Extras

Question 1

How should a HCP support adherence?

Answer 1

Barriers, Behavioural strategies + Beliefs and intentions

Barriers
- are there barriers? Such as trouble understanding or remember?

Behavioural strategies
- can we implement some behavioural strategies to improve adherence
- incentives, reinforcement, modelling, reminders

Beliefs and intentions
- is non-adherence intentional?
- is it due to their beliefs, concerns or socio-cultural beliefs

Adherence is unstable so always changing
Therefore it should be followed up and reviewed

Question 2

Problems with HCPs being treated by other HCPs

Answer 2

Pt may fear lack of confidentiality
Embarrassment
Potentially, a conflict of interest may arise, between himself and his doctors, if his health threatens the health of his patients
Stigma of mental health problem
The GP may feel challenged by a patient who is as knowledgeable as them, or more in specific areas
GP may find it more difficult to ask difficult questions e.g. mental health, addiction, sexual history, relationships

Question 3

Pharm representative gifts

Answer 3

Cost money (like other advertising).
Influence behaviour (like other advertising).
Create obligation, need to reciprocate (unlike advertising).
Create a sense of entitlement (unlike advertising).
Erode professional values; demean profession (probably unlike advertising).

Question 4

Can you define flexible compassion?

Answer 4

Being able to switch between focusing on the task at hand and blunting emotions and then processing the feelings and emotions from a situation

Question 5

Example of flexible compassion

Answer 5

e.g. resuscitation situation
Must think analytically /carefully to save a life
Don’t let emotions cloud judgement or inhibit necessary actions.
After the resuscitation,
turn off the analytical & cognitive processes
concentrate on empathy and compassion for the frightened relatives and patients.

Question 6

Can you give examples of compassionate behaviours?

Answer 6

Notice me
- Make eye contact
- Smile / welcome

Basic good manners
- be respectful, polite, kind
- Touch (+/-)
- Introduce themselves in a way that means something to me
- Hello, my name is…

Make me feel comfortable
- Safe (appear confident
- Expected (have read the notes)
- Unhurried (anything we haven’t covered, you’d like to ask? )

Focus on me and my needs
- Treat me as a person (not just a condition)
- Ask about my situation
- Really listen
- Identify my concerns
- Respond to my comments/Qs
- Ask me Qs
- Explain (in terms I understand)
- Ask for my views

Proper Endings
- When I’m sure the person has understood
- When we’re both ready

Question 7

Can you outline personal and systemic challenges to compassion?

Answer 7

Personal
* Time pressures
* Feeling helpless or unable to ‘do’ anything
* Opening a ‘can of worms’
* ‘Making’ someone cry
* Not understanding the perspective of the other person
* Saying the wrong thing
* Sounding patronising
* Getting upset oneself
* Negative interactions with other

Systemic
* Time
* Tired & overworked
* Shift patterns
* Under - resourced (££, PPE)
* Burnt - out

Question 8

Can you define the different types of euthanasia?

Answer 8

ACTIVE EUTHANASIA = deliberately intervening to end someone’s life - injecting with sedatives

PASSIVE EUTHANASIA = causing a person’s death by withholding treatment needed to maintain life (withholding antibiotics in someone with pneumonia)

VOLUNTARY EUTHANASIA = person makes conscious decision to die and asks for help to do this

NON VOLUNTARY EUTHANASIA = person can’t give consent (coma) so another person takes decision on their behalf

INVOLUNTARY EUTHANASIA = killing a person against their expressed wishes

Question 9

Can you explain what the doctrine of double effect is? relate to giving morphine as euthanasia

Answer 9

The doctrine of double effect says an action with both good and bad consequences can be morally permissible if certain conditions are met:

• The nature of the act is not bad
• At least one of the acts consequences is good
• At least one of the acts consequences is bad
• There is a sufficiently serious reason for allowing a bad consequence to occur
• The bad consequence is not a means to the good consequence
• The agent foresees the bad consequence but intends the good consequences

As long as the bad consequences are not intended (and there are good consequences, it is morally ok
as long as the bad side effect wasn’t intended and even if you did forsee it (just as long as not intended)

Question 10

Describe the ethics of the DDE

Answer 10

pro (theologians): it argues that what matters morally are our intentions

con (consequentialists): the consequences are the same no matter the intentions - death and so it is immoral

extra: can be difficult to prove what the clinician’s intentions were

Question 11

Can you explain who the director of public prosecution is and outline the guidance available to those who wish to travel abroad for euthanasia?

