Formative Questions 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.
List four aspects of lifestyle you MAY cover in a consultation with ANY patient when giving advice to promote a 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. Although initially surprised, she and Stuart are happy about the pregnancy, but worried about how they might cope in the future.
Which factors enable you, as her GP, to be the most appropriate professional to guide her about her current worries?
- Aware of Hannah’s current and past medical history
- Aware of Hannah’s social circumstances e.g. family support
- GP has knowledge of a broad range of illnesses and health conditions
- Trusted health professional who is likely to have been known by the patient for some time, perhaps all their life
- 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 question - asks about a specific item
- Closed question - can only be answered by “yes” or “no”
- Leading question - presumes the answer (and is best avoided)
- Reflected question - the doctor does not answer the question but asks 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. Research from psychology has produced behaviour change theories such as Social Cognitive Theory (Bandura, 1993). There are five core concepts associated with the Social Cognitive Theory.
List the five core concepts associated with the Social Cognitive Theory.
- Observational learning/modelling (people learn by observing others - learned behaviours)
- Outcome expectations
- Self-efficacy
- Goal setting
- Self-regulation
According to Social Cognitive Theory, an individual’s behaviour is influenced by personal, behavioural and environmental factors.
Give three examples of environmental factors which may influence an individual’s behaviour.
- Culture
- Location
- Income
- Social support
- Time
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?
Health is a state of complete physical (1 mark), mental (1 mark) and social (1 mark) well-being and not merely the absence of disease or infirmity (1 mark).
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.
- 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 prevalence of obesity.
- 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 e.g. cycle lanes
- Funding of NHS treatment for obesity e.g. 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?
The understanding of diverse attitudes, beliefs, behaviours, practices, and communication patterns attributable to a variety of factors (such as race, ethnicity, religion, SES, historical and social context, physical or mental ability, age, gender, sexual orientation, or generational and acculturation status)
List five potential difficulties which may arise when consulting with a patient from a different culture.
- 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 e.g. 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).
- Blood
- Sexual contact
- Inhalation
- Ingestion
List two categories of hazard (other than chemical) AND give an example of each in relation to Jenni’s work in the chemistry lab
- Physical - heat, noise, radiation from lab equipment
- Mechanical - trips and slips
- Biological - spread of infection amongst colleagues e.g. respiratory, GI
- Psychological/stress - anxiety re job security, relationships with colleagues, stressful when busy/deadlines to meet
You treat Jenni’s rash and arrange to review her in two weeks.
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 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
- Advise the patient of the expected course of the illness/recovery
- Advise of symptoms indicating deterioration
- Advise who to contact if patient deteriorates
List three other ways in which Neighbour suggests risk can be minimized.
- 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 e.g. 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.
What is meant by the term “gatekeeper” in this context?
The person who controls patients’ access to specialist or secondary care.
List four advantages of GPs as gatekeepers.
- Identify those patients who are in need of 2° care assessment
- Personal advocacy
- Patient does not necessarily know which specialty to go to
- Increases likelihood of referral to appropriate department
- Increases likelihood of appropriate referral/use of resources
- Limits exposure to certain investigations e.g. MRI scan, X-rays
- GP acts as co-ordinator of care
- Puts GP in position to provide patient education
Approximately what percentage of patients presenting with illness in the community are admitted to hospital each month?
3% (accept 1-5%)
Whilst Michelle is awaiting assessment at the chest clinic, you decide to contact other members of the health and social care team who work in the community to assist with her care.
List three health and social care team members who work within the community whom you may decide to contact to assist with Michelle’s care AND give an example of their role.
- Physiotherapist e.g. help to clear chest secretions
- Pharmacist e.g. advice on medication/interactions/timing of antibiotic medication/encouragement re-concordance
- Dietician - assessment of nutrition and advice on improving appetite/weight gain
- Counsellor - assessment and management of low mood
- Practice nurse - assessment and advice re inhaler use/chronic disease (long term condition) monitoring clinics/flu and pneumococcal immunisation
- Occupational therapist - assess for aids to assist daily living e.g. stair lift, shower rail
You decide that Michelle’s recent care has been sufficiently complex and challenging to warrant writing up a Significant Event Analysis (a form of audit of patient care). As you do this, you reflect on the four ethical principles that underpin medical practice and how these apply to the scenario about Michelle.
One of these ethical principles is Justice.
List the three other ethical principles.
- Beneficence (do good)
- Non-maleficence (do no harm)
- Autonomy
Explain how each of the three principles you have listed in the previous question may apply to the scenario about Michelle.
