Health and Society

Question 1

What 4 things does a patient have to do to enter the “sick role” according to Parsons?

Answer 1

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.

Question 2

What is the function of NHS Acute Trusts?

Answer 2

To employ all the staff working in hospitals, to manage hospitals, and to have service agreements with Clinical Commissioning Groups.

Question 3

What is the function of Primary Care Trusts (PCTs)?

Answer 3

Employ doctors to work in general practice, and commission care services from hospitals (providers).

Question 4

Name the approaches to health promotion.

Answer 4

Legislative action (prevention paradox).
Health persuasion techniques (e.g media).
Personal counselling (e.g opportunistic prevention, screening).
Community development.
Health education.

Question 5

What were the determinants of health inequalities according to the Black report?

Answer 5

Artefact - healthy people move up the classes.
Natural selection.
Poverty causes ill health.
Life style differences.

Question 6

What is the evidence that inequality in society itself, rather than the absolute level of deprivation, is responsible for health inequality?

Answer 6

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.

Question 7

Name recent government initiatives to reduce child poverty.

Answer 7

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.

Question 8

Why would the child poverty indicators have increased in the 1980s?

Answer 8

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.

Question 9

What are the reasons for the symptom iceberg - why would someone take longer to visit a health professional?

Answer 9

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.

Question 10

Name three theories showing the link between lower social class and higher mortality and morbidity.

Answer 10

Cultural behavioural model.
Materialist model.
Social selection.

Question 11

What factors trigger help-seeking behaviour?

Answer 11

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.

Question 12

What is the inverse care law?

Answer 12

The people who most need support services and treatment have least access to it.

Question 13

What is the coexistence of different medical traditions called?

Answer 13

Medical pluralism.

Question 14

What is the symptom iceberg?

Answer 14

Only a small minority of the symptoms experienced by patients (10-15%) result in a consultation with a health professional.

Question 15

Who delivers most of the health care in the community according to the symptom iceberg model?

Answer 15

Lay people.

Question 16

What is the role of the Medicines and Healthcare products Regulatory Agency?

Answer 16

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.

Question 17

What is the role of NICE?

Answer 17

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.

Question 18

What is an ecological study?

Answer 18

An observational study at population level.

Question 19

What is standard deviation?

Answer 19

A measure of the spread of the population around the mean.

Question 20

Which way does negatively-skewed data shift?

Answer 20

Towards the higher numbers of the x-axis, so mode > median > mean.

Question 21

Which way does positively-skewed data shift?

Answer 21

Towards the lower numbers of the x-axis, so mode

Question 22

What is standard error?

Answer 22

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.

Question 23

What is the difference between primary, secondary, and tertiary prevention?

Answer 23

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.

Question 24

Why can it still be said that ethnicity has a genetic basis, even when some argue it is self-defined?

Answer 24

There are genetic conditions related to ethnicity.

Question 25

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?

Answer 25

Ethnocentricity.

Question 26

Name some ways in which screening for genetic diseases related to ethnicity could engender racism/

Answer 26

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?

Question 27

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.

Answer 27

More carriers will be found so the program will be more cost-effective.

Question 28

What is salutogenesis?

Answer 28

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).

Question 29

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?

Answer 29

Epidemiological transition.

Question 30

Name the broad categories that determine health outcomes.

Answer 30

Biological (genetics), social and economic (employment, education, housing), environmental (transport, pollution, water), lifestyle (diet…), access to health services, social class, country you live in.

Question 31

Define health promotion.

Answer 31

Social and environmental interventions that enable people to increase control over, and improve, their health.

Question 32

What are the five aspects of health promotion defined by the WHO?

Answer 32

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.

Question 33

Define health education.

Answer 33

Facilitating voluntary actions conductive to health, providing advice and information to encourage people to improve health.

Question 34

Define health protection.

Answer 34

Legislation (from the Health Protection Agency) to control infectious disease outbreaks and improve public health (e.g smoking ban, seat belts).

Question 35

What is the difference between primary, secondary and tertiary prevention?

Answer 35

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.

Question 36

In Beattie’s typology, what are the four main areas that health promotion is divided into?

Answer 36

Health persuasion, legislative action, community development, personal counselling.