Answer 11

DPP is responsible for overseeing the prosecution of criminal cases on behalf of the state or the public

Travelling abroad for euthanasia:

factors weighing favour of prosecution
- under 18
- if capacity is unclear
- process not initiated by the person who dies or evidence of coercion
- No terminal illness, severe and incurable physical disability or severe degenerative disease

factors weighing against prosecution
- A clear, settled and informed wish to die
- Process was initiated by person who died
- Person had terminal illness, severe and incurable physical disability or severe degenerative disease with no possibility of recovery
- assistance provided was minor

DPP guidance:
Assisted suicide, assisted dying and euthanasia remain illegal in the UK
All cases will be investigated and treated on an individual, case-by-case basis by the DPP
Those in a position of responsibility (e.g. doctors) should NOT assist in suicide

Question 12

Can you define the different types of pain?

Answer 12

Pain definition: a unpleasant sensory and emotional experience resembling or associated with actual or potential damage

Nociception = phenomenon that results from activation of nociceptive via a noxious stimulus that threatens to damage healthy tissue - a biologically hardwired response to damage

Nociceptive pain: injury to body and tissues, sharp, aching, throbbing

Neuropathic pain: associated with lesion or disease of somatosensory system - compression, infection

Nociplastic pain: arises from altered nociceptive pain despite no clear evidence of disease

Question 13

Can you contrast perception and sensation?

Answer 13

Perception = recognition, integration and interpretation of raw sensory stimuli and information
Sensation = process of detecting the presence of stimuli by sensory organs

Question 14

Bottom up theory of pain

Answer 14

Bottom up suggests info is drawn directly from sensorial data

Visual perception: patterns of light perceived by the retina are all that is necessary for perception to occur

Texture gradients: closely packed together things are suggestive of things being far away

Perceiving motion: Optic flow patterns, use depths to tell us when we are moving
Things closer to us appear to move more quickly than things far away

Horizon ratios: Used to judge the vertical size of object
I.e. when the perceiver and object are positioned approximately at ground level, they can relate fairly accurate determinations about themselves and height

Question 15

Top down theory of pain

Answer 15

Top down suggests = combo of this sensorial data with other psych constructs like expectancies and previous experiences
- the brain’s cognitive and emotional experiences shape our perception of pain
- suggests management of pain should involve psychological factors as well as physical symptoms

Question 16

Describe the 2 studies regarding expectancy and pain

Answer 16

Open-hidden paradigm:
* Both groups receive a dose
* One group receives a clinician openly administering a drug
* One group is given it at a unknown time
* First group does better - respond to anticipation of treatment

Open-label placebo:
* People openly know they are taking drugs that are placebos
* People can reduce pain by a third compared to control group - even if they know they are fake
* Can also reduce the taking of opioids
* Whether the effects last is questionable
* works because of the effect of taking the pills = conditioned response

Question 17

Give 5 factors that affect perception

Answer 17

emotion - e.g. depression will interpret info/pain worse
personality - different personalities will behave differently
anxiety - enhanced perception for threatening info
attention - pain is lower when distracted
physiological - perception is affected by injury or disease

Question 18

Aims of psychological interventions

Answer 18

AIMS
- To identify maladaptive thoughts/beliefs (cognitions), challenge them & change them to become more adaptive (cognitive restructuring).
- Develop effective coping strategies
- Help the patient to gain some insight into their cognitive and emotional functioning

• Requires some understanding of the relationship between thoughts/feelings/behaviour
• Learning to question automatic thoughts and beliefs, assumptions and predictions that often lead to negative emotions
• Replacing negative thinking with more realistic and positive beliefs.
• If we can change the way we look and feel about situations, we can change the feelings that follow