- Beneficence - her care has been maximised i.e. treatment of infection, discussion with colleagues in microbiology, involvement of practice team, referral for specialist opinion
- Non-maleficence - culture of sputum and discussion with microbiology to minimise risk antibiotic resistance
- Autonomy - patient’s right not to take advised treatment (inhalers) even if fully informed of benefits
Define prevalence
the number of people in population with a specific disease at a single point in time or in a defined period of time
Define Incidence
The number of new cases of a disease in a population
List 4 examples of what the GP could do to help individual patients with obesity
● role model
● prescribing
● tailored advice (diet / exercise)
● referral (dietician etc)
● treat diseases that contribute to obesity
● arrange to see regularly
● education about risks associated with obesity
● tackle underlying causes (depression / low self-esteem)
List 5 other health professionals who could also be involved in obesity
● community dietician ● psychologist ● pharmacist ● bariatric surgeon (2ndary care) ● practise nurse ● school nurse ● health visitor ● midwife
) Explain the difference between statistical and cultural definitions of normality:
● statistical normality = based on the normal distribution curve / standard deviation
● cultural normality = based on norms and values within a certain group (community)
7) How might changes in cultural perceptions of normality have led to the observed statistical differences illustrated earlier (in part 5):
● the fact that people see more obese people shifts their notion of what is normal; it becomes accepted, and normal, to eat eat more junk food, take less exercise etc
● thus being obese becomes normal; obesity may be perceived to be related to affluence or attractiveness or health
8) How might obesity affect an individual’s health at each of the 3 levels listed below:
● psychological = reduced self-esteem
● physical = difficult to move or keep fit
● social = ostracization by peers
List 2 disadvantages of GPs as gatekeepers
○ patients have less choice in secondary care
○ puts stress on GP to know everything about every disease / symptom
○ dependent on individual GP knowledge, attitudes, skill, practice organisation
○ puts stress on a good doctor-patient relationship
○ seeing a GP might increase the time it takes to receive the needed treatment
○ patients have less choice in secondary care
○ puts stress on GP to know everything about every disease / symptom
○ dependent on individual GP knowledge, attitudes, skill, practice organisation
○ puts stress on a good doctor-patient relationship
○ seeing a GP might increase the time it takes to receive the needed treatment
● physical:
○ James might be too tired to do long shifts
○ dangers of working on an oil rig
○ dangers of transportation to the oil rig
○ adjustment to day / night shift patterns
○ potential for obesity due to abundance of food in canteen
○ potential for improved physical health in James if he makes use of healthy eating options & facilities offshore
○ Sandra might be tired of the ‘single-parent’ role when James
● psychological:
○ anxiety & stress in James and Sandra due to dangerous working environment / separation from family
○ both James and Sandra might be anxious about the security of his employment in the current economic climate
○ anxiety & stress about uncertain return home (weather delay)
○ anxiety & stress about helicopter journeys
○ possible depression in either due to repeated periods of isolation
○ anxiety & stress in children due to separation / father’s job
● social:
○ relation difficulties due to nature of James’ job
○ able to spend additional time with family and friends during onshore periods
○ discipline problems in children due to ‘absent’ father figure
○ substance misuse due to stressful nature of job
○ well paid employment allows family to afford good lifestyle, decent car, to go on holiday
○ no smoking / alcohol when offshore
○ James may binge drink when onshore
2) Unfortunately, the company employing James restructures its workforce and James is made redundant;
2a) Give 2 possible effects this might have on Sandra’s health (2 marks):
● exhaustion due to working extra hours to maintain family finances
● worry / stress about the entire family’s future
● anger that the husband has been made redundant
● stress at husband being at home all the time = change of friendly dynamics
● enjoyment of increased time to spend with husband
● positive future outlook with possibility of husband gaining more family-friendly employment
2) Unfortunately, the company employing James restructures its workforce and James is made redundant;
2b) Give 2 possible effects this may have on James’ health (different answers to part 2a) (2 marks):
● feelings of worthlessness
● guilt that he is no longer supporting his family
● anxiety about finding another job / retiring
● depression
● anger at his employer’s
● positive outlook for new future employment
● enjoyment of more time with family
● substance misuse as coping mechanism
2c) Sandra attends to see you for a routine appointment and asks you about her husband’s health; state how you would with her enquiry (2 marks)
● maintain James’ confidentiality (MUST be mentioned as 1 mark)
● consider need to maintain James’ trust
● consider GCM guidelines
● acknowledge Sandra’s concern
● ask Sondra why she is concerned
Define Culture, Ethnicity, Race
● culture (either of the 2)
○ complex whole which includes knowledge / beliefs / art / morals / law / customs (Tyler 1874)
○ systems of shared ideas, systems of concepts, rules and meanings that underlie and are expressed in the ways that human beings live (Keesing 1981)
● ethnicity
○ cultural practises and outlooks that characterise and distinguish a certain group of people; characteristics identifying an ethnic group may include a common language, common customs and beliefs and tradition; term preferred over ‘race’
● race
○ a group of people linked by biological / genetic factors
4) Your next patient that morning is Jenny Shand, a 15 year old schoolgirl who has a chest infection. You discover that she smokes 12 cigarettes per day. After dealing with her chest infection and discussing her smoking, you use the reminder of the consultation to enquire about other aspects of her social health.