Question 37

In Beattie’s typology, what is the link between health persuasion and legislative counselling?

Answer 37

Authoritative intervention (“top down”).

Question 38

In Beattie’s typology, what is the link between legislative action and community development?

Answer 38

Collective focus.

Question 39

In Beattie’s typology, what is the link between community development and personal counselling?

Answer 39

Negotiated intervention (“bottom up”).

Question 40

In Beattie’s typology, what is the link between personal counselling and health persuasion?

Answer 40

Individual focus.

Question 41

In Beattie’s typology, give an example of health persuasion.

Answer 41

Media campaigns e.g “5 a day”.

Question 42

In Beattie’s typology, give an example of legislative action.

Answer 42

Smoking ban, seat belts, water fluoridation.

Question 43

In Beattie’s typology, give an example of community development.

Answer 43

Food banks.

Question 44

In Beattie’s typology, give an example of personal counselling.

Answer 44

Opportunistic prevention during consultations.

Question 45

Why would some people take issue with diverting more resources towards primary prevention?

Answer 45

Resources are limited, so diverting resources upstream seems unfair. Think about the opportunity cost.

Question 46

What are the three ethical dilemmas associated with health promotion?

Answer 46

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.

Question 47

What are the challenges for opportunistic prevention during GP consultations?

Answer 47

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.

Question 48

What is the Prevention Paradox?

Answer 48

Preventative measures which bring a lot of benefit to the population, provide very little benefit to the individual (e.g minimum pricing of alcohol).

Question 49

Name three ways health professionals can get involved in health promotion.

Answer 49

Providing individual advice and support.
Getting involved in organisations.
Lobbying governments.

Question 50

What are social inequalities in health?

Answer 50

Differences in people’s health linked to social inequalities.

Question 51

Health is not all “good” above a certain income threshold, and “poor” below, what term describes the pattern?

Answer 51

Social gradient.

Question 52

Names some ways of measuring inequalities.

Answer 52

Measuring education, occupation status, housing tenure, looking at the Index of Multiple Deprivation (IMD).

Question 53

The major killers have a social gradient, which means that…

Answer 53

Overall mortality has a social gradient, as the smaller killers have little impact on overall mortality.

Question 54

The social gradient of health inequalities persists over which two factors?

Answer 54

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.

Question 55

What are the four possible explanations for socioeconomic health inequalities given in the Black report?

Answer 55

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

Question 56

What is the difference between structural and material social inequalities?

Answer 56

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.

Question 57

What is the cycle caused by structural and material social inequalities?

Answer 57

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.

Question 58

Why do childhood circumstances in particular influence health into adulthood?

Answer 58

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.

Question 59

Name some effects of being born in poor circumstances on early life.

Answer 59

Disabilities, premature birth, death.
Poor nutrition.
Difficulties of family change (e.g parental divorce, unemployment, illness, financial stress).

Question 60

Name some effects of being born in poor circumstances on adolescence.

Answer 60

Leaving school early, without qualifications.

Smoking, drinking, being physically inactive.

Question 61

Name some effects of being born in poor circumstances on adulthood.

Answer 61

Poor physical health (BMI, diastolic blood pressure).
Increased mortality and morbidity.
Financial stress from job insecurity etc.

Question 62

What is narrative based medicine?

Answer 62

How people tell you what’s wrong with them, which depends on their interpretation (illness cognition).

Question 63

Describe 3 different types of health benefits and what together they lead to.

Answer 63

Allopathic (western) medicine, lay medicine (ask friends, family, internet), complementary therapists (osteopaths, acupuncture). Together they lead to medical pluralism.

Question 64

What is medicalisation?

Answer 64

Defining an increasing number of life’s problems as medical problems (e.g grief, sexuality, childbirth).

Question 65

What is pharmacologisation?

Answer 65

Transformation of human condition/capabilities into opportunities for pharmacological intervention.

Question 66

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.

Answer 66

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

Question 67

Name an advantage and a disadvantage to lay diagnosis and self care.

Answer 67

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

Question 68

What is culture?

Answer 68

A cumulative deposit of knowledge, experience, belief, values, attitudes, meanings, material objects, possessions, acquired by a group of people.

Question 69

What is enculturation?

