General Flashcards
What is the sick role?
The rights and responsibilities for patients and doctors when they have a consultation. It is the behavior expected of a person who is physically ill, mentally ill, or injured
What are patients expected to do in the sick role?
Must want to get well as quickly as possible
Should seek prompts medical advice and cooperate
Allowed to shed normal activities and responsibilities, e.g., work
Regarded as in need of care and unable to get better on their own
Criticism of the sick role
Symptom iceberg - patient’s do not necessarily come to the dr for help
Patients with chronic illness and MUS find it difficult to enter the sick role
People try to label themselves as sick
Conflict between best interests of patient and cost to society of the allocation of resources
What are the two agendas of sickness?
Disease - the pathology/ what is wrong with the body
Illness - the patient experience of disease
Legislation that supports carers
Employment act
Carers and disability act
Carers act
Equality act
Financial support available for carers
Carer’s allowance
Disability living allowance
Attendance allowance
Sources that should be used when making a clinical decision
Patient preference
Available resources
Research evidence
Clinical expertise
Why is evidence based decision making important
Deals with uncertainty
Medical knowledge is incomplete/shifting
Patients will receive most appropriate treatment
Constant need for innovation/improvement
Improving efficiency of healthcare services
Reduces practice variation
Why does medicine used guidelines
Allows practice to be more evidence based
Enables care to be more consistent across the country
Aspects of research cycle
Identify a clinical problem
Basic research - laboratory based
Applied (clinical) research
Clinical care
Roles of post mortem examination
Relatives cannot register death until a medical identification of death is classified
Information recorded on certificate underpins national mortality data
Importance in monitoring population health - epidemiological research
Informs authorities of need for intervention and allows targeting of that
Research - tissue pathology allows development of understanding of natural Hx, potential tests for investigation of disease presence, ID drug targets
Reasons a death should be referred to a coroner
Cannot readily be certified as being due to natural causes
The deceased was not seen by a doctor within the 14 days prior
Element of suspicious circumstances
History of violence
Death linked to an accident
Question of self-neglect or neglect by others
Death occurred or illness arisen during/shortly after being detained in custody
Detained under MHA
Death is linked with an abortion
May have been contributed to by actions of the deceased himself
Hx of drug or solvent abuse, self-injury or overdose
Receiving war pension/industrial disability pension unless death shown to be unrelated
Due to industrial disease or related to deceased’s employment
During an operation/before full recovery from anaesthetic/related to anaesthetic (24 hours)
Related to a medical procedure or treatment
Due to lack of medical care
Unusual or disturbing features to the case
Occurs within 24 hours of admission
May be wise to report death where there is an allegation of medical mismanagement
Aims of an audit
Clinical education
Encourages teamwork
Improve service/care
Gain financial incentives
Fulfils contractual obligations
Stages of an audit
Set standards - NICE/local guidelines
Measure current performance
Compare vs standards - how are we doing
ID barriers/steps to improve - how can we/what’s stopping us getting better?
Make changes - implement plan
Re-audit - did the plan work?
