Health and Society Flashcards
What is the social model of disease ?
The social model of disease recognizes broader influences on health alongside biology.
Health is made up 4 factors surrounding that individual;:
- Biology
- Lifestyle
- Social factors
- Environment
How is medicine understood ?
( Biomedical model of disease)
Biomedicine is the most dominant way of understanding health and illness.
Biomedicine understands the problems of disease and illness as being about a biological cause.
The problems with the biomedical model of disease:
- The problem is that the biomedical model fails to see illness as a matter of the whole person, in that it overlooks the importance of social, lifestyle and psychological factors in the onset of complex and chronic disorders.
- Reductionist: its tends to reduce problems to a biological cause
- Individualistic: focuses on individuals rather than groups or populations.
- Relies on a dualistic view: believe that the mind and body are both real and neither can be assimilated to the other
What is the dualistic view ?
Mind and body dualism represents the metaphysical stance that mind and body are two distinct substances, each with a different essential nature
What is epidemiology ?
The branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health.
Epidemiology is the method used to find the causes of health outcomes and diseases in populations.
In epidemiology, the patient is the community and individuals are viewed collectively
What is public health ?
‘The art and science of improving health and protecting people from ill health…’
Focus on health of whole populations
Intervention on environment and healthcare services
How would you find the cause of an illness ?
-Looked for a cause
-Tested a hypothesis
-Collected data
-Analysed data
-Looked for patterns
Societal change and health.
Describe Industrialization, in 19th century London ?
- Industrialization took place in London between 1760 to 1850.
- Between 1800- 1850 the London population rose from 1 to 5.5 million.
- There was a rapid increase in urban density which promoted disease.
What contributed to bad health:
- poor sewerage which was uncapable of managing quantities of human and animal waste.
- Coal burning created poor air quality
- Factory child labour was common
What is industrialization ?
Industrialization refers to a process which has occurred in the history of all economically ‘developed’ nation states and which remains an aspiration for most of the governments of those many populations which remain today relatively undeveloped.
Through industrialization the economy of a country is dramatically transformed so that the means whereby it produces material commodities is increasingly mechanized since human or animal labour is increasingly replaced by other, predominantly mineral sources of energy in direct application to the production of useful commodities1. Industrialization is a special case of the near-universal phenomenon of human trade and economic change. It refers to a period of marked intensification of such activity, which in all known cases has resulted in an irreversible change in a country’s economy, after which the production and international trading of commodities remains permanently at a much higher level of intensity.
This is largely because the factorial increase in productive capacities made possible by the technological shift in power supply simultaneously entails a wide range of accompanying transformations in the social relations of work, trade, communications, consumption and human settlement patterns and so, inevitably, also implies profound cultural, ideological and political change.
Describe what demographic transition is with an example ?
Demographic transition: is a historical shift from high birth rates and high death rates in societies with minimal technology, education (especially of women) and economic development, to low birth rates and low death rates in societies with advanced technology, education and economic development.
- An example is 17th century (1601-1699) and 18th century (1701-1799) England where infant mortality was very high.
- In London during this time period infant mortality was about 250-350/ 1000 births.
- Infectious diseases was a major killer and infants and children were particularly vulnerable.
- Infnat mortality fell between 1850-1950 dramatically. In 1950 infant mortality was about 10 deaths/ 1000 births.
Why did infant mortality fall ?:
- improved access to medicine and healthcare such as vaccinations and antibiotics
- Others such as McKeown (1979( argued it was living standards not medicine, that improved life expectancy. These included improved sanitary conditions (which reduced waterborne diseases) and improved nutrition ( increased resistance)
- McKeown argues it is societal conditions that fundamentally determine health
What is Epidemiological transition ?
In demography and medical geography, epidemiological transition is a theory which “describes changing population patterns in terms of fertility, life expectancy, mortality, and leading causes of death
What was the epidemiological transition that took place int he UK during the 20th century ?
