Health and Society Flashcards
What 4 things does a patient have to do to enter the “sick role” according to Parsons?
1) Want to get well as soon as possible.
2) Give up on their normal daily activities and responsibilities for this time.
3) Seek medical advice and cooperate with the doctor.
4) Accept that he/she is in need of care and can’t get better on his/her own.
What is the function of NHS Acute Trusts?
To employ all the staff working in hospitals, to manage hospitals, and to have service agreements with Clinical Commissioning Groups.
What is the function of Primary Care Trusts (PCTs)?
Employ doctors to work in general practice, and commission care services from hospitals (providers).
Name the approaches to health promotion.
Legislative action (prevention paradox).
Health persuasion techniques (e.g media).
Personal counselling (e.g opportunistic prevention, screening).
Community development.
Health education.
What were the determinants of health inequalities according to the Black report?
Artefact - healthy people move up the classes.
Natural selection.
Poverty causes ill health.
Life style differences.
What is the evidence that inequality in society itself, rather than the absolute level of deprivation, is responsible for health inequality?
Greatest improvement in health after WW2, when Britain was most equal, and improvements slowed down as inequality increased.
Most unequal societies have the worst health.
Name recent government initiatives to reduce child poverty.
Promising an end to child poverty. Childcare tax credit. Child benefit. National minimum wage. Free childcare for working parents. Nutrition/fruit scheme. Teenage pregnancy scheme.
Why would the child poverty indicators have increased in the 1980s?
Unemployment after WW2, so that more families had no family member in work. More single-parent families. Lower pay. Cutting expenditure in some services. Cutting benefits. More indirect taxation.
What are the reasons for the symptom iceberg - why would someone take longer to visit a health professional?
Bad previous experiences with health professionals.
Perceived lack of access.
Difficulty in transport/childcare/time off work.
Lack of sanctioning/Lay Referral system.
Denial that there’s anything wrong.
Name three theories showing the link between lower social class and higher mortality and morbidity.
Cultural behavioural model.
Materialist model.
Social selection.
What factors trigger help-seeking behaviour?
Interference with work/ physical activity/ social life/ daily activities/ relationships.
Sanctioning from friends and family.
Interpersonal crisis (e.g death in the family).
Putting a time-limit on symptoms.
What is the inverse care law?
The people who most need support services and treatment have least access to it.
What is the coexistence of different medical traditions called?
Medical pluralism.
What is the symptom iceberg?
Only a small minority of the symptoms experienced by patients (10-15%) result in a consultation with a health professional.
Who delivers most of the health care in the community according to the symptom iceberg model?
Lay people.
What is the role of the Medicines and Healthcare products Regulatory Agency?
Licensing medicines and medical devices in the UK.
MHRA is responsible for:
1) Ensuring that medicines, medical devices and blood components for transfusion meet applicable standards of safety, quality and effectiveness.
2) Ensuring that the supply chain for medicines, medical devices and blood components is safer and more secure.
3) Promoting international standardisation and harmonisation to assure the effectiveness and safety of biological medicines.
4) Helping to educate the public and healthcare professionals about the risks and benefits of medicines, medical devices and blood components, leading to safer and more effective use.
5) Supporting innovation and research and development that’s beneficial to public health.
6) Influencing UK, EU and international regulatory frameworks so that they’re risk-proportionate and effective at protecting public health.
What is the role of NICE?
National Institute for Health and Care Excellence is designed to look at all available treatments and make judgements on which should be available on the NHS.
What is an ecological study?
An observational study at population level.
What is standard deviation?
A measure of the spread of the population around the mean.
Which way does negatively-skewed data shift?
Towards the higher numbers of the x-axis, so mode > median > mean.
Which way does positively-skewed data shift?
Towards the lower numbers of the x-axis, so mode
What is standard error?
A measure of how precisely you know the true mean of the population, taking into account the standard deviation and the sample size.
It can show sampling variability. Standard deviation doesn’t show sampling variability.
What is the difference between primary, secondary, and tertiary prevention?
Primary prevention means preventing a condition developing before it has started e.g carrier screening, prenatal diagnosis and termination.
Secondary prevention means early diagnosis, e.g postnatal screening, (which helps management in the event of a sickle cell crisis).
Tertiary screening means management of the condition and prevention of further deterioration (e.g for sickle cell anaemia: avoiding chest infections, pneumococcal vaccinations, staying hydrated.
Why can it still be said that ethnicity has a genetic basis, even when some argue it is self-defined?
There are genetic conditions related to ethnicity.
What is it called when research is done into a condition more because it is rare and only found in a particular ethnic group, than because it is a significant burden on the population?
Ethnocentricity.
Name some ways in which screening for genetic diseases related to ethnicity could engender racism/
If tests are based on ethnicity, people may be stigmatised.
Promoted the impression that ethnic minorities are sicker and are bringing disease into the country.
There could be resentment against resources being directed towards ethnic minorities.
If the screening programs are only run in regions with a high population of ethnic minority groups, is it fair for people living elsewhere who are still at risk to miss out?
When screening for a genetic disease related to ethnicity, why could it be seen as better to direct the screening program at a more common condition.
More carriers will be found so the program will be more cost-effective.
What is salutogenesis?
It describes an approach where the focus is on factors that support human health and wellbeing rather than factors that cause disease (e.g bacteria).
What is the term used to describe the shift in mortality that has occurred as there has been a decline and control of infectious diseases, and a rise of chronic degenerative diseases?
Epidemiological transition.
Name the broad categories that determine health outcomes.
Biological (genetics), social and economic (employment, education, housing), environmental (transport, pollution, water), lifestyle (diet…), access to health services, social class, country you live in.
Define health promotion.
Social and environmental interventions that enable people to increase control over, and improve, their health.
What are the five aspects of health promotion defined by the WHO?
1) Healthy public policy - consider the consequences on health of all political policies.
2) Supportive environments - create environments that are easy to be healthy in (e.g cycle paths).
3) Community action e.g food banks.
4) Personal skills e.g cooking.
5) Reorienting health services - divert resources from tertiary care to primary care and primary prevention.
Define health education.
Facilitating voluntary actions conductive to health, providing advice and information to encourage people to improve health.
Define health protection.
Legislation (from the Health Protection Agency) to control infectious disease outbreaks and improve public health (e.g smoking ban, seat belts).
What is the difference between primary, secondary and tertiary prevention?
Primary prevention prevents the onset of disease (e.g through immunisation, screening for risk factors, health promotion). Secondary prevention detects disease at an early onset, so treatment is more effective (e.g cancer screening). Tertiary prevention manages disease to alleviate symptoms and minimise the effects on life, but the disease progression is already established.
In Beattie’s typology, what are the four main areas that health promotion is divided into?
Health persuasion, legislative action, community development, personal counselling.
In Beattie’s typology, what is the link between health persuasion and legislative counselling?
Authoritative intervention (“top down”).
In Beattie’s typology, what is the link between legislative action and community development?
Collective focus.
In Beattie’s typology, what is the link between community development and personal counselling?
Negotiated intervention (“bottom up”).
In Beattie’s typology, what is the link between personal counselling and health persuasion?
Individual focus.
In Beattie’s typology, give an example of health persuasion.
Media campaigns e.g “5 a day”.
In Beattie’s typology, give an example of legislative action.
Smoking ban, seat belts, water fluoridation.
In Beattie’s typology, give an example of community development.
Food banks.
In Beattie’s typology, give an example of personal counselling.
Opportunistic prevention during consultations.
Why would some people take issue with diverting more resources towards primary prevention?
Resources are limited, so diverting resources upstream seems unfair. Think about the opportunity cost.
What are the three ethical dilemmas associated with health promotion?
There is an opportunity cost from diverting resources from tertiary care to primary prevention.
It’s difficult to get evidence of the effects of health promotion as the effects are more long-term, the outcomes are difficult to measure, and it is hard to control for different influences.
There is a fine balance between individual freedom (autonomy) and social control.
What are the challenges for opportunistic prevention during GP consultations?
There is limited time during a consultation.
The patient may not be receptive.
You must respect the patient and listen to their views.
Preaching and paternalism must be avoided.
It must be treated as part of a long term relationship.
What is the Prevention Paradox?
Preventative measures which bring a lot of benefit to the population, provide very little benefit to the individual (e.g minimum pricing of alcohol).
Name three ways health professionals can get involved in health promotion.
Providing individual advice and support.
Getting involved in organisations.
Lobbying governments.
What are social inequalities in health?
Differences in people’s health linked to social inequalities.
Health is not all “good” above a certain income threshold, and “poor” below, what term describes the pattern?
Social gradient.
Names some ways of measuring inequalities.
Measuring education, occupation status, housing tenure, looking at the Index of Multiple Deprivation (IMD).
The major killers have a social gradient, which means that…
Overall mortality has a social gradient, as the smaller killers have little impact on overall mortality.
The social gradient of health inequalities persists over which two factors?
TIME - even when there is an epidemiological transition and the major killer shifts, as it becomes more common a social gradient will emerge.
PLACE - USA and UK have similar social gradients.
What are the four possible explanations for socioeconomic health inequalities given in the Black report?
1) A statistical artefact (not real)
2) People’s health drives social class (ill health pushes people into poverty) = health selection
3) There are differences in health behaviour - ill health is caused by lifestyle factors determined by social factors.
4) There are broader social inequalities in people’s lives - social inequalities are material and structural
What is the difference between structural and material social inequalities?
Structural inequalities are the position in the social structure into which people are born, and this is influenced by things like parent’s occupations. Material inequalities are the everyday environments and living and working conditions people experience.