Answer 69

Learning from just the single knowledge base of your culture - as if learning a list of facts (simple learning).

Question 70

What is acculturation?

Answer 70

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.

Question 71

What is allopathic medicine?

Answer 71

Using pharmacology and interventions to treat or suppress symptoms or disease.

Question 72

Describe some differences between complementary therapy and allopathic medicine.

Answer 72

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.

Question 73

Name some reasons a person would want to use complementary therapy.

Answer 73

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.

Question 74

What is complementary therapy best used for?

Answer 74

Allevating symptoms (e.g back pain), not diagnosis.

Question 75

Name some things narrative medicine will depend on.

Answer 75

The person’s gender, culture, language, whether the patient sometimes distress (e.g saying they have a stomach ache, but the cause is depression).

Question 76

What are most complaints in the NHS due to?

Answer 76

Poor communication.

Question 77

What are the benefits of the Calgary-Cambridge model?

Answer 77

It improves the doctor-patient relationship. It increases the likelihood of the patient sticking to treatment. It is realistic.

Question 78

What are the main principles of patient centred care, and the main outcomes?

Answer 78

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.

Question 79

What is a diagnosis?

Answer 79

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.

Question 80

What is prognosis?

Answer 80

Assessment of the future course and outcome of a patient’s disease.

Question 81

What is evidence?

Answer 81

Results of rigorous clinical trials and observational studies that can influence clinical decision making.

Question 82

There are three ways of looking at decision-making, name them.

Answer 82

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?

Question 83

What are odds, what is an odds ratio?

Answer 83

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.

Question 84

What is a risk ratio?

What does it mean if it is greater than 1, less than 1?

Answer 84

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.

Question 85

What are the advantages and disadvantages of a cross-sectional study?

Answer 85

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".

Question 86

What are the advantages and disadvantages of a cohort study?

Answer 86

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.

Question 87

What are the advantages and disadvantages of a case control study?

Answer 87

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.

Question 88

Which model of clinical reasoning do most junior doctors follow?
Which model do senior clinicians follow, considering they have more experience?

Answer 88

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).

Question 89

What is self medication?

Answer 89

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.

Question 90

Name some different types of things people could self medicate with.

Answer 90

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.

Question 91

Name some places that patients can get access to medication.

Answer 91

From doctors in GP, hospital, private clinic, clinical trial.
Pharmacy.
Lockable shop e.g supermarket.
Health food shop.
Internet.
Black market.

Question 92

Which organisation licenses medication, saying they are safe and effective and deciding if they are POM, P medicine, or GSL?

Answer 92

Medicines and Healthcare Products Regulatory Agency (MHRA).

Question 93

What are the 3 ways that MHRA can classify medications?

Answer 93

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.

Question 94

What are all newly licensed medicines classed as by MHRA?

Answer 94

POM (prescription only medication).

Question 95

What criteria must a medicine fulfil to be changed from POM to P medicine?

Answer 95

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

Question 96

What criteria must a medicine fulfil to be changed from P medicine to GSL?

Answer 96

Can reasonably be sold or supplied not under supervision of pharmacist
Safe for self-selection

Question 97

Why might the licence for P medicines be different to their equivalent POM?

Answer 97

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.

Question 98

Name some services available from community pharmacies.

Answer 98

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

Question 99

Why is important to establish if a patient is self-medicating at all when taking a history?

Answer 99

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)

Question 100

Describe 3 different patient perspectives on taking mild analgesics.

Answer 100

Reluctant to take any pill
Don’t think twice about taking mild analgesics
Want to let the pain run its course

Question 101

Why would people be encouraged to use OTC medication?

Answer 101

Perceived effectiveness
Familiarity with brand name
Perceived safety

Question 102

Name the two different types of data.

Answer 102

Quantitative - a numerical value that can be continuous or discontinuous
Qualitative - people’s perspectives

Question 103

What is dichotomous qualitative data?

Answer 103

A choice between two categories

Question 104

Name the three types of qualitative and quantitative data in order of most useful to least useful.

Answer 104

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

Question 105

What are the three stages of data analysis?

Answer 105

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

Question 106

What is the point of inflection in a normal distribution?

Answer 106

The point that is 1 standard deviation from the mean.

