Formatives

Question 1

List 4 aspects of lifestyle you may cover in a consultation with any patients when giving advice to promote a healthier lifestyle

Answer 1

a. Diet
b. Smoking
c. Alcohol
d. Sexual health
e. Exercise
f. Illicit drug use

Question 2

Eight weeks later, Hannah books another appointment. She has 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 clinical 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 as her GP to be the most appropriate professional to guide her about her current worries?

Answer 2

a. Aware of Hannah’s current and past medical history
b. GP has knowledge of a broad range of illnesses and health conditions
c. Aware of Hannah’s social circumstances e.g family support
d. Trusted health professional who is likely to have been known by the patient/family for some time, perhaps lifelong
e. GP has role in prevention as well as diagnosing/treating illness/disease i.e GP is responsible for holistic patient care
f. GP likely to be local to Hannah’s home and therefor accessible

Question 3

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 questions which can be used in the consultation.
List 4 other types of question which may be used in a consultation and give a brief explanation of each (8 marks)

Answer 3

a. Direct question – asks about a specific item
b. Closed question – can only be answered with ‘yes’ or ‘no’
c. Leading question – presumes the answer (best avoided)
d. Reflected question – the doctor does not answer the question but asks the patient to think about the answer themselves

Question 4

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)

Answer 4

a. Health is a state of complete physical (1mark), mental (1 mark) and social (1 mark) well-being and not merely the absence of disease of infirmity (1 mark)

Question 5

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.
5b) 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)

Answer 5

a. Age-older people concentrate on functional ability, younger people tend to speak of health in terms of physical strength and fitness
b. 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
c. 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)
d. Culture-different perceptions of illness/disease, differences in concordance with treatment

(4x2 = 8 marks)

Question 6

Georgina’s obesity may increase the symptoms associated with her angina and emphysema and is a risk factor from 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 6 actions the government could take to stem the rise in obesity (6 marks)

Answer 6

a. Health education – diet and exercise
b. Tax on unhealthy foods
c. Legislation-proper labelling, lists of ingredients/food content
d. Enforcement of legislation
e. Ban on advertising unhealthy food
f. Improve exercise/sport facilities
g. Subsidise healthy food
h. Transport policy e.g cycling lanes
i. Funding NHS treatment for obesity e.g specialist clinics, bariatric surgery

Question 7

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)

Answer 7

a. Cultural competence is the ongoing capacity of healthcare systems, organizations and professionals to provide for diverse patient populations high quality care that is safe, patient- and family- centered, evidence-based, and equitable

Question 8

List five potential difficulties which may arise when consulting with a patient from a different culture; (5 marks)

Answer 8

a. Lack of knowledge about NHS/UK health care system
b. Lack of knowledge about common health issues/different health beliefs
c. Fear and distrust
d. Racism
e. Bias and ethnocentrism
f. Stereotyping
g. Language barriers
h. Presence of a third party e.g family member, translator in the room
i. Difference in perceptions and expectations between patient and doctor
j. Examination taboos
k. Gender difference between doctor and patient
l. Religious beliefs
m. Difficulties using language line
n. Patient may not be entitled to NHS care

Question 9

1Jenni 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)

Answer 9

Injection
Inhalation
Blood
Sexual

Question 10

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)

Answer 10

a. Physical – heat, noise, radiation from lab equipment
b. Mechanical – trips and slips
c. Biological – spread of infection amongst colleagues e.g respiratory, GI
d. Psychological/stress – anxiety re job security. Relationships with colleagues, stressful when busy/deadlines to meet

Question 11

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 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).
9a) List three aspects of advice you may give to the patient/their carer when safety netting. (3 marks)

Answer 11

a. Advise the patient of the expected course of illness/recovery
b. Advise of symptoms indicating deterioration
c. Advise who to contact if patient deteriorates

Question 12

List 3 other ways in which Neighbour suggests risks can be minimised

Answer 12

a. Summarise and verbally check that reasons for attendance are clear
b. 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
c. Deal with housekeeping of recover and reflection e.g record keeping, referral if necessary, pausing to reflect before the next patient

Question 13

What is meant by the term gatekeeper?

Answer 13

aThe person who controls patients’ access to specialist or secondary care

Question 14

What are the 4 advantages of a GP being a gatekeeper

Answer 14

a. Identify those patients who are in need of secondary care assessment
b. Personal advocacy
c. Patient does not necessarily know which specialty to go to
d. Increases likelihood of referral to appropriate department
e. Increases likelihood of appropriate referral/use of resources
f. Limits exposure to certain investigations e.g MRI scan, X-rays
g. GP acts as a co-ordinator of care
h. Puts GP in position to provide patient education

Question 15

Approximately what percentage of illnesses occurring in the community are referred onto 2ndry care

Answer 15

1%

Question 16

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. (6 marks)