Structural influences material conditions.
What is the cycle caused by structural and material social inequalities?
STRUCTURAL inequalities (a person’s position in society from birth and throughout life) influence MATERIAL conditions and behavioural risk factors, which influences HEALTH, which in turn influences STRUCTURAL position again.
Why do childhood circumstances in particular influence health into adulthood?
Childhood is an important period as you have rapid development and heightened sensitivity. Environmental differences can become hard-wired (epigenetics). Biological and psychosocial impact is greater in childhood.
Name some effects of being born in poor circumstances on early life.
Disabilities, premature birth, death.
Poor nutrition.
Difficulties of family change (e.g parental divorce, unemployment, illness, financial stress).
Name some effects of being born in poor circumstances on adolescence.
Leaving school early, without qualifications.
Smoking, drinking, being physically inactive.
Name some effects of being born in poor circumstances on adulthood.
Poor physical health (BMI, diastolic blood pressure).
Increased mortality and morbidity.
Financial stress from job insecurity etc.
What is narrative based medicine?
How people tell you what’s wrong with them, which depends on their interpretation (illness cognition).
Describe 3 different types of health benefits and what together they lead to.
Allopathic (western) medicine, lay medicine (ask friends, family, internet), complementary therapists (osteopaths, acupuncture). Together they lead to medical pluralism.
What is medicalisation?
Defining an increasing number of life’s problems as medical problems (e.g grief, sexuality, childbirth).
What is pharmacologisation?
Transformation of human condition/capabilities into opportunities for pharmacological intervention.
With narrative-based medicine, the patient can be in one of three categories depending on what they want from the consultation. Describe those three categories.
Chaos - they feel they can’t control their life already and this is just another thing they can’t control so they don’t even what a choice in it and just want you to make the choices.
Restitution - they just want their life to get back to the way it was
Quest - want to know what the cause is, and what they can change in their life to improve it. They seek complementary therapies and information from many different sources
Name an advantage and a disadvantage to lay diagnosis and self care.
Advantage = potentially reduces pressure on primary care services Disadvantage = can lead to a delay in diagnosis and treatment leading to worse outcomes, so could actually increase the pressure on primary care/A+E
What is culture?
A cumulative deposit of knowledge, experience, belief, values, attitudes, meanings, material objects, possessions, acquired by a group of people.
What is enculturation?
Learning from just the single knowledge base of your culture - as if learning a list of facts (simple learning).
What is acculturation?
Learning from lots of different sources alongside your own culture, picking up tips and snippets (complex learning). This is how patients transmit knowledge gathered from google and lay referral systems and put their own interpretation on it.
What is allopathic medicine?
Using pharmacology and interventions to treat or suppress symptoms or disease.
Describe some differences between complementary therapy and allopathic medicine.
Complementary therapy focusses on wellbeing, and has high contact time but is less invasive. There is a shorter wait for an appointment, and it costs less but is less effective. It is difficult to test the effectiveness, but it is regulated (General Chiropractic Council, General Osteopathic Council).
Allopathic medicine is more focussed on the biomedical side of disease, it is more high tech and more scientific and evidence based. It is highly regulated.
Name some reasons a person would want to use complementary therapy.
They don’t want to have to wait to see the consultant.
They have experienced a poor doctor-patient relationship.
They don’t believe in the science, it may be against their religious views.
They have had experience of iatrogenic medicine (illness caused by medical examination or treatment).
They are desperate.
They want something non-invasive.
What is complementary therapy best used for?
Allevating symptoms (e.g back pain), not diagnosis.
Name some things narrative medicine will depend on.
The person’s gender, culture, language, whether the patient sometimes distress (e.g saying they have a stomach ache, but the cause is depression).
What are most complaints in the NHS due to?
Poor communication.
What are the benefits of the Calgary-Cambridge model?
It improves the doctor-patient relationship. It increases the likelihood of the patient sticking to treatment. It is realistic.
What are the main principles of patient centred care, and the main outcomes?
Principles:
1) Explore the patient’s main reason for the visit, their concerns, and need for information.
2) Seek an integrated understanding of the patient’s world - their whole person, emotional needs, and life issues.
3) Find common ground with the patient on what the problem is, and mutually agree on management.
Outcomes:
1) Enhances prevention and health promotion.
2) Enhances the continuing relationship between the patient and the doctor.
3) Is realistic.
What is a diagnosis?
Determining the nature of a disorder by considering a patient’s signs and symptoms, results of lab tests, and medical imaging. It is not directly therapeutic.
What is prognosis?
Assessment of the future course and outcome of a patient’s disease.
What is evidence?
Results of rigorous clinical trials and observational studies that can influence clinical decision making.
There are three ways of looking at decision-making, name them.
Normative - what should you be doing according to social and professional norms?
Descriptive - what are you doing?
Prescriptive - how can we improve what we’re doing?
What are odds, what is an odds ratio?
Odds are the probability of the thing occurring over the probability it doesn’t. The odds that an outcome will occur with an intervention, compared to the odds it will occur without an intervention.
What is a risk ratio?
What does it mean if it is greater than 1, less than 1?
The risk with an intervention over the risk without an intervention.
If it is greater than one then the risk with the intervention is greater than the risk without the intervention.
If it is less than one then the risk without the intervention is greater than the risk with the intervention.
What are the advantages and disadvantages of a cross-sectional study?
Advantages = descriptive, gives representation of population, describes the situation at present, can estimate prevalence, can choose sample size to fit question Disadvantages = difficult to establish causal relationship because it's not across a time period, can't estimate absolute risk, sometimes not representative of the population as a whole, doesn't answer the question "why".
What are the advantages and disadvantages of a cohort study?
Advantages = gives an alternative to experimental study which would be unethical if intervention was harmful, can sometimes be done historically if data was collected, can be used to estimate incidence. Disadvantages = other variables in the population can't be controlled so the causal relationship is not as certain, the study has a long duration to get results, the disease studied needs to be common.
What are the advantages and disadvantages of a case control study?
Advantages = it is easy to allocate people to either group, it is faster than a cohort study, it can be used even for rare diseases, can be used to estimate odds ratio. Disadvantages = other variables can't be controlled, reliable past data is needed.
Which model of clinical reasoning do most junior doctors follow?
Which model do senior clinicians follow, considering they have more experience?
Hypothetico-deductive model, which means forming a hypothesis then seeking evidence to disprove it (starting with Cue Acquisition from the patient’s history, then Hypothesis Formation, Cue Interpretation, Hypothesis Evaluation).
Senior clinicians use Pattern Matching (having seen a similar patient before).
What is self medication?
The ability to select and use medication to treat self recognised illnesses and symptoms.
It is part of self care, which is important because it reduces demand on health services.
Name some different types of things people could self medicate with.
Pharmacy medicines - taken under supervision of pharmacist.
General sales list medicines - purchased from a lockable premise.
Herbal medicines.
Vitamins, minerals, food supplements.
Illicit drugs, alcohol.
Name some places that patients can get access to medication.
From doctors in GP, hospital, private clinic, clinical trial. Pharmacy. Lockable shop e.g supermarket. Health food shop. Internet. Black market.
Which organisation licenses medication, saying they are safe and effective and deciding if they are POM, P medicine, or GSL?
Medicines and Healthcare Products Regulatory Agency (MHRA).
What are the 3 ways that MHRA can classify medications?
POM - prescription only medicine.
P medicine - can be bought without prescription but only in a pharmacy under the supervision of a pharmacist.
GSL - general sales list medicine, sold in general retail outlets without pharmacist supervision.
What are all newly licensed medicines classed as by MHRA?
POM (prescription only medication).
What criteria must a medicine fulfil to be changed from POM to P medicine?
Unlikely to be a direct or indirect danger to human health
Generally used correctly, not normally preconceived as injection
Not contain substances whose activity or side effects require further investigation
What criteria must a medicine fulfil to be changed from P medicine to GSL?
Can reasonably be sold or supplied not under supervision of pharmacist
Safe for self-selection
Why might the licence for P medicines be different to their equivalent POM?
Only a smaller dose of the medication may be licences for over the counter not prescription. Or it may have a certain age limit below which you need a prescription to buy it.
Name some services available from community pharmacies.
Minor ailments schemes (supporting and encouraging responsible self care)
Emergency contraception and sexual health
Medicine use review (having a discussion with the patient and maintaining adherence to medication)
New medicine service (answering patient questions about medication)
Health education and promotion
Ensuring patient safety
Why is important to establish if a patient is self-medicating at all when taking a history?
Prevent adverse drug interactions (e.g with St. John’s wort)
Prevent abuse of OTC medication e.g co-codamol (which contains codeine and paracetamol)
Describe 3 different patient perspectives on taking mild analgesics.
Reluctant to take any pill
Don’t think twice about taking mild analgesics
Want to let the pain run its course
Why would people be encouraged to use OTC medication?
Perceived effectiveness
Familiarity with brand name
Perceived safety
Name the two different types of data.
Quantitative - a numerical value that can be continuous or discontinuous
Qualitative - people’s perspectives
What is dichotomous qualitative data?
A choice between two categories
Name the three types of qualitative and quantitative data in order of most useful to least useful.
Interval - quantitative discrete or quantitative continuous
Ordinal - qualitative where there are more than two categories and they have a logical order
Nominal - qualitative where there are more than 2 categories but they have no logical order
What are the three stages of data analysis?
Descriptive analysis - organise, summarise, and describe the data using graphs etc
Correlational analysis - find relationships in the data
Inferential analysis - use statistics and relationships to make generalisations about a population
What is the point of inflection in a normal distribution?