Question 19

Examples of cognitive interventions

Answer 19

Using decisional balance intervention when making lifestyle changes
- Thinking about costs and benefits of changing and not changing a specific behaviour
- Determining what is involved in the decision to change current habits
- Change is difficult - are the costs worth it

Motivational interviewing
- Goal: to guide individuals to explore their own conflicting beliefs and attitudes towards a decision regarding particular behaviour - helps to reduce ambivalence to change
- Effective in reducing smoking, alcohol/drugs misuse, addictions, improving adherence to lifestyle changes

Distraction techniques
- Cognitive technique which involves deliberately focussing attention away from whatever is causing distress
- Effective in reducing moderate to acute pain/distress
- Short term - lasts as long as the person remains distracted
- Distraction activities might include a task like counting games/colouring, doing a puzzle, talking to a nurse, crosswords, TV, music etc.

Question 20

Decisional balance sheet

Answer 20

A tool to allow individuals to weigh the pros and cons of changing behaviours
e.g. in the context of considering whether someone should undertake more physical activity

• on one side: change behaviour and undertake physical activity
• benefits = more energy, feel better physically, more self confidence
• costs = have to buy equipment, could get injured etc
• on other side: maintain current behaviour of inactivity
• benefits = one less thing to think about, avoid discomfort
• costs = more easily stressed, weight gain etc

Question 21

Aims of behavioural interventions and how they differ to cognitive interventions

Answer 21

AIMS
- Substitute maladaptive behaviours for adaptive ones
- Relieve symptoms
* Examples: Modelling, Conditioning, Reward and reinforcement, Relaxation training, Graduated Exposure & Flooding, Biofeedback

Comparison to cognitive interventions
* Insight &/or understanding of the theory is not a requirement THIS IS DIFFERENT TO COGNITIVE THERAPY
* Basically goes on the theory that maladaptive behaviours are learnt and can be changed and replaced

Question 22

examples of behavioural therapies

Answer 22

Modelling → i.e. giving a teddy an injection before giving it to the child (performing stressful task without negative effect)

Behavioural rehearsal → practising risk in a safe environment (practice anger management and assertiveness training with difficult persons)

Relaxation techniques → progressive muscle relaxation of specific muscle groups

Systematic desensitisation → Gradually controlled increased exposure (imagined or real) to the feared subject whilst maintaining a relaxed state until fear is extinguished.

Flooding → Inescapable continuous exposure to the feared subject, until anxiety subsides (extinction).

Biofeedback →
Aim: To achieve voluntary control over certain automatic physiological processes we are usually unaware of
Method: Identify & record the physiological stress response. This may involve using a mechanical device to monitor heart rate, respiratory rate, blood pressure, muscle tension, peripheral temperature
Patient learns relaxation/breathing techniques to reduce the physiological readings which is a type of reward
Positive reinforcement -patients can feel/ see immediate response.

Question 23

Cognitive behavioural therapy - what it is, aims, features, adv + disadv

Answer 23

Cognitive behaviour therapy
- A popular integrated therapy that combines cognitive therapy (changing self - defeating thinking) with behaviour therapy (changing maladaptive behaviour)
- Way an individual thinks affect their way to cope

Aims of CBT:
- Identify and modify maladaptive beliefs and strategies
- Teach positive strategies for coping and managing
* Empower patients to become own therapist

Features of CBT - highly structured approach and problem solving
* EDUCATION
* COLLABORATION
* IDENTIFYING
* GUIDED DISCOVERY AND SOCRATIC QUESTIONING
* COGNITIVE
* RESTRUCTURING
* GOAL SETTING
* HOMEWORK
* RELAPSE PREVENTION
* EMPOWERING

Advantages of CBT:
* Can be used in a wide range of disorders and for kids/adults
* Self help versions available - written manuals, online programmes, facilitated groups
* Good evidence base for mild cases but also for severe cases alongside meds
* Brief and time limited - 5-20 sessions

DISADVANTAGES of CBT:
- Needs willingness to engage, not passive

Question 24

Transactional leadership, transformational leadership, charismatic leadership

Answer 24

transactional
- style in which the leader promotes compliance of their followers though both rewards and punishments.