Answer 16

a. Physiotherapist e.g help to clear chest secretions
b. Pharmacist e.g advice on medication/interactions/timing of antibiotic medication/encouragement re concordance
c. Dietician – assessment of nutrition and advice on improving appetite/weight gain
d. Counsellor – assessment and management of low mood
e. Practice nurse – assessment and advice re inhaler use/chronic disease (long term condition) monitoring clinics/flu and pneumococcal immunisation
f. Occupational therapist – assess for aids to assist daily living e.g stair lift, shower rail

Question 17

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.
What are the 3 other ethical principles? (3 marks)

Answer 17

a. Beneficence – her care has been maximised i.e treatment of infection discussion with colleagues in microbiology, involvement of practical team, referral for specialist opinion (1 mark)
b. Non-maleficence – culture of sputum and discussion with microbiology to minimise risk of antibiotic resistance (1 mark)
c. Autonomy – patients right not to take advised treatment (inhalers) even if fully informed of benefits (1 mark)

Question 18

The World Health Organisation (WHO) defines three categories under which disability can be described. List these three categories and give a brief explanation of each. (6 marks)

Answer 18

i. Body structure and function impairment - is defined as abnormalities of structure, organ or system function (organ level)
ii. Activity limitation - is defined as changed functional performance and activity by the individual (personal level)
iii. Participation restrictions - is defined as the disadvantage experienced by the individual as a result of the impairments and disabilities (interaction at social and environmental level)

Question 19

You are a newly qualified GP in an Aberdeen City practice. You are consulting in your normal afternoon surgery. One of your patients, John Young is brought in by his mother. He is seven years old and has cerebral palsy. He walks with a limp and has mild learning difficulties, although manages to attend mainstream school. John’s mother is concerned because he has had earache for two days.

a. The World Health Organisation (WHO) defines three categories under which disability can be described. List these three categories and give a brief explanation of each.

i. Body structure and function impairment
ii. Activity limitation
iii. Participation restrictions

Give any four examples of how these definitions could apply to John. (4 marks)

Answer 19

i. Damage to motor area of brain
ii. Damage to cognitive area of brain
iii. Limited mobility
iv. Learning difficulty
v. Exclusion or difficulty participating in certain activities e.g. riding a bike, certain sports

Question 20

Disability has far reaching implications for patients, their families and others around them. In general, what might be the effect of a disabled child on their parents, siblings, peers and teachers? Give examples of how it might affect the parents

Answer 20

a. Parents
iMother and/or father may not be able to combine work with the demands of caring for disabled child - financial implications for family

iGuilt at having passed on the causative gene if genetic disorder

Psychological strain

Caring for disabled child may be detrimental to parent’s physical health

Some parents may have difficulty bonding with disabled child

Some parents may form a particularly strong bond with disabled child

Marital problems

Increased risk of child abuse

Over-protection of disabled child

May become a strong advocate for their child

Question 21

Disability has far reaching implications for patients, their families and others around them. In general, what might be the effect of a disabled child on their parents, siblings, peers and teachers? Give examples of how it might affect the siblings

Answer 21

Resentment at time parents spend caring for disabled child

Resentment at restrictions to normal family life

May have to develop carer role

Grow up with greater understanding of disability

Question 22

Disability has far reaching implications for patients, their families and others around them. In general, what might be the effect of a disabled child on their parents, siblings, peers and teachers? Give examples of how it might affect the peers

Answer 22

May look out for disabled child

Friend may be stigmatised along with the disabled child

May grow up with greater understanding of disability

May need to adapt activities to include disabled friend

Teasing by other peers

Question 23

Disability has far reaching implications for patients, their families and others around them. In general, what might be the effect of a disabled child on their parents, siblings, peers and teachers? Give examples of how it might affect the teachers

Answer 23

iMay have lack of understanding of disability/lack of training

iMay have tendency to over-protect disabled child

May be lack of willingness to integrate in mainstream activities

May be additional challenges in personalising education for disabled child

Stress of managing both mainstream and additional support needs pupils in the same class

Question 24

As the parent of a child with a disability/long term condition, John’s mother could be classed as an expert patient. List two different points to show your understanding of the term “expert patient”. (2 marks)

Answer 24

a. Patient/carer has an in-depth knowledge of their condition (or in this case the condition of the person they care for), sometimes exceeding that of health professionals
b. Utilising the knowledge of the patient/carer (mutual decision making about management of the condition) is likely to greatly benefit the patient’s care and quality of life
c. Historically, the knowledge and experience held by the patient/carer has been an under-recognised resource

Question 25

On this occasion John’s presenting symptom is not serious and his mother is happy with the advice you give. Your next patient is 62 year old Marion Yule. She has developed symptoms of chest discomfort and breathlessness when walking uphill over the last four months and found some information which suggested attending her GP.