The point that is 1 standard deviation from the mean.
What percentage of the population in a normal distribution will be within 1 and within 2 standard deviations from the mean?
68% within 1 standard deviation
95% within 2 standard deviations
Describe where the mean, median and mode are in a normal distribution, positively skewed distribution, and negatively skewed distribution.
Normal = mean, median and mode at the midpoint
Positively skewed = mode median > mean
How can you unskew a skewed distribution?
Make it a semi-log plot
What is the difference between the null hypothesis and alternative hypothesis?
Null hypothesis (H0) says that no significant difference between the groups exists. Alternative hypothesis (H1) says there is a significant difference between the populations.
What is a p-value and what does it mean if it is less than 0.05?
P-value is the probability that the difference between the populations would be seen if the null hypothesis was true
P
What’s the difference between and type 1 and type 2 error?
Type 1 error means rejecting the null hypothesis when you should have kept it.
Type 2 error means keeping the null hypothesis when you should have rejected it (the probability of which is measured by Statistical Power).
How can p-values, statistical power, and confidence intervals be decreased?
Increase the sample size.
What is the difference between the basis of statistical significance and the basis of clinical significance?
Statistical significance is shown by a p value
What are the two categories of population research?
Descriptive (a survey, case report, case series - no control is used and you only look at a point in time)
Analytical (seeks to answer question “why”, uses a control and is over a period of time, can be experimental or observational)
Name 4 types of research methods.
Cross-sectional study
Cohort study
Case control study
Randomised controlled trial
Why would you use a cohort study or case control study instead of a randomised control trial?
Ethical issues are raised if the intervention is harmful (no equipoise), because you can’t knowingly allocate people a harmful intervention.
Describe the hierarchy of study design based on resistance to bias.
Systematic review of randomised controlled trial
Randomised controlled trial
Systematic review of observational studies
Observational study
Physiological study
Unsystematic clinical observations
What is the difference between a systematic error and random error?
Systematic error = something wrong with the measuring instrument or it is wrongly used by experimentor
Random error = error in experimental measures due to unknown cause of unpredictable changes on environment or measuring instrument
What is confidentiality?
Not divulging patient information to others without the patient’s consent.
Describe the reasons to respect patient confidentiality.
It is a legal (human rights act) and professional (GMC) requirement.
It establishes and maintains trust so the patient feels able to divulge all relevant information to the doctor.
It ensures information is not obtained by people who would use the information to cause the patient harm.
It respects patient autonomy, the patient has control over their personal information.
Trustworthiness is part of being a virtuous doctor -acting with honesty and integrity
You must never abuse the patient’s trust in you or the public’s trust in the profession.
In which two cases can information be shared without breaching confidentiality?
Sharing information with people directly involved in the care of the patient
Sharing information after obtaining the patient’s informed consent
Beige breaching confidentiality, what is it essential to do?
Inform the patient of what you are going to do.
In what circumstances can confidentiality be justifiably breached?
Non-disclosure puts the wider community at risk e.g patient refuses to disclose that they are HIV+ to partner
The patient is at risk of harm and lacks capacity (e.g child who is the victim of abuse)
A court order demands the confidentiality breach
It is not practical to seek patient consent
Describe 4 things to do when sharing patient information.
Use anonymised information if practical
Get patient’s informed consent
Disclose the minimum amount of information necessary
Keep up to date with and observe common legal requirements
What are the two models of disability?
Medical model - the person’s disability is caused by their impairment, which needs to be treated and fixed. This can lead to exclusion from society
Social model - the disabled person is only at a disadvantage because of the discriminatory way society is organised, and the barriers of assumption stereotype and prejudice
A compromise can be found between the theories by embodiment - the spare spect for the individualism of each person’s situation (biopsychosocial model)
Describe the critiques of the medical model of disability.
Shows disability as an individual tragedy, rather than in a community context
Doesn’t account for social barriers causing difficulty for disabled people
Shows disability as something that needs to be cured by doctors - paternalistic
Describe the critiques of the social model of disability.
Aspires to idyllic society where impairments cause individuals no problems - can't exist Doesn't recognise the complexity in disabled people's lives, developed on,y for white middle class men with spinal injuries Some people may see disability as a type of social oppression imposed on people with impairments, which restricts their activity and undermines their psychoemotional wellbeing
How is disability defined in the Equality Act 2010?
A disabled person is someone with a physical or mental impairment which had a substantial and long term negative effect of their ability to carry out normal daily activities.
What is the radical disability model?
Disability only applies to those who are externally defined as disabled, or self identify as disabled (not some deaf people).
What is risk?
The probability an event will occur within a specified time (not necessarily a bad thing).
What are the three ways in which risk can be presented?
Natural frequency e.g 1 in 84
Probability (decimal)
Percentage
What is the difference between absolute risk and relative risk?
Absolute risk is the risk of you developing an illness over a certain period of time, relative risk compares the risk in different groups (e.g risk ratios and odds ratios).
How do you calculate risk difference?
Risk with intervention - risk without intervention
What does it mean if the odds ratio is greater than 1, equal to 1, less than 1?
Odds ratio > 1 means the control is better than intervention
Odds ratio = 1 means there is no difference
Odds ratio
In what situations are the risk ratio and odds ratio equal, and in what situations is the odds ratio greater than the risk ratio?
When outcomes are rare the odds ratio and risk ratio are identical.
When outcomes are common the odds ratio is greater than the risk ratio.
What would make people more willing to accept a risk?
If the risk is: Voluntary Controllable Familiar Non-catastrophic Fair (e.g higher risk for more benefit)
What would make people less willing to accept a risk?
If the risk is: Uncontrollable Potentially catastrophic There is dread The benefit does not increase with the risk Unknown Unobservable Unfamiliar
What is the basis of organ and blood donation in the UK?
Altruism
What are the arguments against remunerated blood donation (according to Titmuss)?
It would undermine the altruism
Erode sense of community
Sanction profits in hospitals and clinics, and so subject medicine to market place rule
Increase blood supply from poor, unskilled, unemployed, so increase infection risks
How much blood is in a person, and how much can they survive losing?
8-10 pints in a person, can survive losing 2-3 pints if given saline and iron tablets.
How is the UK blood donation system funded (costs for advertising, collecting, storing and distributing)?
Publicly funded.
What are the arguments for remunerated blood donation (according to Cooper and Culyer)?
Blood is no different from any other tradeable product
Financial incentives would increase the supply of blood
You could offer direct payment, or exemption from payment for blood used in future
Name some organs that can be transplanted.
Kidney Liver Lung Cornea Heart Heart and lungs
Sins the demand for organs far exceeds supply, people may be placed in a waiting list for a kidney transplant. What treatment will they have to receive whilst on the waiting list, and is it more or less const effective?
Placed on dialysis - more expensive than transplant in the long term.
Haemodialysis = £35,000 per patient per year
Continuous ambulatory peritoneal dialysis (CAPD) = £17,500 per patient per year
Transplant = £17,000 then £5,000 a year for immunosuppressive drugs
Transplant is more cost effective and provides better quality of life to patient.
Describe some potential ways to increase the supply of organs.
Give people who are on the donor list precedence to receive a transplant.
Use an opt-out policy - relatives permission doesn’t need to be given to obtain organs.
Have transplant coordinators in hospitals to talk to patient’s and quickly but sensitively obtain a decision on loved one’s organs.
Use financial incentives.
What are some problems with using financial incentives for organ donation?
Can lead to corrupt doctors harvesting organs then selling them on to make profit.
Chinese criminals who receive the death penalty have their organs harvested, but is this injustice?
Can lead to desperate people selling organs and greatly harming their own health.
Why does Rottenburg argue in favour of financial incentives for organ donation?
He says people have the right to do what they want with their own body, and doctors only stand in the way because they find commerce “ethically offensive”.
What is epidemiology?
The study of the distribution of the determinants of health-related states and events in populations, and the application of this to the control of health problems.
What is incidence?
The number of new cases in a particular time period, as a proportion of the at-risk population.
Technically a measure of rate.
In a dynamic population the denominator will change so you need to use “person-time incidence rates”
What is prevalence?
The number of people with the disease at a particular time, as a proportion of the whole population.
Among young people, are there higher rates of smoking for girls or boys?
Girls.
What is the symptom iceberg?
A large proportion of the symptoms people experience (85%) don’t result in a consultation with a health professional.
What is illness behaviour?
How people perceive, evaluate, and act upon their symptoms.
Across what categories might illness behaviour vary?
Age, gender, social class, race, culture.
What is medical pluralism?
The co-existence of deferentially designed and conceived medical traditions and systems (e.g allopathic Western medicine, homeopathy, acupuncture, herbalism).
What is the lay referral system?
Consulting other people about your symptoms before going to see the GP e.g relatives, friends, pharmacist, NHS Direct, Internet.
What are the triggers that cause people to consult a doctor about symptoms?
Interference with work or physical activity Interference with social relations Interpersonal crisis Putting a time limit on symptoms Sanctioning
What is Information Age medicine?
Patients have as access much access to the evidence base of medicine as doctors.
What does Information Age medicine mean for patients?
They can check symptoms warrant medical attention
Gives patients confidence to ask questions
Patients can clarify doctor’s advice
Patients can access social support
Allows patients self management and a feeling of being in control over illness
Patients still rely on and trust doctors
Shared decision making (i.e patient cantered care)
What are some barriers to help seeking?