- During the 20th century life expectancy increases
- In the 20th century chronic diseases (rather than infections) became the main cause of death.
- In the era of infectious disease a biomedical model of disease made sense.
_ However now in the era of long term disease a biopsychosocial model is more relevant.
What is a population ?
What is odd ratios ?
- is a statistic that quantifies the strength of the association between two events
What is confidence interval ?
- The confidence interval (CI) is a range of values that’s likely to include a population value with a certain degree of confidence.
- 95% confidence level is the most common, but other levels such as 90% or 90% are sometimes used.
Factors which effect the width of the confidence interval:
- confidence level
- sample size
- variability in the sample
- All other factors being the same a larger popularion
What is confidence interval ?
- The confidence interval (CI) is a range of values that’s likely to include a population value with a certain degree of confidence.
- 95% confidence level is the most common, but other levels such as 90% or 90% are sometimes used.
Factors which effect the width of the confidence interval:
- confidence level
- sample size
- variability in the sample
- All other factors being the same a larger population will produce a narrow confidence interval
- Greater variability in the sample produces a wider confidence interval.
- A higher confidence level would demand a wider confidence interval.
What is evidence- based medicine ?
Evidence-based medicine is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”
What is Cochrane Collaboration (1993) ?
What are the themes focused on in Health and Society ?
What is medical professionalism ?
- A set of values, behaviors and relationships expected of docters.
What actions do you display if you have medical professionalism ?
What does professionalism mean as a medical student at HYMS ?
- Behave according to ethical and legal principles
- Reflect, learn and teach others
- Learn and work effectively within a multidisciplinary team
- Protect patients and improve care
What issues give rise to fitness to practice concerns ?
- Lack of probity / honesty
- Course engagement issues , including unauthorized absences
- Behaviors that cause or threaten to cause harm
- Breaches of patient
confidentiality - Substance abuse
- Misuse of social media
- Withholding or misinterpretation of health issues
What is medical ethics ?
What is moral theory ?
Moral theories seek to provide an account of what makes an action right or wrong
A moral theory consists of more or less connected claims arranged to determine what a morally good or right action or stance is, and what it is that makes it either right or good.
The 3 main types of moral theory are:
- Consequentialism
- Duty- based ethics (deontology)
- Virtue ethics
What is consequentialism ?
-Consequentialism is a theory that says whether something is good or bad depends on its outcomes.
- An action that brings about more benefit than harm is good, while an action that causes more harm than benefit is not.
-the consequences of one’s conduct are the ultimate basis for judgment about the rightness or wrongness of that conduct
- For instance, most people would agree that lying is wrong. But if telling a lie would help save a person’s life, consequentialism says it’s the right thing to do.
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What is Duty-based ethics (Deontology) ?
- The theory that the morality of an action should be based on whether that action itself is right or wrong under a series of rules and principles, rather than based on the consequences of the action.
- Ethical actions follow universal moral laws
Examples:
- Do not kill
- Do not steal
- Do not lie
- Respect Elders
- Keep your promises
What is virtue ethics ?
What is virtue ethics ?
Characteristics a virtuous person would have:
- humility
- charity
- chastity
- gratitude
- temperance
- patience
- diligence
What are the 4 principles of biomedical ethics ?
- Autonomy
- Beneficence
- Non- maleficence
- Justice
What would make a doctor feel uncertain about a medical decision ?
- You may not have enough information available to assist with accurate diagnosis (technical uncertainty)
- You may not be sure what the patient wants ( personal uncertainty )
- You may have difficulty applying the knowledge you have (from general guidelines) to a specific patient (conceptual uncertainty)
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What is the role of evidence when making medical decisions ?
- Evidence is a way of reducing UNCERTAINTY in medical decision making. Evidence is used to inform decisions.
Where can you get evidence from to help you with a medical decision:
- your personal experience - so what you think is right based on the experience you have and situations you have been in before
- Other peoples experiences - use other peoples expertise
- The view of ‘experts’ - these people will have the most uptodate and relevant information on the given topic
-Information from books and journals
The most reliable evidence is empirical evidence which has been peer reviewed and is accessible world wide.