4a) List 2 other aspects of Jenny’s social health which you may want to discuss in the consultation (2 marks):
● sexual health ● alcohol ● illicit drugs ● exercise ● diet-eating patterns ● family influence (parental smoking for e.g) ● peer pressure to smoke
4b) It is known that the prevalence of smoking varies according to social class. Social class is a form of social stratification. The most common occupational classification currently in use, and used in Britain since the 1911 Census has 6 social classes. List these 6 social classes (6 marks):
● professional ● managerial & technical ● skilled non-manual ● skilled manual ● partly skilled ● unskilled
4c) Give an explanation as to how culture may influence smoking behaviour in different social classes (2 marks):
● lower social classes see larger numbers of people around them smoking and are more likely to accept it as normal behaviour
● those around them are also more likely to accept the start of another individual smoking as normal behaviour (no stigma attached)
Possible reasons for social class correlating with obesity
● early life experience ● education ● cooking facilities / ability ● cost of healthy food ● cultural expectations ● access to good quality food provision ● carry-out culture ● unhealthy budgeting choices (e.g cigarettes, convenience foods over healthy foods) ● some students may note that the ‘blip’ in quintile 1 males relates to executive lifestyle / ‘business lunch culture’
6) The next patient you see that day is Alan McCann, an Aberdeen taxi driver. During the consultation, he tells you that he is feeling very stressed at work as one of his colleagues was recently stabbed and robbed by a drunken passenger. His stress is being made worse by current difficulties in his marriage. Various models have been described to explain individuals’ experience of, and response to, stress.
6a) One of the 3 models of stress is described as part of the community course case study is the engineering model. List the other 2 models (2 marks):
● medico-physiological model
● psychological or transactional model
6b) Briefly describe the engineering model of stress (2 marks):
● stress acts as a stimulus which the individual must resist
● if the stimulus becomes too intense or prolonged, the individual breaks
6c) Show how the engineering model of stress applies to Mr McCann’s situation (2 marks):
● mr McCann makes efforts to resist the stress and anxiety he feels at work and about his domestic circumstances
● however, if the stressors are prolonged or if his work / marriage situation deteriorates further, he may no longer be able to cope and he may suffer a pathological stress reaction
6d) Give 2 possible coping mechanisms an individual may use when faced with a stressful situation (2 marks):
● problem focused
● emotion focused
● combination of problem / emotion focused
7) The way in which you discuss the diagnosis of stress with Mr McCann is at least important as the treatment that he is eventually given. There are 3 main styles of doctor-patient relationship listed in the year 1 community course workbook. One of these is ‘guidance/co-operation’.
7a) Describe this style of doctor-patient relationship (2 marks):
● the doctor exerts a degree of authority and the patient is obedient
● the patient does have a little feeling of autonomy and participates to a small degree in the relationship
7b) Name the other two styles of doctor-patient relationship described by Szasz and Hollender (1956) (2 marks):
● authoritarian / paternalistic
● mutual participation
7d) Not all communication is verbal. List 2 different ways in which the doctor can facilitate the interview in a nonverbal way (2 marks):
● listening ● use of silence ● posture ● body language ● specific gestures ● facial expressions ● eye contact ● layout of room (not talking across desk) ● staying in room (not leaving to take a phone call)
8d) Approximately how many patients are registered on average with each GP in the NHS in the UK (1 mark):
● 1200-2000 patients each
2) 8 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. Although initially surprised, she and Stuart are happy about the pregnancy. Some of their friends already have babies. Teenage pregnancy is more common in deprived areas than in more affluent areas
2a) List 4 other aspects of health which are likely to be worse for children (of all ages) living in the most deprived areas compared to those living in the least deprived areas (4 marks):
● lower birth weight ● less likely to benefit from breastfeeding in infancy ● poorer dental health ● higher rates of obesity ● more likely to take up smoking