The provision and availability of health services
The attitudes of staff (e.g receptionists and doctors)
The inverse care law
Geographical distance from services
Difficulties with time and effort taken, loss of earnings, childcare
Transport - costs and availability
Past bad experiences with health care (iatrogenic)
Long waiting times
What is a carer?
Someone who, without payment, provides help and support to someone who could not manage without their help.
(Informal care is unpaid and not carried out by professionals)
Why is the demand for informal care increasing?
Life expectancy is increasing, but disability free life years is not increasing.
What is care poverty?
People losing money due to the expense of being a carer (e.g home adjustments, equipment, transport to appointments) and being unable to work.
Why is informal care beneficial to the economy?
It reduces bed blocking (patients are able to go home earlier), and it reduces the workload of institutional care.
What proportion of the population are carers?
1 in 10. The majority are women, and over 50.
Why might young carers be more likely to go unrecognised?
They may be reluctant to speak out about their role if they think they or their younger siblings might be taken away from their parents care.
They have less to gain because they will not get carers allowance if they are under 16 or a full time student.
Describe some tasks carers might carry out.
Provide practical help (food shopping, cooking)
Keep an eye on the patient and provide company
Provide personal care (washing, dressing, toileting)
Give medications
Provide physical help (getting in and out of bed - can lead to musculoskeletal injuries without training on how to lift loads properly)
Why do doctors need to be able to identify carers?
To make them aware of services and support they can access.
Which type of carers are most likely to suffer harm to physical and mental health?
Co-resident carers, and elders carers who are likely to already have a health condition of their own.
Give some examples of policy and legislation recognising the importance and contribution of carers.
National Carers Strategy 1999 Carer (Equal Opportunities) Act 2004 Equality Act 2010 Carers Strategy refresh November 2010 Carers Act/Children and Families Act 2014
What are the key elements of recent policy and legislation on carers?
Carers have a right to an assessment of their own needs, even if the patient refuses one.
Carers Special Grant provides funding for respite and short breaks for carers (can be difficult if the person they’d want to take a break with is the patient).
Carers need to gain awareness of their entitlement to an Assessment and an Independent Advocate. The assessment considers the carer’s wishes about employment, training, education, leisure, and the carer’s wellbeing.
Name some of the conditions that need to be met for a carer to receive Carer’s Alowance.
Caring for more than 35 hours a week
Patient already receiving qualifying disability benefit
Not under 16 or full time student
Amount received is reduced if carer is also earning
Other benefits that carers can receive = tax-credits, disability living allowance if they are disabled themselves, attendance allowance for severely disabled people over 65
Why does Bedroom Tax cause difficulties for carers?
Working age claimants who live in social housing and need help with their rent are allowed one bedroom per couple, one for two children under ten or two children of the same sex over ten. Any “spare” bedrooms will result in house benefit being cut.
This is difficult if the patient has disturbed sleep so carer needs to sleep in separate room, or if a disabled child needs their own room, or if a room is needed to store equipment.
What legislation allows carers of adults to request flexible working?
Work and Families Act 2006
What do carers generally need?
Information and advice on services available and how to access them
Information on the patient’s health needs and treatment
Social security benefits
Practical and emotional support (e.g training, someone to listen to them)
Respite care (e.g short breaks, time to go shopping and know patient is cared for)
Name some needs specific groups of carers might have.
Rural carers - transport and practical support
Parents of disabled children - help accessing mainstream services
Black and ethnic minority carers - culturally sensitive support, language support
Young carers - emotional support
Young minority carers - contact with social services, and interpretation for the care-receiver
Why might the supply of informal care be decreasing?
Increasing demand due to longer life expectancy
Smaller, more spread out families
Changing role of women
Raised pension age
What is a clinical trial?
A planned experiment involving patients, which determines the most appropriate treatment for future patients with a given medical condition
Describe the 2 phases of clinical trials.
Phase 1 = healthy volunteers are used to find a safe dose range for the drug, and study the pharmacology, toxicology and side effects (use small groups as this is the first time the drug is given to humans)
Phase 2 = initially investigate drug efficacy by giving to patients, screen out any inactive or toxic drugs, show the early outcomes and give a further idea of safety
Phase 3 = randomised controlled trial to compare the drug to the current standard
Phase 4 = continued monitoring for late adverse effects, long-term follow up
Name some alternatives to using a randomised controlled trial.
Case series (no control group so insufficient evidence to replace current standard) Historical control (potential for selection bias(prognostic index) and performance bias - way outcomes are measured may have changed) Before and after design (potential for regression to the mean leading to type 1 error) Concurrent (non-randomised) control (great potential for selection bias) Solve these problems by having a contemporaneous control group.
What is regression to the mean?
If a variable is extreme on its first measurement, it will tend to be closer to the mean on its second measurement.
Why is randomisation used?
It ensures a balance across comparative groups of known and unknown baseline factors that could affect the outcome.
What is equipoise?
It means it is not known whether one intervention is beta than another, and it is essential in a randomised controlled trial.
How can you ensure a particular baseline factor (e.g prognostic index) will be balanced across comparative randomised groups, to ensure there is not a bias by chance?
Stratify the baseline factor during the randomisation process.
If you are conducting a multi-centre randomised controlled trial, why is it important to ensure roughly equal numbers are allocated to the intervention and control groups?
To balance the cost and difficulty of administering the intervention, as different centres will vary in expertise.
What is bias?
Systematic distortion of the estimated effect of an intervention away from “truth” due to inadequacies in design, conduct or analysis of a trial.
Name the three types of bias in randomised controlled trials.
Selection bias - systematic error in allocating the intervention groups so that comparative groups differ in certain baseline factors and with respect to prognosis, or the sample is not representative of the general population.
Ascertainment bias - the person assessing the outcome has knowledge of the group allocation (e.g patient or investigator).
Performance bias - other than the intervention, there are systematic differences in the care received by comparative patient groups.
Why would there be selection bias if doctor were allowed to allocate their patients to intervention groups in clinical trials?
They might think the study will be more likely to get published with better results, so put better prognosis patients in intervention group.
Might think healthier patients will cope better with the side effects of the intervention so out more of them in that group.
Might think sicker patients need the intervention more.
How can you allocate patients to intervention or control groups in a way that can’t be subverted?
Get the randomisation list to be confidential and dealt with someone not involved in delivering or assessing intervention e.g Trials Unit (independent organisation who use computer programme for randomisation)
Ensures allocation concealment (prevents selection bias)
I randomised controlled trials, what type of bias does Blinding particularly reduce?
Ascertainment bias.
What has the historical opposition to randomised controlled trials led to?
Treatments being introduced and later turning out to have no effect, or harmful effects.
E.g HRT increases risk of cardiovascular disease
Pure oxygen given to premature babies and causing blindness
Arrhythmia drugs given to patients after MI actually increasing mortality
Folate supplements increasing MI risk
Counselling women after difficult birth increasing depression
What is stigma?
Any physical or behavioural attribute that is negatively valued, or leads someone to be regarded as unacceptable or inferior.
Why does Foucault (1967) suggest that when lepers (who were treated as socially-dead non-people) started to disappear from Europe, people with mental health problems started to be discriminated against to “fill the gap”?
We need people who are “other” to make us feel normal.
Why would the stigma of being labelled “mad” be more socially damaging than being labelled “bad”?
“Bad” means you can be credited with free will, take your punishment, and repay your debt to society. A psychiatric record is more scarring and permanent than a criminal one.
Name the 5 steps in producing stigma.
Labelling (deciding which of the arbitrary differences between people matter and which don’t)
Stereotyping (assigning characteristics to the group instead of the individual)
Othering (labels are used to separate yourself from the group, and individuals become fundamentally different and become their label)
Stigmatising (the characteristics attributed to the other category are undesirable, you devalue people based on the undesirable attribute/behaviour)
Discriminating (the undesirable characteristics given to that person by the label justify you acting differently towards the person)
What are the three levels of discrimination?
Individual (e.g hate crime)
Institutional (laws passed by government e.g ugly laws in US)
Structural (seen as acceptable within society e.g chaining people with mental illness in Benin)
What did Rosenhan argue about mental illness?
Mental illness is a social phenomenon which is just a consequence of labelling.
What are the two types of stigma based on whether an individual can pass for “normal” or not?
Discreditable - stigmatising condition can be hidden, person can present a front of normality
Discrediting - stigmatising condition can’t be hidden and is immediately apparent, person has mo control over the stigmatising process
What are three types of stigma?
Felt stigma - person feels ashamed/scared
Enacted stigma - people respond to stigma, behave in discriminating way
Courtesy stigma - stigma spreads from individual to people involved with them
Name 6 ways sigma can be managed.
Internalising - social views that they are a lower status are absorbed and impact on personal beliefs and behaviours
Non-disclosure of discreditable stigma
Passing - presenting a false front to appear normal and not acknowledge symptoms (felt stigma may still be experienced, leading to mental health issues)
Covering - non-disclosure by avoiding situations and reducing visibility (solution is sought to stigma but not to condition)
Withdrawal - symptom is socially acknowledged, and individual withdraws from socially expected interactions and relationships (high psychological cost which can lead to stress and depression)
Resisting - individual doesn’t accept label and contests stigma-related outcomes (groups resisting stigma can lead to positive change e.g legalised gay marriage)
Describe some of the implications of stigma for medicine.
Fear of stigma may be a barrier to seeking medical advice and acknowledging condition.
Patients at have concerns about confidentiality, especially if there could be professional implications on them (e.g they are a doctor/pilot)
A diagnosis is good in that it increases access to treatment, but can be challenging in that it labels the individual and places them in a category.