Factors that influence the rate of infection
Infectious agents - pathogenicity, ability to spread
Environment - animals, water, population
Mode of transmission - airborne, faecal-oral, droplets, aerosol
Portal of entry - mouth, nose, GIT
Host factors - chronic illness, nutrition, age
Nosocomial infections
MRSA Catheter-associated UTI Pneumonia C diff Surgical wounds Septicaemia
Reducing nosocomial infections
Prevention - handwashing, infection control programmes, advisory service, surveillance, sterilisation
Detection, investigation and control of outbreaks
Policies and procedures to prevent and control infection - education and training
What is antibiotic resistance
Bacterial change so antibiotic no longer work in people who need them to treat infections
Causes of antibiotic resistance
Use in livestock
Release of antibiotics into the environment during pharmaceutical manufacturing
Volume of antibiotic prescription
Missing doses when taking antibiotics
Inappropriate prescribing of antibiotics
How to prevent antibiotic resistance
Use antibiotics only when prescribed
Complete full prescriptions
Never share antibiotics
Never use leftover prescriptions
Only prescribing antibiotic when needed
Using the right antibiotic to treat illness
Features of a dependence syndrome
Salience
Compulsion
Tolerance
Withdrawal
Relief after abstinence and reinstatement upon abstinence
Narrowing of repertoire
What makes drugs addictive
Pleasure producing potency
Rapid onset of action/ short duration of action
Tolerance
Withdrawal effects
Medical conditions wholly attributable to alcohol misuse
Alcoholic liver disease
Alcoholic neuropathy / Korsakoffs
Chronic pancreatitis
Alcoholic cardiomyopathy
Alcoholic gastritis
Alcohol related accidents
Ways to stop smoking
Brief advice
Behavioural support - motivational interviewing, CBT, telephone service
NRT - bupropion, varenicline
Health promotion for alcohol/substance misuse
Education - PSHE and TV/radio, FRANK education programme
Policy - minimum unit pricing, taxation, stricter licensing laws
Mass media campaigns - Drink await
What is lay referral system
People talk to other people before seeking help
Zola’s triggers for help-seeking behaviour
Interference with work or physical activity
Interference with social relations
Interpersonal crisis (i.e. death in family)
Putting time limit on symptoms
Sanctioning (relative/friends tell them to seek health care advice)
Barriers to help-seeking behaviour
Provision & availability of resources
Transport - cost, car ownership
Disruption to work
Attitudes of staff
Previous bad experience
Inverse care law
Geographical distance from healthcare
Time/effort
Long waiting times
Inability for time off work/children
What is paternalism?
Interference with person’s freedom of information and choices in health care
What is Bolams test
is a means of assessing clinical negligence in Court
If a Dr/nurse reaches the standard of a responsible body of medical opinion, he is not negligent
What is Bolitho amendment
An addition to the Bolam test of the legal standard of care required in negligence actions, which states that a professional’s acts or omissions be assessed to see if (i) they accord with a reasonable body of opinion and (ii) they withstand the logical analysis of the court.
The concept that doctors should behave in a logical way
What is beneficence
The principle of beneficence is the obligation of physician to act for the benefit of the patient
What is autonomy
is the right of competent adults to make informed decisions about their own medical care.
What is normative ethics
study of the means of deciding what is right and wrong
What is meta ethics
refers to the nature of ethical terms and concepts and to the attempt to understand the underlying assumptions behind moral theories
is the study of the nature, scope, and meaning of moral judgment
study of moral concepts
What is deontology
is an ethical theory that uses rules to distinguish right from wrong
also known as “duty-based ethics”. This ideology states that the correct course of action is dependent on what your duties and obligations are.
It means that the morality of an action is based on whether you followed the rules, rather than what the consequence of following them was.
What is applied ethics
The use of moral principles and reasoning to solve problems that arise in practical fields, such as health care, law, or management.
Social constructionist regarding disability
The concept that there is no such thing as a disabled individual but that society makes people individual
Social model of disability
Discrimination against disabled people is due to the organisation of society
Medical model of disability
The medical model of disability says people are disabled by their impairments or differences
What is opportunity cost?
The loss of other alternatives when one alternative is chosen
What is eugenics
Improving a population by controlled breeding
Wordens four tasks of mourning
accept the loss
acknowledge the pain of the loss
adjust to a new environment
reinvest in the reality of a new life
What does the Marmot review summarise to address health care inequalities?
- giving every child the best start in life
- enabling all children, young people and adults to maximize their capabilities and have control over their lives
- creating fair employment and good work for all
- ensuring a healthy standard of living for all
- creating and developing sustainable places and communities
- strengthening the role and impact of ill-health prevention.
Process of stigma
Labelling
Stereotyping
Separating
Lose social status
Discrimination
What is technical efficiency?
Investing in healthcare interventions which make the best use of scarce resources
Calculating incidence
New case of disease (within a period) / no initially free of disease
Calculating prevalence
( number of existing cases / total population ) X 1000
What is care poverty?
the inability to work because you are a carer
What is flat curve of medicine?
There is an increase in cost and no further improvement on health
What is the implementation gap?
Gap between scientific understanding and patient care
SPIKES for breaking bad news
Setting up and starting Perception Invitation Knowledge Emotions Strategy and summary
Herd immunity formula
1 - (1/R0)
What is statistical power?