A lay source of information is just one of a number of factors influencing the uptake of medical care. List five different sources of information used by the general public which may influence their uptake of medical care. (5 marks)

Answer 25

a. Peers / family / friends
b. Internet - general information e.g. google, social media
c. TV
d. Health pages of newspaper or women’s magazine
e. “What should I do?” / “When should I worry?” booklet
f. SHOW (Scotland’s health on the web) website, NHS inform website
g. GP practice leaflet
h. GP practice website
i. Adverts in public places e.g. bus stops, railway stations
j. Health awareness events e.g. health fairs
k. Pharmacies e.g. posters, leaflets

Question 26

By sourcing information, Marion has shown a degree of health literacy. Health literacy is being increasingly recognised as a significant health concern around the world. Provide a brief description of health literacy. (2 marks)

Answer 26

Health literacy is about people having the knowledge, skills, understanding and confidence to use health information, to be active partners in their care, and to navigate health and social care systems.

Question 27

Following investigation, Marion is diagnosed with angina and she commences treatment. In managing Marion’s angina, you refer to SIGN (Scottish Intercollegiate Guidance Network) Guidelines.

The guidelines are based on a systematic review of the scientific literature and are aimed at aiding the translation of new knowledge into action, and are intended to achieve three main aims. List the three intended aims of SIGN Guidelines. (3 marks)

Answer 27

a. Help health and social care professionals and patients understand medical evidence and use it to make decisions about healthcare
b. Reduce unwarranted variations in practice and make sure patients get the best care available, no matter where they live
c. Improve healthcare across Scotland by focusing on patient-important outcomes

Question 28

1Scotland has a high prevalence of the risk factors associated with heart disease, such as smoking, poor diet and physical inactivity. Overall, it is estimated that around 7.5% of men and 4.6% of women are living with Coronary Heart Disease/CHD (2015 data).

Ascertaining prevalence of diseases within a population is important for health service planning and funding.

Doctors working in population health use a variety of sources and types of epidemiological data to ascertain prevalence of a large number of diseases found within the population.

Answer 28

a. Mortality data
b. Hospital activity statistics
c. Reproductive health statistics
d. Cancer statistics
e. Accident statistics
f. General practice morbidity
g. Health and household surveys
h. Social security statistics
i. Drug misuse databases
j. Expenditure data from NHS
k. ISD Scotland statistics

Question 29

The results of studies looking at risk factors for diseases can be made harder to interpret by the presence of confounding factors. Give a brief explanation of what is meant by a confounding factor AND give two examples of common confounding factors. (4 marks)

Answer 29

a. A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease.

b. Common confounding factors
Age
Sex
Social class

Question 30

Population pyramids for all countries show general trends of increasing numbers of older people and fewer younger people. Some reasons for these trends relate directly to improvements in health care provision e.g. better treatment and prevention of diseases. However, there are a number of reasons for these trends in population demographics which are not directly related to health care provision. List six reasons for these trends which are not directly related to health care provision.

Answer 30

a. Decrease in birth/fertility rates
b. Improvements in housing
c. Improvements in water supplies
d. Improvements in sanitation/sewerage systems
e. Improvements in nutrition
f. Improved safety and reduction of injury
g. Migration (some areas only)
h. War/genocide (some areas only)

Question 31

Ageing populations have a variety of implications and consequences in different countries. List five different social implications associated with Scotland’s increasing elderly population. (5 marks)

Answer 31

a. Increasing dependence on families and/or carers who are also ageing and perhaps still working themselves
b. Demand for home carers likely to increase
c. Demand for Care home/nursing home places likely to increase
d. Increasing emphasis on social activities for the elderly within communities
e. Role of elderly as grandparents and carers of grandchildren likely to change e.g. may have fewer/no grandchildren, may still be in employment themselves
f. Housing demands are likely to change as more elderly people live alone e.g. increased demand for one-bedroom flats, sheltered housing
g. Elderly people remaining in employment for longer may lead to an increase in unemployment rates in the young (this point could equally well be made as an economic implication)

Question 32

You ask Sadie to stop the ibuprofen because you are concerned about potential side-effects. Suggest three possible side-effects of Sadie’s use of ibuprofen which may concern you. (3 marks)

Answer 32

a. Worsening of hypertension/interaction with anti-hypertensive medication
b. Cardiotoxicity
c. Nephrotoxicity
d. Exacerbation COPD
e. GI upset

Question 33

Statistics show that 40% of carers care for their parents or parents-in-law. Being a carer may carry a significant financial impact, as well as other social, physical and mental implications.

List four possible financial implications of being a carer. (4 marks)

Answer 33

a. Almost 1 in 3 (30%) carers had seen a drop of £20,000 or more a year in their household income as a result of caring/significant loss of income due to caring role - e.g. working less hours in order to fulfil carer role
b. A third of carers had cut back on essentials like food and heating (32%)/cutting back on household basics
c. 45% (large numbers) of carers said their financial circumstances were affecting their health
d. 42% (large numbers) of carers have missed out on financial support, e.g. missing out on benefits, as a result of not getting the right information and advice

Question 34

It is increasingly common for elderly patients with multimorbidity such as Sadie, to have Anticipatory Care Plans (ACPs). ACPs usually include legal, personal and medical issues. List two examples of legal issues which may be included in an Anticipatory Care Plan for ANY patient. (2 marks)

Answer 34

a. Welfare power of attorney
b. Financial power of attorney
c. Guardianship