In some cultures the stigma attached to a diagnosis (e.g HIV) leads to a lack of medical care.
In some cultures there is a strong stigma associated with mental and sexual health.
Doctors have a role in public health education, and can work to reduce stigma.
What is stress?
An imbalance between the demands made on us and our personal resources to deal with those demands.
A challenge to the body’s ability to maintain homeostasis.
How do Life Events relate to stress?
It is not the Life Event itself that causes stress, but the interpretation and meaning given to it by the individual. The Life Event may seem positive but still cause distress.
The process is
Life Event -> Appraisal -> Stress
What is the difference between primary appraisal and secondary appraisal of a Life Event?
Primary appraisal - appraisal of the Life Event itself
Secondary appraisal - appraisal of your personal coping abilities, including personal resources and external resources (mainly the immediate social network)
Whether the stress response develops depends on the secondary appraisal.
What are is the emotional (affective) stress response?
Feeling on edge, depression, despair, anxiety, anhedonia, irritability, tearfulness, over-reacting.
What is the cognitive stress response?
Difficulty concentrating, ruminating, thoughts racing - difficulty switching off, self-critical, difficulty making decisions and problem solving.
What is the behavioural stress response?
Comfort eating/ loss of appetite
Increased drinking/ smoking
Withdrawing from exercise and social activity
Disturbed sleep
What is the physiological stress response?
Fight or flight
Increased heart rate, breathing rate, blood pressure
Increased muscle tension
Increased sweating
Describe some examples where the physiological symptoms of stress could be misinterpreted as illness.
Increases heart rate and palpitations misinterpreted as a heart attack
Increased respiratory rate misinterpreted as a heart attack or asthma
Unconsciously tensed muscles over a period of time causing pain and misinterpreted as arthritis
Increased sweating misinterpreted as a fever as a result of infection/malignancy
What cycle does the misinterpretation of the physical symptoms of stress lead to?
Stress -> physiological response -> physical symptoms
Physical symptoms -> misinterpretation
Misinterpretation -> worry/anxiety
Worry/anxiety -> physiological response
What would make someone more likely to misinterpret the physical symptoms of stress?
If the person has a tendency to worry, previous mental or physical illness, illness beliefs (e.g a family history of heart disease).
What are medically unexplained symptoms?
Physical symptoms that can not be explained by organic disease, and that cause distress and impair functioning.
What are functional symptoms?
Symptoms that arise from a problem in nervous system functioning, not caused by a structurally or pathologically defined disease.
What is a psychosomatic illness?
A physical disease caused or made worse by mental factors such as stress/anxiety.
What is a somatoform disorder?
Mental illness that causes physical symptoms (e.g pain) that can’t be traced back to any physical cause.
What proportion of patients in primary and secondary care have medically unexplained symptoms?
Primary care = 25%
Secondary care = 40-50%
Name two ways in which stress can cause MUS.
Some MUS arise from misinterpretation of the normal physiological stress responses.
Some MUS arise from minor pathologies that are exaggerated at times of stress.
Why might someone develop physical symptoms to protect themselves from an adverse life event?
It may be that physical symptoms led to child abuse stopping e.g abuser gets slipped disc/ child has to go into hospital for appendicitis, so the child learns to associate physical symptoms with being protected.
How do the behavioural responses to stress have an indirect effect on existing physical illness.
Maladaptive behavioural responses may negatively affect the existing illness e.g
Poor compliance with medication
Increased smoking/ alcohol intake
Decreased exercise
Poor diet
Social withdrawal
(Stress can also have a direct effect at a cellular level due to activation of the HPA axis and SAM system)
What is Broken Heart Syndrome (stress myocardiopathy)?
Increased risk of death in the six months following loss of a spouse, due to stress leading to high circulating levels of catecholamines, causing hypertension and increasing the risk of ischaemia.
What is illness cognition?
The patient’s own implicit common sense beliefs about their illness. These provide a framework around which the patient understands and copes with their illness.
What are the five dimensions to illness cognitions?
Identity - label and symptoms of illness Timeline - perceived duration Consequences - expected outcome Causes - punishment? Cure/control - how to control it/ recover
What are the three stages of illness cognitions?
Patients make an interpretation of their illness
Patients select a coping strategy
Patients appraise the coping strategy
What are the two different types of coping strategies?
Problem solving - controlling the problem and reconstructing it as manageable
Emotion focused - managing emotions and maintaining an emotional equilibrium
Give some examples of problem focused coping strategies.
Seeking information about the condition Seeking support Learning new procedures and behaviours Identifying new activities/ alternative rewards Developing a realistic action plan
Give some examples of emotion-focused coping strategies.
Emotional discharge - talk about the problem and your feelings
Making and maintaining supportive friendships
Gaining emotional support e.g from religion
Resigned acceptance - coming to terms with the inevitable
What is hyperacusis?
Sensitivity to all sorts of sounds.
How does depression affect your pain threshold?
Lowers your pain threshold.
What are common affective reactions to grief?
Guilt, anhedonia, longing, yearning, anxiety, depression, shock + numbness.
What are cognitive reactions to grief?
Intrusive ruminations - preoccupation with thoughts of deceased, hallucinating presence of the deceased, denial, low self esteem, hopelessness.
What are behavioural reactions to grief?
Agitation, restlessness, fatigue, searching, crying spontaneously, social withdrawal.
What are physiological reactions to grief?
Initial weight loss then possibly weight gain, sleep disturbances, energy loss, physical complaints similar to the deceased, suppressed immune system, hypertension, self neglect.
Name an aspect of grief that is universal for all cultures.
Crying.
Which part of the brain is connected to “yearning and searching” in the grief response?
Nucleus accumbens.
What are the 4 stages of grief?
Numbing
Yearning and searching
Disorganisation and despair
A greater or lesser degree of organisation
What are the two ways in which people can deal with grief?
Loss orientated - concentrating on the grief, risking becoming socially isolated if not given help to get into volunteering and things to keep busy
Restoration orientated - get on with things, try and find ways to keep busy, emotional avoidance
What is complicated grief?
Pathologised grief. Complicated grief has some similar symptoms to normal grief but has a much longer duration.
Can manifest as anxious and depressive thoughts, painful memories, dreams and preoccupation with the deceased.
Name some things that can complicate normal grief.
Pre-existing mental health problems, unfinished business with the deceased, guilt, remorse, financial difficulties, unemployment.
What are the three stages in the short of classifying mental distress?
Religious - involves soul
Moral - madness is a punishment for actions
Scientific - medical and social models
What is panopticism?
Used in prisons so inmates can be constantly surveyed and never know if they’re being watched or not so have to behave well.
Demonstrates that knowledge is power.
Which type of mental health disorder is more common in women, which type is more common in men?
Women are more likely to be diagnosed with neurosis (post-natal depression, anorexia nervosa, bulimia nervosa, anxiety, depression, PTSD, dementia and depression in old age).
Men are more likely to be diagnosed with psychosis (antisocial personality disorder, sex offenders, substance misuse).
Give some possible explanations for the fact that women are more likely to e admitted to psychiatric hospitals, receive a prescription for a psychotropic drug, receive a diagnosis of depression.
Women are more likely to be classified as suffering from depression.
Women are more likely to seek help for emotional distress.
Women are more likely to suffer from a mental disorder.
Biological experiences of women are pathologised e.g childbirth, menstruation, menopause, medication
Do boys or girls show higher rates of mental illness?
Boys.
Why is male suicide a big issue?
Constructions of masculinity leave men unwilling to express their emotions, which may lead to hiding anxieties and uncertainty.
Men’s bodies are supposed to represent strength and health.
Men may be unwilling to use health services and require sanctioning especially from female partners.
Name some social and environmental factors which increase the risk of mental I’ll health.
Childhood poverty Social inequality Early exposure to urban environments Migration Belonging to an ethnic minority Early separation from parents Childhood sexual/physical/emotional abuse Bullying in school Debt Unhappy marriage Excessively demanding work environment Threat of unemployment
What is the Minority Stress Model?
Difference in health outcomes between ethnic groups are caused by environment not genetics, and there are chronically high levels of stress experienced by minority groups.
1) minority status increases exposure to distal (external) stressors
2) as a by-product of distal stress, there is increased exposure to proximal stress
3) exposure to proximal and distal stress leads to adverse health outcomes e.g hypertension
What is meant by proximal and distal stressors in the Minority Stress Model?
Distal stressors = external stressors e.g experiences of rejection/prejudice/discrimination
Prosoma like stressors = internal stressors e.g concealment of minority identity, vigilance, negative feelings
Describe some ways attitudes in practice can be changed to reduce the differences in health outcomes between different minority groups.
Recognise diversity through culturally competent care
Recognise the role of context and social factors in the aetiology of mental health
Acknowledge that mental health services and labelling can be seen as a form of social control (especially when it leads to imprisonment)
Describe some ways GP practices can be changed to reduce the differences in health outcomes between different minority groups.
Be culturally competent and recognise the variety of presentations of mental distress
Recognise that the reason people give for a consultation might not be their real reason for coming
Ask all mental health patients about childhood trauma
Provide support for the individual, the family, mental health workers themselves
What is epigenetics?
A change in phenotype without a change in genotype. Physiological phenotypic trait variations that are caused by external or environmental factors that switch genes on and off, and affect how the cell reads the genes rather than changing the DNA sequence itself.
Describe some factors that make it difficult to access mental health services.
Fear of showing difference
Shame
Experience of prejudice
Lack of insight - not realising you’re ill
Name 3 effects culture has on how patients use mental health services.