The probability of rejecting a null hypothesis when it is false
What is a CDSS?
clinical decision support system (CDSS)
Examples:
- laboratory information systems (LISs) highlighting critical care values or pharmacy information systems (PISs) presenting an alert ordering a new drug and proposing a possible drug-drug interaction
- drug dosage advice
- screening alerts
- reminder systems
What is the Gini coefficient
is a measure of statistical dispersion intended to represent the income inequality or the wealth inequality within a nation or a social group
measure of inequality
What is a decision tree?
decision support tool that uses a tree-like model of decisions and their possible consequences, including chance event outcomes, resource costs, and utility
square = decision circle = chance
What is relative risk
The ratio of the probability of developing an outcome in those exposed compared to those not exposed
What is a never event
Serious incidents that are entirely preventable because of guidance or safety measures
Explanations of black report 1980
statistical artefact
health or social selection
materialist/structuralist cultural/behavioural health difference
poverty causes poor health
Findings of black report 1980
The group found that there were differences in mortality rates across the social groups, with those in lower social groups suffering higher rates of mortality. The report also found inequalities in access to health services, particularly preventative services, with low rates of uptake by the working classes
Recommendations of the black report
increasing child benefit
improving housing
agreeing minimum working conditions with unions.
What is the Ulysses arrangement
Advanced directive for Bipolar Disorder
Bowlbys stages of grief
Shock and numbness. · Yearning and searching. · Despair and disorganization. · Re-organization and recovery.
ABDCE method of breaking bad news
Advance preparation Build therapeutic environment/relationship Communicate well Deal with pt/family reactions Encourage and validate emotions
Types of stigma
Social stigma, which involves the prejudiced attitudes others have around mental illness
Self-perceived stigma, which involves an internalized stigma the person with the mental illness suffers from
Anticipated stigma - expectation bias from others
Experienced stigma
Discrimination - the behavioural result of prejudice
Discredited - stigma known about
Discreditable - stigma not known about
Bradford Hill criteria
Strength of association Consistency Specificity Temporality Biological gradient Plausibility Coherence Experiment Analogy
What is exculpation
Confirming the symptoms are not the patients fault
Regulated complementary and alternative medicine?
Osteopathy
What is cost-effective analysis
costs and outcomes are combined into a single measure to allow comparison
Leventhal model of illness
1) how people identify an illness using symptoms and a disease label (identity),
2) beliefs about cause,
3) duration (timeline),
4) personal consequences
5) control
Requirements for valid consent
Well informed
Voluntary
Has capacity
Why is consent required
Improve trust between pt and dr
Legal requirement
Respects autonomy
Professional duty
When can confidentiality be breached
Law
Consent by patient
Public best interest
What law allows you to break pt confidentiality if pt has STI/HIV?
public health act
Summary of Swiss cheese model
Many layers of defence lie between hazards and accidents
Flaws in each layer align and allow accidents to occur
Causes of human error
Inexperience Unfamiliarity with task Shortage of time Inadequate checking Poor procedures Poor human equipment interface
Types of violation
Routine - regularly performed shortcuts due to the system, process or task being poorly designed
Reasoned - occasional deviation form a protocol or procedure which we believe have good reason for making
Reckless - deliberate deviation from protocol and includes ignoring foreseeable harm even though it may not be intended
Malicious - deliberate deviation from protocol with intention to cause harm
How to know if a hospital is safe?