Empirical evidence is information that is acquired by observation or experimentation and is used to prove or disprove a hypothesis
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What is the importance of collecting evidence based data and organizing an interpreting it in a systematic way ?
This drug thrombolytic was used to help dissolve blood clots in patients and reduce their chances of getting a heart attack.
However it did come with the risk of causing internal bleeding such as a bleed in the brain.
The first trial was done in 1960 and randomized control trials continued until 1990. Someone collected all the trails done and interpreted the data in a systematic way and by doing this you can see that it was clear that thrombolytic was an effective drug.
The reason this realization had not come sooner is because the evidence had not been pooled together (no internet) so it was not clear by one study alone to see how effective the drug was.
The consequences of not pooling the data together earlier is that some patients who would have benefited from taking thrombolytic never had the opportunity to because there was not enough concrete data supporting its effectiveness. By collecting all the randomized trails and pooling the data it was much easier to see the effectiveness of that drug. A bigger sample population makes the confidence interval narrower. In the end we had a p value of P<.00001 which suggests the chance of thrombolytics clot dissolving effects being due to chance was 1 in 100,000 which is pretty low. Which shows the drug works.
So the disadvantages of not being organized and looking at evidence systematically is that you may not see the benefits of a specific treatment.
Example of why evidence based medicine is important (SIDS)
SIDS (sudden infant death syndrome) caused deaths in many infants.
- SIDS is thought to be caused by a viral infection the baby might have and then they end up overheating in the night.
- Decades of advice said put the baby to sleep on their front because they wont choke if they get sick.
- Even Dr Spock wrote many books on how to take care of infants advising them to sleep that baby on their front.
- By 1986 there was research evidence proving the increased risk of sleeping a baby o their front compared to their back
- However in 1990 they started a campaign advising parents to put babies to sleep on their backs. The graph shows their was a dramatic decrease in SIDS after this campaign begun.
This is a nice example of expert opinion not based on evidence but based on intuition and judgement but was wrong. And it was only with research studies we found that putting babies on their back was the safest way for babies to sleep and not die from SIDS.
SIDS incidence fell by 50-70% in many countries, associated with a fall in front sleeping
From 1974 until 1991 (start of the UK ‘Back To Sleep’ campaign) estimated 11,000 excess deaths or nearly 12 extra babies dying each week in the UK
Health advice to put infants on their front for almost 50 years contrary to evidence (available from 1970) that this was likely to be harmful
The importance of timely evidence
- A review found there was a long delay between evidence from research suggesting a treatment was effective and when textbooks gave
the same information. - Textbooks around treatment will go out of date really quickly.
What is the effects of the rise of using evidence based medicine ?
What is a diagnosis ?
What is prognosis ?
What is a treatment decision ?
What are the theories of decision making ?
Understanding decision making is important because it helps accelerate your decision making skills and also helps you avoid making mistakes other may have made.
There are a number of decision making theories:
- Normative: what you should be doing, according to social or professional norms
- Descriptive theories: what are you doing ? Describes what people are doing at a particular time
- Prescriptive theories: how can we improve what you are doing ?
What is diagnostic clinical reasoning ?
- Docters use a Hypothetico-deductive model. This is where you set up a hypothesis about what is going on, an explanation for what you are seeing and then you try to find evidence to try and disprove your hypothesis.
A null hypothesis is a type of statistical hypothesis that proposes that no statistical significance exists in a set of given observations.
Example of null hypothesis: If one plant is watered with distilled water and the other with mineral water, then there is no difference in the growth and nourishment of these two plants
In recent research by Norman 2005, it was found:
- Hypothetico-deductive model is more common in less experienced doctors
- In experienced Docters the hypothetico- deductive model is used for less familiar diagnostic problems
- More experienced clinicians will use a approach called pattern matching. This is matching the patients signs and symptoms with patients they have seen with similar problems.