Trust in services - less willing to believe he will be understood
Access to services - later in illness
Respond of services - dealt with more restrictively
Describe the 3 vicious cycles that sustain stigma in mental illness.
1) experience prejudice -> fear of showing difference -> become secretive -> experience shame -> not use opportunities -> become exclusive -> experience prejudice
2) communities don’t trust mental health services -> only contact in crisis -> individual needs not known so treated insensitively -> feel badly treated by services -> communities don’t trust mental health services
3) keep mental illness a secret -> go into crisis -> use services -> get label -> lose job -> poverty/exclusion -> keep mental illness a secret
Define impairment, disability, handicap.
Impairment = a loss or abnormality in psychological, anatomical, or physical structure or function Disability = a restriction in ability to perform an activity in a manner considered normal Handicap = a disadvantage for an individual that limits or prevents fulfilment of a role that is normal
Describe the historical factors leading to the development of the medical model of disability.
Power of the medical profession to define who is fit for work
Social Darwinism
Industrial revolution (replacing low tech work)
Revival of Christian morality (formation of philanthropic societies to help the disabled)
Advances in technology (so something can be done)
Give some examples of recognised assessments of disability.
Barthélemy index Functional Assessment Measure SF36 Nottingham Health Profile EQ5D Health Assessment Questionnaire (HAD)
Describe ways an occupational therapist can help patients before and after a surgery.
Functional Assessment Goal setting Advise and arrange adaptations for employment/hobbies Quality of Life Assessment Activities of Daily Living Assessment
Why is it important to measure the epidemiology of mental health in the population?
Helps to target interventions at the group of people where problems are most prevalent
Finds the patterns of need
Find trends in mental health - how prevalence is changing over time
Explore the causes and triggers of mental health, allowing you to provide earlier intervention
What are the challenges to measuring mental health in the population?
Great scale of exercise, mental health is common and varied
Diagnosis can be subjective
Prevalence of mental illness varies on different subgroups in the population
What are descriptive statistics?
Describing the data by collecting, summarising, and describing it in terms of mean, standard deviation etc.
What are inferential statistics?
Use statistical tests and confidence intervals to make generalisations about a population.
What is standard error used for?
Describing how good is our estimate of the true population mean. It is the standard deviation of the sampling distribution.
What is the difference between standard error and standard deviation?
Standard deviation is a descriptive tool used when talking about distributions, to show how spread out the data is.
Standard error is used in inferential statistics to show how accurate is the estimation of the population mean.
How do you calculate standard error for a sample mean?
SE = SD/[square root]n
n is the sample size, so the bigger the sample size, the smaller the standard error.
Or SE = [square root]p(1-p)/n
What are confidence intervals, and what are confidence limits?
Confidence interval = a range of values that probably contains the population mean or proportion.
Confidence limits = values that state the boundaries of a confidence interval (upper and lower limits).
Why isn’t it ever possible to calculate a useful interval estimate that will always contain the population mean?
There is always the possibility the sample will be extreme and contain a lot of ether very small, or very large observations.
Why is the number 1.96 always used when calculating a 95% confidence interval?
What number is used when calculating a 90%, or 99% confidence interval?
95% of the normal distribution will lie within 1.96 standard deviations of the true population mean.
90% confidence intervals are narrower, and the number used is 2.58.
99% confidence intervals are wider, and the number used is 1.65.
What is the p-value, confidence interval, and risk ratio if the difference is statistically significant, or not statistically significant?
Statistically significant: P-value 0.05 Confidence interval includes null hypothesis value Risk ratio = 1 Risk difference = 0
What is NNT?
Number Needed to Treat - measures the impact of an intervention by estimating the number of patients that need to be treated for there to be a positive outcome for one person.
What is addiction?
The continued repetition of a behaviour, despite adverse consequences.
All addicts have a degree of ambivalence, what is ambivalence?
Holding two contradictory beliefs/ideas at the same time (e.g liking and disliking the addictive behaviour).
What are the 7 criteria of dependence syndrome?
1) Salience - the use of the substance takes on higher priority than other previously valued behaviours
2) Tolerance - e.g can drink bigger amount of alcohol without getting drunk
3) Withdrawal - physiological withdrawal symptoms of substance removed
4) Relief of withdrawal symptoms by further use - e.g “hair of the dog”, “eye opener”
5) Compulsion - subjective need to use the substance so it becomes a habit
6) Narrowing of repertoire - other interests neglected, becomes a habit
7) Reinstatement after abstinence - brain is primed to be addicted
What are the four parts of the biaxial model of addiction?
High dependence, low problems = methodone maintenance patient
High dependence, high problems = addict
High problems, low dependence = binge drinker getting into fights
Low problems, low dependence = “social drinker”
What 3 things can you get addicted to according to the DSM?
Alcohol, drugs, gambling
Potentially Internet gaming
What 4 things make some substances more addictive than others?
1) pleasure producing potency (intensity of dopamine release) e.g crack cocaine vs cacao leaves
2) rapid onset of action e.g cigarettes (directly into blood) vs nicotine patches (slow release throughout day)
3) short duration of action e.g 10 minute high from crack cocaine so there is a need to get it back
4) tolerance and withdrawal
Where did the first suggestion of total abstinence from alcohol come from?
Temperance movement in 19th century USA.
What is the key idea behind AA?
Some people have the “alcohol gene” and are inherently alcoholic.
What factors influence whether someone will become addicted?
There have been a collection of genes found that can predispose someone to alcoholism.
There are many environmental factors e.g sons of alcoholic have a much higher risk of alcohol is, monozygotic twins are more likely to be alcoholic than dizygotic twins, people who have an inefficient isozyme of acetaldehyde dehydrogenase suffer the Flush reaction so are less likely to become dependent.
In what 2 ways is a variable reinforcement schedule more effective than a continuous one?
It creates a high steady rate of responding
It is resistant to extinction
How are positive and negative reinforcement involved in alcohol addiction?
Positive reinforcement (social/ dopamine buzz) starts the alcohol addiction, negative reinforcement (relief from withdrawal symptoms) maintains the alcohol addiction.
What was the evidence found that heroine and cocaine are innately addictive drugs?
Rats will repeatedly administer heroin or cocaine until death, ignoring other activities like running in their wheel or eating or drinking.
Which pathway is responsible for dopamine release producing feelings of pleasure?
Mesolimbic dopaminergic pathway - ventral tegmental area releases dopamine to nucleus accumbens and prefrontal cortex.
All addictive drugs increase dopamine levels in the nucleus accumbens, and this is linked to the salience of the drug.
What factors maintain addiction?
Personality factors e.g risk taking, thrill seeking, impulsive, mood dysregulation.
Social factors e.g peer pressure as adolescents.
Dependence on the drug, as the physiology has adapted to its continued presence over time so it is required for homeostasis.
Unpleasant withdrawal symptoms maintaining the behaviour by negative reinforcement.
What are the characteristics of end stage addiction?
Overwhelming desire to take the drug and diminished ability to control drug seeking.
Biochemical and physiological changes in the brain.
Salience of drug and reduced pleasure from biological rewards.
Taking drug so often it becomes an automated habit.
Relapse triggered by drug cues (e.g walking past pub) even after years of abstinence.
Over learning of drug cues.
Disinhibition due to changes in prefrontal cortex.
What was shown by the fact that only 7% of American GIs remained habitual heroin users on their return from Vietnam, despite the majority having used it regularly whilst in Vietnam?
Drug use and addiction are highly dependent on circumstance and environment (e.g availability, peers)
What was shown by Rat Park?
Severely distressed people and animals will relieve their distress pharmacologically if they can.
Evidence shows that education campaigns have a negligible impact on addiction, what two things are are more effective?
Minimum unit pricing - get rid of severely discounted alcohol in supermarkets
Reduced availability
What two things help to maintain addiction?
Long term memory encoding of substance taking behaviours
Reduced frontal inhibition of such behaviours
What is a case series?
Follow up patients who have had the same exposure or treatment to see how they are doing.
What are some characteristics of chronic illnesses from the patient’s perspective?
Long-term
High degree of self-management involved
Uncertainty in diagnosis, prognosis, complications
Consequences on identity, and on social relationships
Consequences on employment
Source of embarrassment and stigma
Need for information, advice, and support
Impacts on social life, employment, finance
What are some positive consequences for patients on receiving a diagnosis?
Relief
Access to the sick role (which leads to employment rights, and welfare benefits)
Legitimises suffering, so not dismissed as a malingerer by friends and family
Access to information and support groups
What are some negative consequences for patients on receiving a diagnosis?
Facing a new set of uncertainties (in the prognosis etc)
Facing stigma
Fear of reaction of others
Possible limitations on paid work
Worries about being able to fulfil obligations e.g looking after children
Reduced income, may have to claim benefits
Worries about deterioration, or complications
Worries about dealing with medication or equipment
What is the difference between felt stigma and enacted stigma?
Felt stigma is the fear of actual stigma, but enacted stigma means the person actually experiences stigma (and is excluded, sacked, teased etc)
What are the 4 steps to measuring blood sugar with a glucometer?
Calibrate machine Prick finger Spread blood evenly over stix Insert stix into machine Read result
What is prognosis?
An assessment of the future course and outcomes of a patient’s disease based on the knowledge of the course of the disease in other patients and the patients own prognostic factors (general health, age, sex…).
What are prognostic factors?
Characteristics of the patient that can be used to more accurately predict the outcome of their disease.
What are the three categories of prognostic factors?
