Formative Exam

Question 1

Wilson and Jungner (1968) stated that before setting up a screening programme for any disease, several factors need to be taken into consideration.

List ten of them.

Answer 1

Will the test detect the condition at an early pre-clinical stage?

Is the disease an important public health problem?

Is the natural history of the disease adequately understood?

Is a test available for the condition?

Is the test sensitive (low false negatives)?

Is the test specific (low false positives)?

Is the test safe?

Is the test acceptable to the public and professionals involved?

Is the cost of the test reasonable?

Does the overall cost-benefit analysis make it worthwhile e.g. number of tests required to save one life?

Is treatment for the condition being screened for of proven effectiveness?

Is treatment for the condition being screened for safe?

Is treatment for the condition being screened for acceptable to public and professionals?

Are facilities for diagnosis and treatment available?

Question 2

Give a brief description of a case control study

Answer 2

In case control studies, two groups of people are compared: a group of individuals who have the disease of interest are identified (cases), and a group of individuals who do not have the disease (controls).

Data are then gathered on each individual to determine whether or not he or she has been exposed to the suspected aetiological factor(s) and whether or not a conclusion can be drawn that the suspected aetiological agent is a likely cause of the disease in question.

Question 3

Give a brief description of a cohort study

Answer 3

In cohort studies, baseline data on exposure are collected from a group of people who do not have the disease under study.

The group is then followed through time until a sufficient number have developed the disease to allow analysis.

Question 4

When studying population health to aid health care planning, numerous sources of epidemiological data may be utilised. List six possible sources of epidemiological data which may provide information on ischaemic heart disease.

Answer 4

Mortality data

 Hospital activity statistics

 General Practice morbidity/disease registers

 Health and household surveys/population census data

 Social security statistics

 NHS expenditure data

 Any other reasonable source of data suggested by student

Question 5

Your first patient in morning surgery is 45 year old Vladimir Melyanets, who moved to the UK from Russia 18 months ago and works on an offshore oil platform. He presents with dermatitis affecting his hands and lower arms and tells you that he thinks it is work related.
3a) List five points in Vladimir’s history which would help you decide whether occupational contact dermatitis is the likely diagnosis.

Answer 5

Does he work with chemical irritants?

 How much exposure does he have to these irritants (intensity/duration)?

 Do his symptoms improve when not at work e.g. onshore, holiday?

 Is personal protective equipment (PPE) used?

 Does the patient comply with PPE use?

 Does the company enforce PPE use?

 Do other work colleagues have similar symptoms?

 Has he any hobbies/pets/other activities which may be a likely cause?

 Does he use hand cream or other topical agents he may be allergic to?

Question 6

You provide Vladimir with a prescription and advice and ask him to return for review one month later. By this time, his dermatitis is much better, but he has some other issues he wishes to discuss with you. Although he, his wife and his young daughters are happy in Aberdeen and have adjusted well to life in the UK Vladimir complains that he feels anxious and has difficulty sleeping. As a GP you are aware that offshore oil industry workers may suffer a variety of psychological and/or social issues.

3b) List five examples of psychological and/or social issues which may be affecting Vladimir.

Answer 6

Anxiety re travel

 Depression perhaps secondary to loneliness/away from family

 Stress due to shift pattern

 Pressure to maintain standard of living

 Difficulty adjusting back in to family life when onshore

 Abuse of drugs or alcohol

 “Misses” Russian culture/ethnic isolation

 Anxiety re job security

Question 7

There are models relating to behaviour change. One of these models is the Stages (Cycle) of Change model.

The following descriptions (in random order) show how this model can be applied to a patient who smokes. State which stage of the model applies to each description (one has already been completed).

1. I no longer smoke and haven’t done so for 18 months.
2. I have booked an appointment to see my GP about nicotine patches (nicotine replacement therapy).
3. I currently smoke and do not intend to stop in the next six months.
4. I had stopped smoking, but have had a few cigarettes recently because work is so stressful.
5. I stopped smoking one week ago.
6. I currently smoke, but am thinking about giving up.