transormational
- a process whereby leaders engage with and influence other
- by paying attention to their needs, raising their motivation, and providing an ethical framework for decision

charismatic
- built on a foundation of strong communication skills, persuasiveness, and maybe even a little bit of charm to help them get the most out of everyone that works for them

Question 25

Medical leadership competency framework

Answer 25

delivering the framework requires 5 things:

managing services
- managing people and resources

improving services
- facilitating change and ensuring patient safety

setting direction
- making decisions and evaluating impact

demonstrating personal qualities
- maintaing integrity and personal development

working with others
- collaborating with team and encouraging contribution

Question 26

Definition of consent

Answer 26

‘Patients voluntary agreement to treatment, examination or other aspects of healthcare’

Question 27

Valid consent

Answer 27

UNDERSTAND, RETAIN, DELIBERATE, COMMUNICATE

• Understand relevant info (and must be given correct info - separate card)
• Retain relevant info
• Weigh up relevant info
• Communicate decisions
• From a capable/competent person who understands ‘continuing’ - they know they can change their minds
• Children – “a sufficient level of understanding and intelligence” – Gillick
• Capacity is defined in the Mental Capacity act 2005
• consent should ideally be written when recorded

Question 28

Info to give when consenting

Answer 28

What info to give? PARQ
Procedure =(nature, purpose, benefits)
Alternatives - including doing nothing
Risks - including risks of doing nothing
Questions

Question 29

Outline the 4 components of capacity under the MHA

Answer 29

MENTAL CAPACITY ACT OF 2005 → Patient wants to leave the hospital, do you let them? Patient wants to deny treatment, do you let them?

For the purposes of the Act, a person is unable to make a decision for himself if he is unable to:
- understand the information relevant to the decision
- retain that information
- use or weigh that information as part of the process of making the decision, or
communicate his decision
- The fact that a person is able to retain the information relevant to a decision for a short period only does not prevent him/her from being regarded as able to make the decision

Question 30

Types of memory

Answer 30

Short term memory - about 30 seconds - if I interrupt during the rehearsal of it, you will forget it
Working memory
Long term memory
Episodic memory- or autobiographical memory = memory system for facts about yourself
Semantic memory = memory for facts about the world
Declarative = memory for facts you know - asked a question and ‘tip of tongue’, but you know that you know the answer
Procedural = memory for how you perform action sequences - learning to drive a car
Prospective = memory for future intentions - remember to buy bread on the way home (remembering at the right moment)

Question 31

Factors improving recall after info giving

Answer 31

• Higher IQ = better memory
• Greater medical technical information
• Higher anxiety levels = higher improved memory but reduce capacity to solve problems
• Age - younger
• Information is remembered best when it is interpreted to one’s own schema. Make things as similar to what they expect as possible
• Recalling info immediately after it has been stored = good LTM = getting other students to ask questions, could ask patients what do you understand

Question 32

define grief, bereavment and mourning (+ the grief responses)

Answer 32

Bereavement: describes having lost someone significant through death.

Grief: is a normal, natural emotional reaction to loss
- complex - Incorporates psychological (cognitive, social, behavioural) and physical (physiological, somatic) response
- This is the personal process of how we feel

Mourning: the process of adaptation to loss
- with particular reference to the cultural and social rituals and expectations
- Includes the public display of grief and social expression
- May interact with the individual grief response

Grief responses
- acute - short term response
- long term 3-12 mths
- prolonged - grief affects evereyday life for over 1yr
- complicated grief - preoccupation, intrusive thoughts etc

Question 33

5 stages of grief

Answer 33

DENIAL
ANGER
BARGAINING (if I can live longer..)
DEPRESSION
ACCEPTANCE

DABDA

+ stages can be omitted or repeated

Question 34

Dual process model of grief

Answer 34

oscilating between loss-orientated or restoration orientated coping

loss orientated behaviours
- e.g. intrusion of grief, denial

restoration orientated behaviours
- e.g. doing new things, distraction from grief