Question 107

What percentage of the population in a normal distribution will be within 1 and within 2 standard deviations from the mean?

Answer 107

68% within 1 standard deviation

95% within 2 standard deviations

Question 108

Describe where the mean, median and mode are in a normal distribution, positively skewed distribution, and negatively skewed distribution.

Answer 108

Normal = mean, median and mode at the midpoint

Positively skewed = mode median > mean

Question 109

How can you unskew a skewed distribution?

Answer 109

Make it a semi-log plot

Question 110

What is the difference between the null hypothesis and alternative hypothesis?

Answer 110

Null hypothesis (H0) says that no significant difference between the groups exists.
Alternative hypothesis (H1) says there is a significant difference between the populations.

Question 111

What is a p-value and what does it mean if it is less than 0.05?

Answer 111

P-value is the probability that the difference between the populations would be seen if the null hypothesis was true
P

Question 112

What’s the difference between and type 1 and type 2 error?

Answer 112

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).

Question 113

How can p-values, statistical power, and confidence intervals be decreased?

Answer 113

Increase the sample size.

Question 114

What is the difference between the basis of statistical significance and the basis of clinical significance?

Answer 114

Statistical significance is shown by a p value

Question 115

What are the two categories of population research?

Answer 115

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)

Question 116

Name 4 types of research methods.

Answer 116

Cross-sectional study
Cohort study
Case control study
Randomised controlled trial

Question 117

Why would you use a cohort study or case control study instead of a randomised control trial?

Answer 117

Ethical issues are raised if the intervention is harmful (no equipoise), because you can’t knowingly allocate people a harmful intervention.

Question 118

Describe the hierarchy of study design based on resistance to bias.

Answer 118

Systematic review of randomised controlled trial
Randomised controlled trial
Systematic review of observational studies
Observational study
Physiological study
Unsystematic clinical observations

Question 119

What is the difference between a systematic error and random error?

Answer 119

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

Question 120

What is confidentiality?

Answer 120

Not divulging patient information to others without the patient’s consent.

Question 121

Describe the reasons to respect patient confidentiality.

Answer 121

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.

Question 122

In which two cases can information be shared without breaching confidentiality?

Answer 122

Sharing information with people directly involved in the care of the patient
Sharing information after obtaining the patient’s informed consent

Question 123

Beige breaching confidentiality, what is it essential to do?

Answer 123

Inform the patient of what you are going to do.

Question 124

In what circumstances can confidentiality be justifiably breached?

Answer 124

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

Question 125

Describe 4 things to do when sharing patient information.

Answer 125

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

Question 126

What are the two models of disability?

Answer 126

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)

Question 127

Describe the critiques of the medical model of disability.

Answer 127

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

Question 128

Describe the critiques of the social model of disability.

Answer 128

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

Question 129

How is disability defined in the Equality Act 2010?

Answer 129

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.

Question 130

What is the radical disability model?

Answer 130

Disability only applies to those who are externally defined as disabled, or self identify as disabled (not some deaf people).

Question 131

What is risk?

Answer 131

The probability an event will occur within a specified time (not necessarily a bad thing).

Question 132

What are the three ways in which risk can be presented?

Answer 132

Natural frequency e.g 1 in 84
Probability (decimal)
Percentage

Question 133

What is the difference between absolute risk and relative risk?

Answer 133

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).

Question 134

How do you calculate risk difference?

Answer 134

Risk with intervention - risk without intervention

Question 135

What does it mean if the odds ratio is greater than 1, equal to 1, less than 1?

Answer 135

Odds ratio > 1 means the control is better than intervention
Odds ratio = 1 means there is no difference
Odds ratio

Question 136

In what situations are the risk ratio and odds ratio equal, and in what situations is the odds ratio greater than the risk ratio?

Answer 136

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.

Question 137

What would make people more willing to accept a risk?

Answer 137

If the risk is:
Voluntary
Controllable
Familiar
Non-catastrophic
Fair (e.g higher risk for more benefit)

Question 138

What would make people less willing to accept a risk?

Answer 138

If the risk is:
Uncontrollable
Potentially catastrophic
There is dread
The benefit does not increase with the risk
Unknown
Unobservable
Unfamiliar

Question 139

What is the basis of organ and blood donation in the UK?

