast, early, planned response means less spread
- Monitor disease to prevent future outbreaks
What is the role of WHO in public health?
-Providing leadership on matters critical to health and engaging in partnerships where joint action is needed
- Shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge
- Setting norms and standards and promoting and monitoring their implementation
- Articulating ethical and evidence-based policy options
- Providing technical support, catalysing change, and building sustainable institutional
capacity
- Monitoring the health situation and assessing health trends
What are the determinants of effective outcomes of intervention?
-Econonics - Many developing countries can only spend a few dollars per annum per capita on healthcare
- Priorities - ‘Developed world academic’ analyses of cost-effectiveness may not reflect the developing world realities
- Setting - Countries where true reductions in incidence and prevalence have occurred (e.g. uganda) may be characterised by openness in political leadership towards HIV/AIDS and other cultural factors
What are the public health objectives of vaccination?
-To reduce mortality and morbidity from vaccine preventable infections
- To prevent outbreaks and epidemics
- To contain an infection in a population
- To reduce the number of infections
- To interrupt transmission to humans
To generate herd immunity
- To eradicate an infectious agent
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
- Special risk factors
- Reactions to previous vaccine doses, allergies
- Risk of infecting others
Cost
- Are there other ways to control the disease?
- impact on public perception
What is required for a disease to be eradicated using vaccination?
-Where no other reservoirs of the infection exist in animals or environment
- 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
- Herd immunity only applies to diseases which are passes from person to person
- Provides indirect protection to unvaccinated as well as direct effect to the vaccinated
- A disease can therefore be eradicated even if some people remain susceptible
What is R0?
-Basic reproduction rate
- The average number of individuals directly infected by an infectious case during the
infectious period, in a totally susceptible population (number of secondary cases following introduction of infection)
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 the effective reproduction rate?
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 = R0x (x is the fraction of the host population which is susceptible e.g. half population is 0.5)
- R>1 - number of cases increases
- R<1 - Number of cases decreases, needs to be maintained for elimination
- R=1 - Epidemic threshold
What is the equation for herd immunity?
H(R0-1)/ R0
What is WHO’s role in vaccination?
-Makes recommendations for countries on vaccination policy
- Supports less able countries with vaccination strategy implementation
- Works through the international health regulations to ensure the maximum security
against the international spread of disease with a minimum interference with world traffic
List some international immunisation programs?
-Expanded programme on Immunisation (EPI)
- Global Polio Eradication Initiative (GPEI)
- Global Alliance for Vaccines and Immunisation (GAVI)
How are new vaccination programmes implemented- who, how and when?
-Who - To protect vulnerable, contain outbreak, eradicate disease
- How - Pilots, phased introduction, global vaccination
- 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 is more than one reasonable option, no one option has a clear advantage, the possible benefits/harms of each option affect patients differently
What are the pros of vaccination?
- Can save life - Ingredients are safe in the amount used - Adverse reactions are rare - Herd immunity - Save children and parents time and money - Protect future generations - Eradication of diseases - Economic benefits for society
What are the cons of vaccination?
- Can cause serious and sometimes fatal side effects
- Contain harmful ingredients
-Government should not intervene in personal medical choices
-Can contain ingredients some people object to e.g. chicken eggs
-Unnatural
-Pharmaceutical companies main goal is to make profit
-Some diseases that vaccines target are relatively harmless in many cases e.g.
rotavirus
What factors influence decision making?
-Lifestyle - Perception of health -Beliefs about childhood diseases - Risk perception of the diseases - Perceptions about vaccine effectiveness and vaccine components -Trust in institution
What is the population vs individual interest debate?
- For the individual - Protection by ‘herd immunity’ may be safest option as avoids risk of vaccine
- For the community - Avoidance of vaccination leads to reduced coverage so 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 lectures available?
-Free - Diptheria, polio, tetanus, typhoid, hepatitis A, cholera
- Private - Hepatitis B, japanese encephalitis, meningitis, rabies, TB, yellow fever
What factors should be considered when deciding to get a travel vaccination?
-The country or countries you're visiting - When you're travelling - Where you're staying - How long you'll be staying - Your age and health - What you'll be doing during your stay - If you're working as an aid worker - If you're working in a medical setting - If you're in contact with animals
What are the 5 most common cancers in adult men and women in the UK?
- Breast/prostate
- Lung
- Bowel
- Melanoma
- Non-Hodgkin Lymphoma
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 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 healthcare 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
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 medial 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 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
NHS plan followed by several improving outcomes guidance (NICE) which relate to the organisation of services for a particular cancer.
- 2000 manual of cancer - >300 standards relating to the delivary of cancer treatment including provisions of chemotherapy, radiotherapy etc
- 2004 manual of cancer (manual of quality measures) - >900 new measures
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
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 experiences 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 important 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 a 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 outcome
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, so 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
What are the functions of MDT 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