Question 35

Risk factors for complicated grief

Answer 35

1. Environmental circumstances surrounding the loss → sudden and violent, delay in finding out, several family members
2. Individual circumstances → previous history of mental health, dependent children
3. Social support unavailable → positive family and social support is protective, loss of control (selling house)
4. Quality of lost relationship → both close and dependent relationships and difficult/abusive relationships
5. Disenfranchised grief - a loss that cannot be publicly acknowledged (affair)

Question 36

Health belief model + 1 adv and disadv

Answer 36

(an expectancy value model)

• whether someone does a behaviour or not
• is based on their beliefs about the outcomes of it
• and the value placed on its consequences
• e.g. wearing a codom to prevent STIs because they believe that the outcome is bad and important to prevent

Adv:
- identifies important barriers to behaviour change

Disadv:
- intentions don’t often predict behaviour e.g. people will still smoke knowing the conequences

Question 37

Theory of planned behaviour + 1 Adv an Disadv

Answer 37

(expectancy value model)
intention is the result of:
- attitudes
- subjective norms
- perceived behavioural control

and then this might result in a behaviour change

Adv:
- intentions do predict some behaviours

Disadv:
- past behaviour is often the best predictor of behaviours

Question 38

Transtheoretical model + 1 Adv and Disadv

Answer 38

behavioural changes are in 6 stages
- pre-contemplation (don’t think of changing)
- contemplation (desire to change)
- preparation (intend to change soon)
- action (behaviour is changed)
- maintenance
- relapse

Adv:
- broad and identifies many useful processes for behaviour change

Disadv:
- assumes that change is always planned and not spontaneous

Question 39

Cognitive dissonance theory

Answer 39

cognitions can be
- dissonant - contradictory
- consanant - in agreement
- irrelevant - neither and irrelevant

dissonance is uncomfortable so people change beliefs to be consonant e.g. smoking + knowing it is bad, you may convince youreself it is beneficial

Question 40

Determinants of physical activity

Answer 40

→ Self-efficacy , Social support, Beliefs and motivation

self efficacy = confidence a person has in their ability to overcome barriers and perform a behaviour (how confident are you that you would go for a run even in the rain?)

social support = resources we have as a result of relationships with others
e.g emotional support, physical help getting to places

Question 41

Apply PA to theory of planned behaviour

Answer 41

subjective norm - people do go for runs
perceived behavioural control - I know where to go for a run
attitudes - running is good for health

results in an intention to run - barrier after thisd

then whether behaviour of running occurs depends on the barrier between behvaiour and intention - intended to run but never got round to it

Question 42

COM-B model and applied to PA

Answer 42

COMB-B - factors that account for whether a behaviour will change
- Capability - having psychological, physical capacity + necessary skills
- Opportunity - no environmental barriers
- Motivation - brain processes associated with the behaviour e.g. intentions + emotions

PA riding a bike
- Capability - can ride a bike safely
- Opportunity - having a bike and people to ride with
- Motivation - wanting to cycle
- Behaviour as a result is cycling to work

Question 43

Health habits model of PA

Answer 43

cycle:
* Cue = trigger = an emotion, a comment, a person, an event
* Routine = behaviour change
* Reward = positive reinforcement that makes it worthwhile and keeps habits going

Question 44

Health belief model applied to PA

Answer 44

Susceptibility to the disease
Seriousness of disease (beliefs about outcome)
Benefits of the change (value placed on consequence)
Barrier overcoming

Question 45

Different levels of intervention + pro and con

Answer 45

DIFFERENT LEVELS OF INTERVENTION

One-to-one, individual
Pros = tailoring, flexible scheduling
Cons = labour intensive and expensive
Group
Pros = added social dynamic, increase motivation and societal norms, cheaper
Cons = more formal and have to cater for group demands
Organisational, community
Pros = safety, wide impact, existing infrastructure
Cons = availability of trained staff and resources
Societal
= PE lessons etc.
Pros = widest impact
Cons = political will and funding needed

Question 46

Describe resource allocation theories: veil of ignorance, libertarian free market, lottery, need, consequentialism

Answer 46

The veil of ignorance
- If we imagined we are behind a veil of ignorance (know nothing of status, wealth etc)
- we would come up with a fairer society because we would imagine that we were the poorest etc.