Demographic (age, gender…)
Disease specific (e.g grade of tumour)
Co-morbid (any co-existing disease conditions)
What is the difference between prognostic factors and risk factors?
Risk factors predict someone’s likelihood of developing a disease disease in the first place, prognostic factors are associated with different arts of outcomes in the presence of a disease.
What are the three key questions about prognosis to answer with evidence from research?
What are the possible outcomes? (Qualitative aspect)
How likely are the possible outcomes? (Quantitative aspect)
Over what time period will the outcomes happen? (Temporal aspect)
What are the two most appropriate study designs for looking at prognostic factors, and why is a randomised controlled trial not appropriate?
Case-control study, cohort study.
You can’t easily randomise people to different prognostic factors, and you don’t have equipoise.
What are the problems with using a cohort study for looking at prognosis?
The experience of the patients are in the past compared to the patient in front of you who you’re trying to give information to, so there may be performance bias.
The cohort needs to be an inception cohort, so as few prognostic factors are decide by the start of the study as possible.
There can be selection bias as people can’t be randomised.
It can take a long time.
Must try not to cause selection bias by losing people during follow-up.
Must follow-up for a long enough time to allow the outcome to happen.
Blinding needed so people’s expectations don’t cause ascertainment bias.
Historical cohort studies can have recall bias.
Need to study disease/outcomes that are common.
What are the good things about using cohort studies to look at prognostic factors?
The measurement of exposure can’t be biased by knowledge of what the outcome is.
Rare exposures can be looked at.
Several different outcomes and prognostic factors can be looked at at the same time.
Data is provided on the time course for development of an outcome.
BUT need to take into account possibility of selection bias and confounding.
What are the problems with using a case-control study to look at prognostic factors.
Need an appropriate control group (from the same population as the cases)
There is great potential for recall bias if you rely of patient/family accounts (people who have the outcome may be more likely to think more deeply and disclose that they had the exposure, this can lead to a type 1 error)
Potential for selection bias in selecting the controls and cases.
The measurement of exposure to risk factors can be biased by knowledge of presence or absence of the outcome.
What are the three ways the likelihood of an outcome occurring over time can be presented?
Percentage of survival/outcome at a particular point in time (e.g 40% survive for 5 years) Median survival (the length of follow up by which 50% of participants will have died/experienced the outcome) Survival curves (shows the percentage of the original sample who have not yet died/experienced the outcome at each point in time)
For what two reasons is it important to know the cause of a disease?
You can prevent the disease by removing the cause (e.g lung cancer)
An understanding of the natural history of the disease can improve treatment (e.g antibiotics to stop infection)
What is the name of the principle where scientific theories can’t be proven to be true but are just held with the probability of being true and experiments are designed to prove them wrong?
Falsifiability
What are the three steps to trying to prove something?
1) Find an association (use statistical significance and clinical significance)
2) Consider what might cause the association (“chance, bias, confounding, cause” framework)
3) Use Bradford-Hill criteria
What is bias?
A systematic error in the collection or analysis of information
What is confounding?
Both factors are not directly associated, but are linked by a third factor
What are the 9 Bradford-Hill criteria?
Strength of association Temporal association Consistency Specificity Dose-response relationship Experimental evidence Analogy Theoretical plausibility Coherence
What are the four classifications of causes?
Sufficient (one cause leads to the disease)
Not sufficient (many contributing causes)
Necessary (cause must be present for disease to develop)
Not necessary (cause doesn’t necessarily have to be present for disease to develop)
What is medicalisation?
The expansion of medicine into areas of human life previously understood in other ways.
What is meant by medical understandings of sexuality being historically specific?
They change throughout history.
What types of causes of sexual problems are overlooked when sexuality is medicalised?
Social, cutural, relational
Medical understandings of sexuality both REFLECT and REPRODUCE social norms, true or false?
True, e.g Freud saying women were asexual showed the sexism of that time
What is sexuality?
All aspects of social like and subjective experience that have any erotic significance.
What is gender?
Social categories of “femininity” and “masculinity” and their associated expectations, identities, conduct, and subjective experience.
What was the one sex model at the start of the 18th century?
Women and men were two versions of one essential sex, and women had the same genitalia as men just internal instead of external.
What was the two sex model developed after the enlightenment?
There are fundamental biological differences between men and women, and the two sexes are different in all parts of body and soul. This is when the female orgasm was lost. Women were thought of as asexual which justified the gender inequalities of the day.
Why can the Victorians be said to have invented sexuality?
They first started studying it scientifically, and first introduced sexuality (particularly women’s) as a medical problem.
what was the Victorian’s domestic ideology?
Upper and middle class women were predisposed to live quiet domestic lives centred around caring for their husbands and children. Advised by doctors to avoid education and live quietly and safely.
Why did “female hysteria” develop?
Emotional and mental isolation led to epidemic of depression. Fed notion of women as innately sick.
What has contributed to the contemporary sexual liberalisation?
Changes in women’s rights, increasing use of contraception, rallying against sexual repression.
Why might the problem of erectile dysfunction in men have been massively over exaggerated by big pharma?
They receive high profits from selling viagra, which Pfizer (a profit-driven company) discovered by accident.
Why might viagra have a negative effect on a relationship?
Pressure to have sex more frequently, to have more penetrative sex, guilt about not wanting to have sex when pill has already been taken. Partner should be involved in discussions about prescribing viagra.
Why was there a drive by pharmaceutical companies to define Female Sexual Dysfunction (FSD)?
To increase profits by selling viagra to women.
On what 5 grounds is the biomedical model of sexuality criticised?
1) Using male model as standard - does;t define female sexuality in women’s own terms
2) Linear conceptualisation of sexuality and desire - assumes the only correct way to have sex is to progress linearly through the stages
3) Biological reductionism - sexuality is presented as innate, fixed and biologically determined, and the social, emotional and relational factors that contribute to and shape desire are ignored
4) De-politicises sexuality - locates it purely in the individual and ignores contributing political and socio-cultural factors.
5) Medicalises the primarily social experience of sexuality - interprets natural variations in sexuality according to medical model of disease
What do the “New View” group state are the 4 major factors contributing to sexual problems?
1) Sociocultural, political and economic factors
2) Partner and relationship issues
3) Psychological factors
4) Medical factors
So a holistic approach to sexuality is needed
What two things are needed to prevent discrimination of LGBT staff and patients?
Awareness in GP practices that discrimination exists.
Determination to provide people with privacy and dignity (which can be hard to do on the wards).
Why might LGBT people have poorer health outcomes?
They are more likely to smoke, drink alcohol, and use drugs, and more likely to carry this behaviour on past 30 when it usually begins to decrease. They have higher psychological morbidity. They are more likely to have STIs.
What does it mean that there are different layers of discrimination?
Further discrimination can be applied to an LGBT individual if they are disabled, BAME, older/younger.
What are some issues encountered by LGBT people?
More likely to live alone - social isolation.
May not disclose to their GP as they lack trust or don’t feel their confidentiality will be respected in the same way as someone heterosexual.
They may delay screening or seeking treatment, so exacerbate acute and chronic conditions.
What are the negative outcomes of poor communication about sex and sexuality?
Missed opportunities for interventions around risk behaviours (so HIV/STIs not prevented or treated).
May be a feeling that gay sexuality is distinct from experiences of health, illness, wellbeing.
Lack of opportunities to discuss many health issues.
Unequal access to quality health care.
What 3 things continue barriers to communication with LGBT people?
Doctors who feel sexuality should be discussed elsewhere.
Doctors who lack confidence or feel their inquiries will only lead to embarrassment.
Not understanding that patients are usually happy to talk about sexual health if a doctor confidently initiates it, and they don’t feel judged or uncomfortable.
What 4 things are recommended as good practice for GPs by the National Strategy for Sexual Health and HIV (DoH 2001)?
GPs should be confident in taking a sexual history and carrying out a risk assessment.
HIV test discussion (NOT called pre-test counselling due to stigma)
Assessment and referral of men with STI symptoms.
Hepatitis B vaccinations.
What is bisexuality?
Having attraction to more than one gender (attraction regardless of gender)
What did the Bisexuality Report 2010 conclude were the challenges particularly faced by bi and trans people?
Biphobia is different to homophobia. Bi people may feel they experience discrimination from all round - from heterosexual and from lesbian and gay communities.
Bi and trans people challenge the binary way of thinking so may feel excluded from other support networks, feel that people are suspicious of them or that they don’t belong. Leads to higher levels of distress and mental health problems than in equivalent heterosexual or lesbian and gay communities.
What is queer?
Those who challenge the binaries of sexuality.
What was found by the Gay Men’s Sex Survey 2003?
Only just over a quarter had disclosed that they were homosexual to their GP, and there was a general feeling that this was not right.
Men who had disclosed thought staff listened carefully to what they said, they were treated with courtesy and respect, staff seemed to know their job well, and had more confidence in their relationship with their GP than men who had not disclosed.
What are two reasons that sexuality is relevant?
It influences quality of life, and an individual’s capacity to maximise and maintain health (health promotion).
It is clinically relevant, in relation to vulnerability to STIs etc.
What is heterosexism?
Discrimination against homosexuals on the assumption that heterosexuality is the normal sexual orientation.
In what 3 ways can Genitourinary Medicine services help to pathologise sexuality?
Separating sexuality from general health and wellbeing.
Increasing assumptions that it is less acceptable to talk about sexuality in other environments.
Being used as more of a primary healthcare service by LGBT people because they are worried about disclosure at their GP.
What are the 4 recommendations of the sigma report to reduce discrimination against LGBT people in GP surgeries?
