Formative 2017 Flashcards
You are a partner in a large GP practice located in the centre of one of the more deprived housing estates in Aberdeen. You are about to start morning surgery.
Your first patient is 18 year old Hannah Myles. She left school last year, but is now working part-time in a supermarket and attending college two days per week, studying for Highers. She has a regular boyfriend, Stuart, whom she has been seeing for the last six months. She is much more settled at her work and college than she had been at school, but does enjoy attending parties and often drinks more alcohol than recommended by recognised guidelines. She uses the oral contraceptive pill and has booked an appointment today for a routine health check prior to her repeat prescription.
Hannah’s pill check is satisfactory and you use the remainder of the consultation to discuss a healthy lifestyle.
You are a partner List 4 aspects of lifestyle you may cover in a consultation with ANY patient when giving advice to promote healthier lifestyle
Diet Exercise Alcohol Smoking Illicit drug use Sexual health
Eight weeks later, Hannah books another appointment. She had missed some of her pills during a weekend of partying and has now missed a period. She has already attended a local walk-in health clinic and has a positive pregnancy test. Hannah tells you that she has some worries about the pregnancy and the future challenges of being a young mother.
Which factors enable you to be the most appropriate professional (4)
- Aware of Hannah’s past and current medical history
- Aware of Hannah’s social circumstances (family support)
- GP has a knowledge of broad range of health conditions
- GP likely to be local to Hannah’s home and so accessible
- Trusted professional likely to have known family a long time
- GP has role in prevention as well as diagnosing / treating illness / disease i.e. GP is responsible for holistic patient care
When discussing Hannah’s concerns, you use open-ended questions. This type of question is not seeking any particular answer, but simply signals to the patient to tell their story or voice their concerns. This is just one of the types of question which can be used in the consultation. List four other types of question which may be used in a consultation and give a brief explanation of each
- Direct - asks about a specific item / topic
- Closed - can only be answered by yes or no
- Leading - presumes the answer (best avoided)
- Reflected - allows doctor to avoid direct question from patient by asking the patient to think about the answer themselves
One of the topics you discuss with Hannah is that her current alcohol intake may be harmful to the baby. If Hannah is to stop drinking alcohol whilst pregnant, she must be motivated to change. Knowledge from psychology has identified several factors which are related to an individuals motivation to change.
List four factors which would make a patient more likely to be motivated to change their behaviour and stop drinking. For each factor, give an example relating to Hannah.
- Advantages of not drinking (i.e. healthy baby) outweigh the disadvantages
- Anticipating a positive response from others by making the change
- i.e. Hannah’s boyfriend / family also want the unborn child to be health - If there is a social pressure to change
- she may feel looked down on if she is a pregnant woman drinking - Perceiving the new behaviour to be consistent with self-image
- i.e. Perceives herself as an “earth mother” - Belief of ability to carry out a change in a range of circumstances
- i.e. at home, parties
The next patient you see that morning is 78 year old Georgina Smith, a retired cleaner. She lives with her husband and enjoys visits from her family, who live locally. She enjoys spending time in her small garden and also going to play bingo with her friends. She is a heavy smoker, is obese, and has angina and emphysema.
Despite her obesity, angina and emphysema, Georgina considers herself to be healthy and normal. As a GP, you are aware that professional and lay beliefs about health often differ. Health professionals often use the World Health Organisation (WHO) definition of health, (1948).
What is the World Health Organisation (WHO) definition of health? (4 marks)
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity
Blaxter (1995) found that lay beliefs about health included absence of disease, physical fitness and functional ability. Lay beliefs about health are influenced by a number of factors.
List four factors which influence lay beliefs about health AND give an example of how each of these factors may influence lay beliefs about health. (8 marks)
- Age - older people concentrate on functional ability, younger people tend to speak of health in terms of physical strength and fitness
- Social Class - people living in difficult economic and social circumstances regard health as functional (ability to be productive, take care of others), women of higher social class or educational qualifications have a more multidimensional view of health
- Gender - men and women appear to think about health differently - women may find the concept of health more interesting, women include a social aspect to health
- Culture - different perceptions of illness / disease, differences in concordance with treatment
Georgina’s obesity may increase the symptoms associated with her angina and emphysema and is a risk factor for a number of diseases. Scottish government figures show that since 1995 there has been a significant increase in the proportion of adults aged 16-64 categorised as obese (from 17.2% in 1995 to 25.6% in 2013).
