Formative Practice

Question 1

You are a GP in a practice in a deprived urban area. A large number of your patients have ischaemic heart disease (IHD). You are considering setting up a clinic to prevent ischaemic heart disease.

Prior to setting up the IHD clinic, you consider whether to screen for risk factors for IHD e.g. serum cholesterol measurement.

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

Question 2 Part 1 - Several different types of study are encountered in epidemiological research. Give brief descriptions of both case control and cohort studies.

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.

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 3

Question 2 Part 2 - 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 3

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 4

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.

Question 3 Part 1 - List five points in Vladimir’s history which would help you decide whether occupational contact dermatitis is the likely diagnosis.

Answer 4

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 5

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.

Question 3 Part 2 - List five examples of psychological and/or social issues which may be affecting Vladimir.

Answer 5

Anxiety r.e. travel

Depression, perhaps secondary to loneliness/away from family

Stress due to shift pattern

Pressure to maintain standard of living

Difficulty adjusting back into family life when onshore

Abuse of drugs or alcohol

“Misses” Russian culture/ethnic isolation

Anxiety r.e. job security

Question 6

Question 4

As noted above, the Melyanets family have settled well in the UK and you have had no difficulty during consultations with them. However, it is recognised that problems can occur during consultations with patients from a different culture.

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

Answer 6

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 7

Question 5 Part 1 - Look at the two population pyramids for Scotland between 1951 and 2031. Give two possible reasons for the trends shown in the population pyramids.

Answer 7

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 8

Question 5 Part 2 - List three issues this will present to health care services and three social issues relating to the trends shown in the pyramids.

Answer 8

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 9

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.

Question 6 Part 1 - List five ways in which her role as a carer might affect Kathy.

Answer 9

Poor mental health e.g. stress, anxiety, depression, emotional demands

May have to give up work/work fewer 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 10

Question 6 Part 2 - Suggest five ways in which problems Kathy may experience in her role as a carer could be alleviated.

Answer 10

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 11

Question 7

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 11

Question 12

Your final patient of morning surgery is 13 year old Jim who is brought by his mother Anne. Jim’s school teachers have flagged up concerns about him recently appearing sleepy in class. Anne is concerned that he may have developed thyroid problems, as she was diagnosed with an underactive thyroid four years ago.

Question 8 Part 1 - List five factors that may be contributing to Jim’s tiredness, other than possible physical illness.

Answer 12

Poor diet

Inadequate sleep

Excess screen time

Lack of exercise/too much exercise

Academic difficulties

Home/relationship difficulties

Bullying

Social isolation

Mental illness

Question 13

After taking a thorough history, you discover that Jim was recently given an iPad for his birthday and takes it to bed with him in the evenings. Anne is unsure how long he spends on it before going to sleep. He has also been picked for the local football team and has been training three nights per week and on Saturday mornings. Jim comments that they are having less opportunity to sit down as a family to eat together in the evening.

Question 8 Part 2 - How many minutes of exercise should Jim be getting per day as suggested by NHS guidelines?

Answer 13

60 minutes

Question 14

Question 8 Part 3 - How many hours of sleep per night is recommended for teenagers to function best?

Answer 14

8-10 hours

Question 15

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.

Question 9 Part 1 - 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 understands

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

Patients and their carers show a variety of emotional reactions when receiving bad news, some immediately and some over a period of time.

Question 9 Part 2 - 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 has 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

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.

Question 10 Part 1 - 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

Anticipatory Care Planning promotes discussion in which individuals, their care providers and, often those close to them, make decisions with respect to their future health or personal and practical aspects of care. It aims to provide “proactive” rather than “reactive” care.

Question 10 Part 2 - 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

That evening, you attend a meeting of GPs, hospital consultants and Health Board managers. A visiting speaker gives a talk about sustainability in the NHS prior to the group brainstorming ideas about how to make medical careers in the NHS more sustainable.

Question 11 Part 1 - What is the definition of sustainability?

Answer 19

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

Question 20

Sustainability is a term that could also be applied to careers in medicine.

Question 11 Part 2 - 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