Answer 7

1. Maintanence
2. Preparation
3. Pre-contemplation
4. Relapse
5. Action
6. Contemplation

Question 8

List ten potential difficulties which may arise in ANY consultation as a result of cultural differences.

Answer 8

• Lack of knowledge about some health issues/NHS
• Fear and distrust
• Racism
• Bias and ethnocentrism
• Stereotyping
• Ritualistic behaviour
• Language barriers
• Presence of third party e.g. family member/translator in the room
• Differences in perceptions and expectations
• Examination taboos
• Gender difference between doctor and patient
• Religious beliefs
• Difficulties using language line

Question 9

Look at the two population pyramids for Scotland between 1951 and 2031. What two differences in population demographics are apparent from these pyramids?

Answer 9

Increasing elderly population
• Fewer young people
• “Baby boom” bulge may be noted in 2031 pyramid

Question 10

Give two possible reasons for the trends shown in the population pyramids.

(population pyramids show an aging population -> more elderly and less young people)

Answer 10

• Decrease in premature mortality/increased life expectancy
• Decrease in birth/fertility rates
• Migration
• Greater availability of contraception
• Improvements in housing
• Improvements in sanitation
• Baby boom-post war recovery years followed by greater sexual “freedom”
• Health education programmes e.g. smoking, exercise, diet
• Improved safety and reduction of injury

Question 11

List three issues this will present to health care services and three social issues relating to the trends shown in the pyramids.

(aging population)

Answer 11

Health services – Increased numbers of geriatricians and allied health professionals required, increased wards/health care facilities for elderly health care, increased prevalence long term conditions such as diabetes, CVD, renal disease, need for specific health promotion campaigns aimed at elderly

Social - increasing dependence on families and/or carers who are also ageing, demand for home carers and nursing home places likely to increase, increasing emphasis on social activities for elderly within communities, role of elderly as grandparents and carers of grandchildren likely to change, housing demands are likely to change as more elderly people live alone

Question 12

Later in your morning surgery, you see Kathy Roberts. She is 50 years old and cares for her 82 year old mother, Jean Smith. Jean has several co-morbidities and is on multiple medications. She lives with Kathy and her family.
6a) List five ways in which her role as a carer might affect Kathy.

Answer 12

• Poor mental health e.g. stress, anxiety, depression, emotional demands
• May have to give up work/work less hours
• Financial implications e.g. due to impact on work, extra expense of caring for her mother
• Lack of privacy for Kathy and her family
• Restriction on social activities/social isolation
• Less time for hobbies
• Adaptation to Kathy’s house e.g. bathroom modifications, stair lift
• Positively-may gain satisfaction from/enjoy her role

Question 13

6b) Suggest five ways in which problems Kathy may experience in her role as a carer could be alleviated.

Answer 13

• Sitter services e.g. Crossroads
• Home carers to assist with her mother’s personal care
• Elderly frozen food deliveries
• Day care centre
• Respite care
• Benefits e.g. attendance allowance, carers allowance
• Psychological support e.g. carer’s centres, counselling
• Disabled badge scheme
• Physiotherapy/OT assessment and support
• Medication review
• Additional help from other family members, friends, neighbours

Question 14

Amongst her multiple pathologies, Jean has osteoarthritis, ischaemic heart disease, type 2 diabetes and severe renal disease. Her health is rapidly deteriorating.
Several members of the multi-professional team are involved in Jean’s care. List five team members other than the GP and give a brief description of their role in relation to Jean’s care.

Answer 14

1. District nurse and/or practice nurse
   - e.g. pressure areas, bloods, BP monitoring
2. Home carer
   - practical tasks e.g. bathing, dressing
3. Pharmacist
   - advice on medication, dossett box
4. Social worker
   - benefits, contact with agencies
5. OT
   - adaptation living environment to maximise independence e.g. stair lift, hoist, shower modification
6. Physiotherapist
   - maintain any remaining mobility, walking aids
7. GMED/NHS 24
   - out of hours care if unexpected problems
8. Nurse practitioner
   - initial assessment during house call if change in health, GP supported prescribing
9. Dietician
   - advice on diet to minimise further deterioration in renal function
10. Practice staff e.g. receptionist
    - passing on concerns/first point of contact
11. Physician’s assistant
    - GP supported medical assessment and care

Question 15

8a) List six points to consider when breaking bad news to Michael and his sister.