Consequences of pattern matching:
When patient data is analyzed, too often the objective is to take a very large group of patients who may have little in common but for a narrowly defined clinical element, measure an “average patient” and then use that average as the model for treating all patients who have the same disease. But this approach doesn’t always work. Not all patients who have multiple sclerosis are the same; some also have hypertension and some have arthritis, some just gave birth to healthy children, some are on an unwieldy regimen of medications. What works for each of these patients is not what will work for every patient.
Benefits of pattern matching:
- Physicians can provider better, faster care when they know what’s been tried with like patients
- Physicians can better determine whether their patient is at risk — and for what — when they know what’s happened to similar patients
Less common problems we use Hypothetico-deductive model
For more common problems we use pattern matching.
How do we decide if a problem is common or not ?
- Draw on scientific and experiential knowledge
- Reflective practice
Why are clinical decisions difficult and complex ?
What is prospect theory ( Tversky & Kahneman) ?
Prospect theory assumes that losses and gains are valued differently, and thus individuals make decisions based on perceived gains instead of perceived losses
he general concept is that if two choices are put before an individual, both equal, with one presented in terms of potential gains and the other in terms of possible losses, the former option will be chosen.
What is evidence ?
How good is evidence?
Bias definition :
- systematic error [is] introduced into sampling or testing by selecting or encouraging one outcome or answer over others
- Bias can occur at any phase of research, including study design or data collection, as well as in the process of data analysis and publication
-Examples include the phrasing of questions in surveys, how participants perceive the researcher, or the desire of the participant to please the researcher and to provide socially desirable responses
Error Definition :
Is a non-systematic random error.
E.g. if you send out 100 questionnaires and 10 participants do not send the questionnaire back to you this is a systematic error because you have lost 10% of your sample.
Bias produces systematically prejudiced results while errors produce inaccurate results.
Describe the evidence pyramid ?
The Evidence-Based Medicine Pyramid is simply a diagram that was created to help us understand how to weigh different levels of evidence in order to make health-related decisions. It helps us put the results of each study design into perspective, based on the relative strengths and weaknesses of each design.
-Highest quality evidence is towards the top. This evidence has the least level of bias and is the most rigorous.
- So best is Systematic reviews and Meta - analyses
- And under that is Randomized Controlled Double Blind Studies
The health warning with the evidence pyramid:
- there is different study of design for different questions
- So if I wanted to understand the link between smoking and lung cancer. You cant do a trial because it is unethical because it would involves getting one group to smoke and another group to not. So you have to have a cohort study or a case control study.
- Also the evidence pyramid does not take into account qualitative research
What is the 5S Level of organization of Evidence
(adapted from Haynes 2006)
The Integrated “5S” Levels of Organization of Evidence Pyramid depicts the relationship between the Evidence Hierarchy (the small, inset pyramid) and the “5S” model. The Integrated Pyramid also includes foundational resources that do not have transparent evidence-based methodologies
What sort of evidence might be used in a clinical situation ?
Using evidence to create a diagnosis ?
-To identify most likely hypotheses
- To evaluate likelihood of hypothesis being correct, so seeking evidence to try and refute the hypothesis
- The accuracy of diagnostic tests.
How do we use evidence to come up with a treatment decision ?
The Evidence Hierarchy:
What is the “Best Evidence”?
What is “the best evidence” ? :
- The hierarchy of evidence is a core principal of Evidence- Based Practice (EBP) and attempts to address this question
- The evidence hierarchy allows you to take a top down approach to locating the best evidence whereby you first search for a recent well - conducted systematic review and then if that’s not available, then move down to the next level of evidence to answer your question
- Most experts agree that the higher up the hierarchy the study design is positioned, the more rigorous the methodology and hence the more likely it is that the study design can minimise the effect of bias on the results of the study. In most evidence hierachies current, well designed systematic reviews and meta-analyses are at the top of the pyramid, and expert opinion and anecdotal experience are at the bottom.2