List six actions the government could take to stem the rise in obesity. (6 marks)
Health Education - diet and exercise Tax on unhealthy foods - "fat tax" Legislation - proper labelling, lists of ingredients / food content Enforcement of legislation Ban on advertising unhealthy food Improve exercise / sport facilities Subsidise healthy food Transport policy i.e. cycle lanes Funding of NHS treatment for obesity - i.e. specialist clinics, bariatric surgery
Later that morning, you see 28 year old Jenni Chua. She initially moved to the UK from Malaysia to study for a post-graduate degree, but is now happily settled in this country, working as a chemist for one of the large oil companies. Jenni is just one of a large number of patients in your practice population who are from a different culture. This requires you and your colleagues to demonstrate cultural competence.
What is meant by cultural competence? (2 marks)
Cultural competence is the ongoing capacity of healthcare systems, organisations and professionals to provide for diverse patient populations, high quality care that is safe, patient and family centred, evidence based and equitable
7b) List five potential difficulties which may arise when consulting with a patient from a different culture. (5 marks)
- Lack of knowledge about NHS / UK health care system
- Lack of knowledge about common health issues / different health beliefs
- Fear and distrust
- Racism
- Bias and ethnocentrism
- Stereotyping
- Language barriers
- Presence of a third party i.e. family member, translator in the room
- Differences in perceptions and expectations between patient and doctor
- Examination taboos
- Gender difference between doctor and patient
- Religious beliefs
- Difficulties using language line
- Patient may not be entitled to NHS care
Jenni has developed a painful, itchy rash on her hands, which she thinks has resulted from contact with chemicals in the lab.
List three different routes via which someone may be exposed to a hazardous substance (other than via skin)
(3 marks)
Blood
Inhalation
Ingestion
Sexual Contact
List two categories of hazard (other than chemical) AND give an example of each in relation to Jenni’s work in the chemistry lab. (4 marks)
Physical - heat, noise, radiation from lab equipment
Mechanical - trips and slips
Biological - spread of infection amongst colleagues i.e. respiratory, GI
Psychological / Stress - anxiety re job security, relationships with colleagues, stressful when busy / deadlines to meet
You are then consulted by 31 year old James McKay, who has brought his two year old son Mark to see you. James and his wife have been concerned about Mark over the last 24 hours as he has been fevered (pyrexial).
After a careful history and examination you diagnose a viral illness. However, it is well recognized amongst health professionals that young children can rapidly become very unwell. Hence, when reassuring James that you think Mark has a viral infection and advising him on how to deal with it, you also “safety net”. Safety netting is one way in which risk can be minimized in the consultation as described by Neighbour (The Inner Consultation, Roger Neighbour, 2nd edition, 2004).
List three aspects of advice you may give to the patient/their carer when safety netting.
(3 marks)
Advise the patient of the expected course of the illness / recovery
Advise of symptoms indicating deterioration
Advise who to contact if patient deteriorates
9b) List three other ways (other than safety netting) in which Neighbour suggests risk can be minimised.
(3 marks)
Summarise and verbally check that reasons for attendance are clear
Hand over and bring the consultation to a close - i.e. hand over to the patient at the end to ensure all issues have been covered
Deal with the housekeeping of recovery and reflection - i.e. record keeping, referral if necessary, pausing to reflect before next patient
Following this, you see Michelle White, a 55 year old office worker with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis. She had been stable for a number of years and was discharged from the chest clinic some time ago. Over the last three months, she has been unwell with recurrent chest infections and several different antibiotics have failed to help, despite sputum culture and appropriate antibiotic sensitivities being noted and discussions with the microbiology lab having occurred. She has a poor appetite, has lost weight and her mood is low. She also feels her inhalers are not so effective as they used to be and her concordance with treatment is erratic. Fortunately, she has an understanding employer and sick leave has not been a problem. Following discussion with Michelle, you decide to refer her back to the chest clinic, employing your role as a “gatekeeper”. The GP is often described as the “gatekeeper” of the NHS.
10a) What is meant by the term “gatekeeper” in this context? (1 mark)
A person who controls patient’s access (via referral) to specialist / secondary care
List four advantages of GPs as gatekeepers (4 marks)
- Identify those patients who are in need of secondary care assessment
- Personal advocacy
- Patient does not necessarily known which speciality to go to
- Increases likelihood of referral to appropriate department
- Increases likelihood of appropriate referral / use of resources
- Limits exposure to certain investigations i.e. MRI scan, X-ray
- GP acts as a co-ordinator of care
- Puts GP in position to provide patient education