Answer 139

Altruism

Question 140

What are the arguments against remunerated blood donation (according to Titmuss)?

Answer 140

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

Question 141

How much blood is in a person, and how much can they survive losing?

Answer 141

8-10 pints in a person, can survive losing 2-3 pints if given saline and iron tablets.

Question 142

How is the UK blood donation system funded (costs for advertising, collecting, storing and distributing)?

Answer 142

Publicly funded.

Question 143

What are the arguments for remunerated blood donation (according to Cooper and Culyer)?

Answer 143

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

Question 144

Name some organs that can be transplanted.

Answer 144

Kidney
Liver
Lung
Cornea
Heart
Heart and lungs

Question 145

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?

Answer 145

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.

Question 146

Describe some potential ways to increase the supply of organs.

Answer 146

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.

Question 147

What are some problems with using financial incentives for organ donation?

Answer 147

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.

Question 148

Why does Rottenburg argue in favour of financial incentives for organ donation?

Answer 148

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”.

Question 149

What is epidemiology?

Answer 149

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.

Question 150

What is incidence?

Answer 150

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”

Question 151

What is prevalence?

Answer 151

The number of people with the disease at a particular time, as a proportion of the whole population.

Question 152

Among young people, are there higher rates of smoking for girls or boys?

Answer 152

Girls.

Question 153

What is the symptom iceberg?

Answer 153

A large proportion of the symptoms people experience (85%) don’t result in a consultation with a health professional.

Question 154

What is illness behaviour?

Answer 154

How people perceive, evaluate, and act upon their symptoms.

Question 155

Across what categories might illness behaviour vary?

Answer 155

Age, gender, social class, race, culture.

Question 156

What is medical pluralism?

Answer 156

The co-existence of deferentially designed and conceived medical traditions and systems (e.g allopathic Western medicine, homeopathy, acupuncture, herbalism).

Question 157

What is the lay referral system?

Answer 157

Consulting other people about your symptoms before going to see the GP e.g relatives, friends, pharmacist, NHS Direct, Internet.

Question 158

What are the triggers that cause people to consult a doctor about symptoms?

Answer 158

Interference with work or physical activity
Interference with social relations
Interpersonal crisis
Putting a time limit on symptoms
Sanctioning

Question 159

What is Information Age medicine?

Answer 159

Patients have as access much access to the evidence base of medicine as doctors.

Question 160

What does Information Age medicine mean for patients?

Answer 160

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)

Question 161

What are some barriers to help seeking?

Answer 161

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

Question 162

What is a carer?

Answer 162

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)

Question 163

Why is the demand for informal care increasing?

Answer 163

Life expectancy is increasing, but disability free life years is not increasing.

Question 164

What is care poverty?

Answer 164

People losing money due to the expense of being a carer (e.g home adjustments, equipment, transport to appointments) and being unable to work.

Question 165

Why is informal care beneficial to the economy?

Answer 165

It reduces bed blocking (patients are able to go home earlier), and it reduces the workload of institutional care.

Question 166

What proportion of the population are carers?

Answer 166

1 in 10. The majority are women, and over 50.

Question 167

Why might young carers be more likely to go unrecognised?

Answer 167

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.

Question 168

Describe some tasks carers might carry out.

Answer 168

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)

Question 169

Why do doctors need to be able to identify carers?

Answer 169

To make them aware of services and support they can access.

Question 170

Which type of carers are most likely to suffer harm to physical and mental health?

Answer 170

Co-resident carers, and elders carers who are likely to already have a health condition of their own.

Question 171

Give some examples of policy and legislation recognising the importance and contribution of carers.

Answer 171

National Carers Strategy 1999
Carer (Equal Opportunities) Act 2004
Equality Act 2010
Carers Strategy refresh November 2010
Carers Act/Children and Families Act 2014

Question 172

What are the key elements of recent policy and legislation on carers?

Answer 172

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.

Question 173

Name some of the conditions that need to be met for a carer to receive Carer’s Alowance.

Answer 173

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

Question 174

Why does Bedroom Tax cause difficulties for carers?

Answer 174

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.

Question 175

What legislation allows carers of adults to request flexible working?