Answer 15

 Listen to the patient and their carers

 Set the scene

 Check whether Michael wants to speak himself or with his sister present

 Find out what the patient already understand
s
 Find out how much the patient wants to know

 Share the information using a common language/avoid jargon

 Review and summarise the information

 Allow opportunities for questions

 Agree follow up and support

Question 16

8b) List two examples of typical emotional reactions which may be experienced in this situation and state how they may manifest.

Answer 16

Shock-news is completely unexpected, patient may be tearful and anxious

Anger-angry with themselves for earlier health related behaviour e.g. smoking or angry with health care professionals for not being able to provide cure

Denial-patient does not believe it can be true and for a time will fail to acknowledge reality of situation

Bargaining-“if I change something in my life, perhaps I will get better” Relief-patient glad to finally know what is wrong so they can plan for the future

Sadness/depression-low mood common, especially if patient been ill for some time or following bad news

Fear/anxiety-fear of dying, worry about pain, worry about family who are left

Guilt-not able to provide for family any more, guilt that earlier behaviours may have affected health e.g. lack of exercise, XS alcohol intake

Distress-patient unable to cope with news and shows acute anxiety, tearfulness

Question 17

Following surgery, you go on a house call to a poorly patient who has just registered with the practice, following discharge from hospital. Michael Findlay is a 63 year old with severe chronic obstructive pulmonary disease (COPD), who has moved in to his 59 year old sister’s home to facilitate her involvement with his care. Michael took early retirement from his job as a welder due to his COPD. Although he has now stopped smoking, he was a heavy smoker for most of his adult life. He is severely restricted in his activities of daily living due to his COPD. He is breathless on minimal exertion, FEV1<30%, spends most of the morning in bed, sits in his chair most of the afternoon and retires to bed exhausted in the early evening. He receives long-term oxygen therapy. Michael has now had three admissions to hospital with infective exacerbations of COPD in the last six months.
It does not take you long to realise that it is unlikely that Michael will still be alive in six months or so. You also realise that Michael and his sister are unaware of the severity of his COPD and find yourself in the situation of breaking bad news.

After spending a considerable time discussing the severity of Michael’s long term condition with him and his sister, you agree that he should have supportive and palliative care and draw up an Anticipatory Care Plan.

9a) Identify five aspects in Michael’s history which indicate he is a suitable patient to receive supportive and palliative care.

Answer 17

Not expected to be alive in next 6-12 months

Breathless at rest/minimal exertion
FEV1<30%

Spends more than 50% of day in bed or chair

Long term O2 therapy

Three hospital admission with acute exacerbations in last 6 months

Question 18

9b) List five points relating to the proactive care resulting from anticipatory care planning.

Answer 18

 Patient on GP palliative care register and discussed at team meetings

 Information on social and financial support given to patients and their carers and referral to relevant team members to facilitate provision of this

 Usual GP and District Nurse support visits and phone calls

 Assessment of symptoms and partnership with specialists to customise care to patient
and carer needs

 Overall care assessed, including respite and psychosocial needs

 Preferred place of care noted and organised

 Care plan and medication issued for home

 End of life pathway/LCP used

 Dies in preferred place, family bereavement support

 Staff reflect-SEA, audit, gaps in care identified, learn, improve care

Question 19

What is the definition of sustainability?

Answer 19

“(The Ability to be) Able to continue over a period of time”

Question 20

List four positive factors that might contribute to a sustainable medical career.

Answer 20

 Work life balance

 Autonomy

 Flexibility of role

 Job satisfaction

 Team working and development of the team

 Good relationship with colleagues

 Manageable workload

 Ability to develop knowledge and diversify interests.

Intellectual stimulation.

Maximal use of personal abilities and skills

 Outside interests for example hobbies – may promote resilience

 Professional respect from colleagues and patients

 Reasonable occupational health provision

 Potential for educational role

 Job Security

 Financial Security/Reasonable Remuneration

 Stable Terms and Conditions