Increase all staff’s capacity for meaningful communication.
All surgeries develop and display equality policies, statements and guidelines, which explicitly include sexual orientation.
Adhere to clear guidelines around confidentiality and patient’s notes.
Require all staff to act according to guidelines.
What are 4 things that highlight the scarcity of resources in the NHS?
1) Advances in medical technology - can be expensive and not yield benefits worth the costs
2) Demographic trends - ageing population with more comorbidities so more cost to the health service, and relatively less of the working population to pay taxes to fund the NHS
3) Budgetary restrictions on the NHS - currently there is static real expenditure on the NHS but an increasing demand
4) Public expectations - people no longer expect to live with knee pain, expect a knee replacement
What is rationing in healthcare?
When someone is denied (or not offered) an intervention which everyone agrees would do them good and which they would like to have.
NICE try and ration things at a national level so people in all areas receive the same and it is more fair.
What are two criteria for something to be considered rationing in healthcare?
There must be an evidence base for the effectiveness of the intervention (homeopathy is not rationed).
If the patient turns down the intervention out of choice, that is not rationing.
Before the NHS started, how was healthcare rationed?
Healthcare was rationed by price
At what 3 levels in the organisation of funding of the NHS is healthcare rationed?
1) Central government decides the funding for the NHS then divides it between the 4 nations
2) NHS England allocates the NHS budget to CCGs on the basis of population weighted by “need”. CCGs fund hospitals, NHS England funds primary care
3) Doctors and other healthcare professionals act as primary rationing agents and ration patient’s access to care (by making decisions on referring, admitting, and treating)
Why might it not be a good idea to ration healthcare by price?
It excludes the poorest and discourages the rest from using healthcare, so leads to a reduction in population health.
What are need, demand and utilisation?
Need means there is an effective and acceptable treatment or cure.
Demand means the individual considers he has a need and wishes to receive care.
Utilisation occurs when an individual actually receives care.
So, need isn’t always expressed as demand, demand isn’t always followed by utilisation, and there can be demand and utilisation without any underlying real need.
What two things are looked at in NICE appraisals?
Evidence for relative treatment effects on health related quality of life from randomised controlled trials and systematic reviews.
Evidence of cost, to economically evaluate the cost per QALY.
What are the two types of appraisals NICE carry out?
1) Technology appraisals - look at the new intervention and decide whether or not the CCG should fund it (this decision is MANDATORY)
2) Clinical guidelines - advise recommended treatments for a whole disease area (these are ADVISORY so CCGs can choose to fund things differently)
What is the problem with rationing healthcare by need?
Rationing by need is defined by cost per QALY, which assumes a QALY is of equal value to all citizens.
What are the three principles to guide rationing?
1) Treat equals equally and with dignity
2) Meet people’s needs for healthcare as efficiently as possible and impose the least sacrifice on others
3) Minimise inequalities in the lifetime health of the population
What are the characteristics of long term conditions?
Long-lasting
Insidious, poorly defined onset so hard to diagnose
Uncertainty in prognosis, diagnosis, complications
Can’t be cured but can be controlled
High levels of self-care management, and becoming an “expert patient”
Biological and social factors interact
Impact on identity, relationships, work, finance
Cause embarrassment and stigma
Cause pain
Lead to social isolation
Have very high financial costs (so a large percentage of annual healthcare expenditure is targeted at a disproportionally small group of the population)
What sort of demographic are more likely to develop a long term illness?
People with a lower income
Older people
Economically-inactive people (so can’t receive benefits)
People living in Wales
What are the challenges posed to a health care professional by a patient with a long term condition?
1) Can’t cure people (which exposes the limits and weaknesses of medical science), but have to work with them on a long journey
2) The existential issues around diagnosis means the patient is having to reconstruct who they are and their future
3) The pain the patient feels can’t be avoided or eradicated by modern medicine, and has to be endured
4) Many illnesses in old age can only be treated palliatively
For what reasons does the Sick Role apply better to acute illness than chronic illness?
It can be many years before diagnosis of a LTC is made, so harder to gain access to the sick role.
People with a LTC may be seen as responsible for their illness.
The course of a LTC is less predictable and much more likely to be deterioration than actually getting better.
The diagnosis is very important, as it provides an explanation and legitimises symptoms that may have been experienced for many years.
For what 5 reasons could diagnosis of a chronic condition be seen as positive in the short term?
1) Legitimises suffering, patient is not dismissed as a malingerer
2) Confirms the symptoms are not “all in your head”
3) Leads to acceptance by family and friends
4) Provides a label and access to treatment
5) Provides a gateway to welfare benefits, sick leave, support groups and information
Why might diagnosis of a chronic condition change to being seen as something more negative in the long term?
Brings new uncertainties about the effects on the rest of your life:
Social - finance, employment, relationships
Clinical - relapse and remission, uncertainty in prognosis and the rate of deterioration
Diagnostic uncertainty - whether the doctor has got it right
What is Biographical Disruption?
Destabilisation and questioning of identity after the onset of a long term condition. The patient questions their past and future, and the life they thought they were going to have.
What are the three aspects of biographical disruption?
Disruption of taken-for-granted assumptions and behaviours
Disruption to biography (identity, re-examine future plans)
Response to disruption (mobilise resources)
What is it called when people receive a diagnosis of a chronic condition, and look for explanations for it rooted in their biography?
Narrative Reconstruction (which may not be all negative as it may prompt someone to think they are too stressed and take a break from work to spend time with their family)
What are the two types of Meaning Making when faced with biographical disruption?
1) Meaning as a consequence - the extent symptoms disrupt everyday life, and the way you deal with every issues
2) Meaning as a significance - looking at how other people will see you, and dealing with a sense of negativity and stigma and the disvalues bodily changes
What are the three areas of work involved in self-management of a long term condition?
1) Everyday work - deciding who completes what roles (e.g shopping, cooking, financial work)
2) Biographical work - starting again and changing aspirations after a biographical disruption, assessing the future in the light of ones physical and mental resources
3) Illness work - seeking information, membership of support groups, treatment and medication regimens
The concept of biographical disruption doesn’t apply everyone, what will people who have had the long term condition from birth see it as?
Biographical continuity
For what two reasons does the concept of biographical disruption not apply to everyone with a LTC?
It is adult centred, and assumes the life had aspirations and a planned trajectory
The concept of biographical disruption doesn’t apply everyone, what are elderly people and working class people more likely to see it as?
Normal crisis
What is a Normal Crisis?
The illness is part of biographical flow. This applies to people who experience many disruptive episodes in their lives due to poverty, poor housing, ageing. They see the illness as biographical continuity or biographical reinforcement.
What is an example of an LTC being seen as biographical reinforcement?
The HIV crisis being seen as part of their political struggle and identity by gay men.
What is biographical re-invention in terms of an LTC diagnosis?
Seeing the diagnosis as positive in a “whatever-doesn’t-kill-you-makes-you-stronger” attitude.
For what 5 reasons would patients with a LTC not comply to medication?
1) See drugs as best avoided
2) Think drugs are unnatural and unsafe, associated with side effects and hidden risks
3) May adversely perceive drugs due to past negative experience
4) May see drugs as a signifier of ill health, so unwilling to take drugs in front of people for fear of being labelled as ill and facing stigma
What are the reasons that a patient with a LTC would comply to medication?
It has a lot to do with the doctor-patient relationship:
Positive experiences with doctors
Trust in doctor’s advice
The patient being shown the medication is working through being given their bp readings etc
The patient feels better, gains peace of mind
There is no practical alternative to the drugs
There is an absence of symptoms and this guides medicine use
Why would a patient with a long-term condition be a self-regulator in terms of their medication (alter their doses themselves)?
Perceived efficacy - if they don’t think the drugs are working
Perceived side effects
Experiment to see if they can manage without drugs
Drugs reinforce and remind them about their illness identity
They have a fear of dependence on drugs
Practical reasons around social events e.g increasing medication before a party, exam…
With diabetes, self-management of diet is required. What were the 4 types of diet it was found that patients followed?
1) Strict diet - stuck to regimen, as believed diet to be important to avoid complications and have longer life
2) Moderate diet - mostly adhered to prescribed diet, balanced indulgences with extra exercise
3) Flexible diet - often eat restricted foods and may feel guilty over lack of self control, monitor blood glucose so feel they can afford to be risky
4) No diet - not come to terms with diabetes, still angry so eat things in opposition, experience self-loathing and miserably obsessed with food
What was the difference found between how girls with diabetes coped at school and how boys with diabetes coped at school?
Girls incorporated the disease into their identity, it was accepted by their friends, they felt able to take medication at school, it resulted in positive attention.
Boys kept their illness quiet and did not want it incorporated into their identity, they did not want to take insulin injections at school so took less injections during the day which led to poorer health outcomes over time.
How do family relationships affect the management of chronic disease in children?
Teenagers won’t want to stand out at different so are reluctant to use visible medication. This can result in a struggle for autonomy which can lead to poor health outcomes if non-compliance is hidden from their parents. Parents need to find a balance between being responsible carers and granting autonomy and independence.
Which person in a multidisciplinary team will care for people with depression?
General Practitioner
Which person in a multidisciplinary team will screen people with chronic disease for depression?
Practice nurse
Which person in a multidisciplinary team will act as a care programme coordinator for people with severe mental health problems?
Psychiatric social worker
Who at the GP practice coordinates the care for patients from the practice who attend the consultant diabetologist?
Specialist diabetes nurse
Who in the GP practice performs medicine reviews and checks on treatment compliance?
Community pharmacist