Answer 175

Work and Families Act 2006

Question 176

What do carers generally need?

Answer 176

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)

Question 177

Name some needs specific groups of carers might have.

Answer 177

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

Question 178

Why might the supply of informal care be decreasing?

Answer 178

Increasing demand due to longer life expectancy
Smaller, more spread out families
Changing role of women
Raised pension age

Question 179

What is a clinical trial?

Answer 179

A planned experiment involving patients, which determines the most appropriate treatment for future patients with a given medical condition

Question 180

Describe the 2 phases of clinical trials.

Answer 180

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

Question 181

Name some alternatives to using a randomised controlled trial.

Answer 181

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.

Question 182

What is regression to the mean?

Answer 182

If a variable is extreme on its first measurement, it will tend to be closer to the mean on its second measurement.

Question 183

Why is randomisation used?

Answer 183

It ensures a balance across comparative groups of known and unknown baseline factors that could affect the outcome.

Question 184

What is equipoise?

Answer 184

It means it is not known whether one intervention is beta than another, and it is essential in a randomised controlled trial.

Question 185

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?

Answer 185

Stratify the baseline factor during the randomisation process.

Question 186

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?

Answer 186

To balance the cost and difficulty of administering the intervention, as different centres will vary in expertise.

Question 187

What is bias?

Answer 187

Systematic distortion of the estimated effect of an intervention away from “truth” due to inadequacies in design, conduct or analysis of a trial.

Question 188

Name the three types of bias in randomised controlled trials.

Answer 188

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.

Question 189

Why would there be selection bias if doctor were allowed to allocate their patients to intervention groups in clinical trials?

Answer 189

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.

Question 190

How can you allocate patients to intervention or control groups in a way that can’t be subverted?

Answer 190

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)

Question 191

I randomised controlled trials, what type of bias does Blinding particularly reduce?

Answer 191

Ascertainment bias.

Question 192

What has the historical opposition to randomised controlled trials led to?

Answer 192

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

Question 193

What is stigma?

Answer 193

Any physical or behavioural attribute that is negatively valued, or leads someone to be regarded as unacceptable or inferior.

Question 194

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”?

Answer 194

We need people who are “other” to make us feel normal.

Question 195

Why would the stigma of being labelled “mad” be more socially damaging than being labelled “bad”?

Answer 195

“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.

Question 196

Name the 5 steps in producing stigma.

Answer 196

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)

Question 197

What are the three levels of discrimination?

Answer 197

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)

Question 198

What did Rosenhan argue about mental illness?

Answer 198

Mental illness is a social phenomenon which is just a consequence of labelling.

Question 199

What are the two types of stigma based on whether an individual can pass for “normal” or not?

Answer 199

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

Question 200

What are three types of stigma?

Answer 200

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

Question 201

Name 6 ways sigma can be managed.

Answer 201

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)

Question 202

Describe some of the implications of stigma for medicine.

Answer 202

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.

Question 203

What is stress?

Answer 203

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.

Question 204

How do Life Events relate to stress?

Answer 204

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

Question 205

What is the difference between primary appraisal and secondary appraisal of a Life Event?

Answer 205

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.

Question 206

What are is the emotional (affective) stress response?

Answer 206

Feeling on edge, depression, despair, anxiety, anhedonia, irritability, tearfulness, over-reacting.

Question 207

What is the cognitive stress response?

Answer 207

Difficulty concentrating, ruminating, thoughts racing - difficulty switching off, self-critical, difficulty making decisions and problem solving.

Question 208

What is the behavioural stress response?

Answer 208

Comfort eating/ loss of appetite
Increased drinking/ smoking
Withdrawing from exercise and social activity
Disturbed sleep

Question 209

What is the physiological stress response?

Answer 209

Fight or flight
Increased heart rate, breathing rate, blood pressure
Increased muscle tension
Increased sweating

Question 210

Describe some examples where the physiological symptoms of stress could be misinterpreted as illness.

Answer 210

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

Question 211

What cycle does the misinterpretation of the physical symptoms of stress lead to?

Answer 211

Stress -> physiological response -> physical symptoms
Physical symptoms -> misinterpretation
Misinterpretation -> worry/anxiety
Worry/anxiety -> physiological response

Question 212

What would make someone more likely to misinterpret the physical symptoms of stress?