Hospital mortality
Data on other measures of safety - reports of never events, safety thermometer
Monitoring and inspection by regulators - CQC, NHS improvement
WHOs 5 steps of health promotion
Health public policy Action in the community Re-orientating health services Personal skills Supportive environment
Define primary, secondary and tertiary health prevention
Primary - aims to prevent onset of disease (e.g., screening risk factors)
Secondary - detect and cure/reduce effects of disease at an early stage (e.g., cancer screening)
Tertiary - minimise the effects.reduce the progression of irreversible disease (self-management programs for those with chronic disease)
Beattie’s model of health promotion
Health persuasion - public health campaigns, recommended alcohol levels, adverts
Personal counselling - one to one, goal setting, tailored support and action plans
Legislative - food labelling, speed limit on road
Community development - working with stakeholders, community campaigning, group fundraising to improve local services
Prevention paradox
Preventative measure that brings benefit to local population but offers little to each participating individual
Objectives of vaccination
Reduce M+M Prevent outbreaks and epidemics Contain infection within population Generate herd immunity Eradicate infectious agent Interrupt transmission to humans Reduce no of infections
Diseases that have been eradicated with vaccination
Small pox
Polio
What travel vaccines are not free on NHS
Hep B Japanese encephalitis Yellow fever Meningitis Rabies TB
What is reproductive rate
estimates the average number of secondary cases per infection cases in the population made up of both susceptible and non-susceptible hosts
R=RoX
Ro - average number of individuals directly infected by an infectious agent in a totally susceptible population (basic reproduction rate)
X = fraction of the host population which is susceptible
R=1 is epidemic threshold
Adverse effects of screening
Cost and use of medical resources
Adverse effects of screening procedure - stress, radiation
False positive results
Unnecessary investigations and treatment of false positives
Stress of prolonging knowledge of illness without any improvement in outcome
False negative - false security
What is Sojourn time
The duration of a disease in which there are no clinical symptoms but the disease is detectable through screening
Cancer reform strategy 6 key areas
Prevention - tackle smoking, obesity
Screening - diagnose cancer early
Ensuring better treatment - reduce waiting times, increases radiotherapy capacity
Living with and beyond cancer - national cancer survivorship initiative
Reducing cancer inequalities
Delivering care in the most appropriate settings - e.g., locally
Ethical theories
Deontology - an ethical theory that uses rules to distinguish right from wrong
Virtue ethics - person rather than action based: it looks at the virtue or moral character of the person carrying out an action, rather than at ethical duties and rules, or the consequences of particular actions.
Consequentialism - Of all the things a person might do at any given moment, the morally right action is the one with the best overall consequences.
Deductive arguments
Purely logical argument using premises that follow each other
Inductive arguments
Making an argument based on observation with more probable conclusions
Argument valid?
Premises follow each other
Argument does not beg question
Argument sound?
Not if premise is false/opinion/moral claim
Fallacies that should be avoided in arguments
Straw man fallacy - ignore persons actual position and substituting it for a distorted/exaggerated version of that position
Ad Hominems - directing an argument against a person rather than the point they make
Appealing to emotion
Begging the question
Argument from fallacy - conclusion must be false as premises are false
Purpose of cancer registries
Establish incidence and survival over time between demographic groups and social groups to reduce inequality
Track efficacy of screening and primary prevention schemes
Allows comparison between regions - evaluates the quality of care
Evaluates the impact on social and environmental factors
What is recorded on cancer registry
Cancer diagnosis - type, date/location
Cancer treatment - type, date/location
Outcomes - date of death, cause of death
What is national cancer research network? (NCRN)
Aim to ^ speed, quality and integration of research to improve patient care
Supports prospective cancer trials and trials performed by charities
Measures of structure relative to cancer care
Facilities
Resources - human and material
Organisation - ie. clinics, consultants, nurses, mammogram scanner, GPs
Health promotion strategies for MH
Parenting programmes - for children with conduct disorder, prevent PD
HV interventions - for women at ^ risk of PND
School based programmes - prevent violence, bullying, offending and reoffending
Screening and brief intervention - alcohol CAGE
Debt advice
Physical activity campaigns
Anti-stigma campaigns
Promote well being and early depression detection at work
Strengths of ICD-10/DSM
Standardisation of diagnostic criteria
Allows epidemiological studies, geographical comparisons of prevalence and incidence
Alphanumerical format, allows quick referral and easy addition of categories
Limitations of ICD-10/DSM
Two different criteria sets - who uses what
Schizophrenia diagnosis relies on many psychotic Sx, which are a common final pathway in other disease
Just groups commonly co-existing Sx patterns, without understanding underlying cause/nature
Role of CPN and key worker in MH
CPN - talk through problems, offer advice and support, give meds and monitor Fx
Key worker - manage cases and checks in with patients
What is health protection?
Responsibility of PHE to deal with outbreak situations and monitor the emergence of diseases not previously seen in the UK
What is standard error
A measure of the accuracy with which a sample represents a population
What form of service improvement science technique is best to explore the root cause of a problem,?
Fishbone chart
Maximum age by which a smoker will need to quit in order that their life-expectancy remains equal to that of a never smoker
40
What self report impact of urinary incontinence worried most women
Coughing or sneezing