The libertarian free market
- There should be no resources to redistribute → a society built on trades within the free market (like a child’s lemonade stand)
- Issues: Might exclude the poor, discrimination, should healthcare be treated as commodity (tradeable)

The lottery
- Allocate resources using a lottery, everyone treated equally
- Issues: Doesn’t take into account age, need, cost effectiveness, responsibility

Need
- Allocate resources based on need
- Issues: How to compare - hip replacement vs prostate screen
- Too simple and takes no account of cost effectiveness or responsibility

Consequentialism
- Max utility, requires cost-effectiveness calculations
- QALY = one year of perfect health or two years of half perfect health
- Then you can work out a price/QALY for each intervention (NICE uses this)

Question 47

Describe resource allocation theories: responsibility, social worth, democratic way, pleuralism

Answer 47

Responsibility
- Allocation resources based on the maximisation of health choices and lifestyle
- Incentivises people to behave wisely
- Issues: Not all choices are free - addiction, Judgemental medics and too harsh

Social worth: who is worth more
- Allocate resources on basis of past/current/present contribution to society
- Issues: Discrimination, Who decides, Ignoring need

Democratic way
- Allocate resources based on democratic decision making
- OREGON = just give out funding based on a council made up of general public
- Issues:Discrimination and prejudice, Public lack of specialist knowledge, Bizarre choices → tooth capping > appendectomy > surgery for ectopic pregnancy

Pluralism
- Allocate resources based on some or all of the values listed above
- Takes into account complexity but doesn’t measure different values

Question 48

Can you describe barriers to healthcare for those with intellectual disability?

Answer 48

H- hidden disability (for those who are borderline or don’t yet have a diagnosis)
E - equality (competence of HCP and value of life - push it onto specialists)
A - access barriers (understanding language, reading and writing, getting a GP appointments)
R - recognising unwell (might be non-verbal, where the pain is and how they feel unwell)
D - diagnostic overshadowing (everything is related to disability)

Question 49

Can you describe ways in which we can accommodate and adapt consultations for those with intellectual disability?

Answer 49

V - visual aids, booklets and reading material
A - amount of info (communication passport?) - chunk and check, one question at a time
L - language - particularly for the intimate parts of the body
E - environment and experience
T - time, more time and questions
S - speak slower

Question 50

Can you describe common conservative, medical and surgical support options available through the NHS?

Answer 50

conservative - counselling, therapy, CBT
medical - hormone therapy, facial hair removal
surgical - surgery to alter primary and secondary sex characteristics

can also refer to gender identity clinic
- All GPs can refer without need for mental health assessment
- Patients may use private healthcare - NHS waiting time 🙁

Question 51

Can you outline what harm reduction means in terms of transgender healthcare?

Answer 51

Shared care and harm reduction
* NHS still provides healthcare to patients even if they go private
* Should share results of diagnostic methods with private practices
* Patients should be direct to services they want - i.e. it is unlawful to insist a trans man has to be on a women’s bay
* Harm reduction - people will use things illegally so it’s better to just help them
* Legally- name changes and gender changes via the law = it is unlawful to out someone

Question 52

common law vs statute law for confidentiality

Answer 52

common law = balancing the public interest in doctors keeping things confidential with protecting others from harm

statute law - Human Right Act 1998 - also balance between right to privacy, life and freedom of speech

Question 53

When can disclosure be done without a patient’s consent?

Answer 53

justifiable disclosure in the public interest (serious risk of harm)
AND one of:
- not competent to consent themselves
- obtaining consent would put others at risk
- obtaining consent would undermine the purpose
- time is of the essence

Question 54

What factors need to be present to have any chance of proceeding with a medical negligence action?

Answer 54

1 – The patient must have suffered a clear harm – perhaps pain/stiffness/mobility impairment

2 – He must have been treated below the standard of care expected of the team in the Emergency Department

3 – The staff at the hospital must have had a duty of care to the patient

4 – A breach of that duty of care must have occurred

5 – Such a breach of duty must have caused the harm that the patient had suffered.