Answer 212

If the person has a tendency to worry, previous mental or physical illness, illness beliefs (e.g a family history of heart disease).

Question 213

What are medically unexplained symptoms?

Answer 213

Physical symptoms that can not be explained by organic disease, and that cause distress and impair functioning.

Question 214

What are functional symptoms?

Answer 214

Symptoms that arise from a problem in nervous system functioning, not caused by a structurally or pathologically defined disease.

Question 215

What is a psychosomatic illness?

Answer 215

A physical disease caused or made worse by mental factors such as stress/anxiety.

Question 216

What is a somatoform disorder?

Answer 216

Mental illness that causes physical symptoms (e.g pain) that can’t be traced back to any physical cause.

Question 217

What proportion of patients in primary and secondary care have medically unexplained symptoms?

Answer 217

Primary care = 25%

Secondary care = 40-50%

Question 218

Name two ways in which stress can cause MUS.

Answer 218

Some MUS arise from misinterpretation of the normal physiological stress responses.
Some MUS arise from minor pathologies that are exaggerated at times of stress.

Question 219

Why might someone develop physical symptoms to protect themselves from an adverse life event?

Answer 219

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.

Question 220

How do the behavioural responses to stress have an indirect effect on existing physical illness.

Answer 220

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)

Question 221

What is Broken Heart Syndrome (stress myocardiopathy)?

Answer 221

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.

Question 222

What is illness cognition?

Answer 222

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.

Question 223

What are the five dimensions to illness cognitions?

Answer 223

Identity - label and symptoms of illness
Timeline - perceived duration
Consequences - expected outcome
Causes - punishment?
Cure/control - how to control it/ recover

Question 224

What are the three stages of illness cognitions?

Answer 224

Patients make an interpretation of their illness
Patients select a coping strategy
Patients appraise the coping strategy

Question 225

What are the two different types of coping strategies?

Answer 225

Problem solving - controlling the problem and reconstructing it as manageable
Emotion focused - managing emotions and maintaining an emotional equilibrium

Question 226

Give some examples of problem focused coping strategies.

Answer 226

Seeking information about the condition
Seeking support
Learning new procedures and behaviours
Identifying new activities/ alternative rewards
Developing a realistic action plan

Question 227

Give some examples of emotion-focused coping strategies.

Answer 227

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

Question 228

What is hyperacusis?

Answer 228

Sensitivity to all sorts of sounds.

Question 229

How does depression affect your pain threshold?

Answer 229

Lowers your pain threshold.

Question 230

What are common affective reactions to grief?

Answer 230

Guilt, anhedonia, longing, yearning, anxiety, depression, shock + numbness.

Question 231

What are cognitive reactions to grief?

Answer 231

Intrusive ruminations - preoccupation with thoughts of deceased, hallucinating presence of the deceased, denial, low self esteem, hopelessness.

Question 232

What are behavioural reactions to grief?

Answer 232

Agitation, restlessness, fatigue, searching, crying spontaneously, social withdrawal.

Question 233

What are physiological reactions to grief?

Answer 233

Initial weight loss then possibly weight gain, sleep disturbances, energy loss, physical complaints similar to the deceased, suppressed immune system, hypertension, self neglect.

Question 234

Name an aspect of grief that is universal for all cultures.

Answer 234

Crying.

Question 235

Which part of the brain is connected to “yearning and searching” in the grief response?

Answer 235

Nucleus accumbens.

Question 236

What are the 4 stages of grief?

Answer 236

Numbing
Yearning and searching
Disorganisation and despair
A greater or lesser degree of organisation

Question 237

What are the two ways in which people can deal with grief?

Answer 237

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

Question 238

What is complicated grief?

Answer 238

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.

Question 239

Name some things that can complicate normal grief.

Answer 239

Pre-existing mental health problems, unfinished business with the deceased, guilt, remorse, financial difficulties, unemployment.

Question 240

What are the three stages in the short of classifying mental distress?

Answer 240

Religious - involves soul
Moral - madness is a punishment for actions
Scientific - medical and social models

Question 241

What is panopticism?

Answer 241

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.

Question 242

Which type of mental health disorder is more common in women, which type is more common in men?

Answer 242

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).

Question 243

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.

Answer 243

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

Question 244

Do boys or girls show higher rates of mental illness?

Answer 244

Boys.

Question 245

Why is male suicide a big issue?

Answer 245

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.

Question 246

Name some social and environmental factors which increase the risk of mental I’ll health.

Answer 246

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

Question 247

What is the Minority Stress Model?

Answer 247

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

Question 248

What is meant by proximal and distal stressors in the Minority Stress Model?

Answer 248

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

Question 249

Describe some ways attitudes in practice can be changed to reduce the differences in health outcomes between different minority groups.

Answer 249

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)

Question 250

Describe some ways GP practices can be changed to reduce the differences in health outcomes between different minority groups.

Answer 250

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

Question 251

What is epigenetics?

Answer 251

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.

Question 252

Describe some factors that make it difficult to access mental health services.

Answer 252

Fear of showing difference
Shame
Experience of prejudice
Lack of insight - not realising you’re ill

Question 253

Name 3 effects culture has on how patients use mental health services.

Answer 253

Trust in services - less willing to believe he will be understood
Access to services - later in illness
Respond of services - dealt with more restrictively

Question 254

Describe the 3 vicious cycles that sustain stigma in mental illness.

Answer 254

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

Question 255

Define impairment, disability, handicap.

Answer 255

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

Question 256

Describe the historical factors leading to the development of the medical model of disability.

Answer 256

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)

Question 257

Give some examples of recognised assessments of disability.

Answer 257

Barthélemy index
Functional Assessment Measure
SF36
Nottingham Health Profile
EQ5D
Health Assessment Questionnaire (HAD)

Question 258

Describe ways an occupational therapist can help patients before and after a surgery.

Answer 258

Functional Assessment
Goal setting
Advise and arrange adaptations for employment/hobbies
Quality of Life Assessment
Activities of Daily Living Assessment

Question 259

Why is it important to measure the epidemiology of mental health in the population?

Answer 259

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

Question 260

What are the challenges to measuring mental health in the population?

Answer 260

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

Question 261

What are descriptive statistics?

Answer 261

Describing the data by collecting, summarising, and describing it in terms of mean, standard deviation etc.

Question 262

What are inferential statistics?

Answer 262

Use statistical tests and confidence intervals to make generalisations about a population.

Question 263

What is standard error used for?

Answer 263

Describing how good is our estimate of the true population mean. It is the standard deviation of the sampling distribution.

Question 264

What is the difference between standard error and standard deviation?

Answer 264

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.

Question 265

How do you calculate standard error for a sample mean?

Answer 265

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

Question 266

What are confidence intervals, and what are confidence limits?

Answer 266

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).

Question 267

Why isn’t it ever possible to calculate a useful interval estimate that will always contain the population mean?

Answer 267

There is always the possibility the sample will be extreme and contain a lot of ether very small, or very large observations.

Question 268

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?

Answer 268

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.

Question 269

What is the p-value, confidence interval, and risk ratio if the difference is statistically significant, or not statistically significant?

Answer 269

Statistically significant:
P-value  0.05
Confidence interval includes null hypothesis value
Risk ratio = 1
Risk difference = 0

Question 270

What is NNT?

Answer 270

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.

Question 271

What is addiction?

Answer 271

The continued repetition of a behaviour, despite adverse consequences.

Question 272

All addicts have a degree of ambivalence, what is ambivalence?

Answer 272

Holding two contradictory beliefs/ideas at the same time (e.g liking and disliking the addictive behaviour).

Question 273

What are the 7 criteria of dependence syndrome?

Answer 273

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

Question 274

What are the four parts of the biaxial model of addiction?

Answer 274

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”

Question 275

What 3 things can you get addicted to according to the DSM?

Answer 275

Alcohol, drugs, gambling

Potentially Internet gaming

Question 276

What 4 things make some substances more addictive than others?

Answer 276

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

Question 277

Where did the first suggestion of total abstinence from alcohol come from?

Answer 277

Temperance movement in 19th century USA.

Question 278

What is the key idea behind AA?

Answer 278

Some people have the “alcohol gene” and are inherently alcoholic.

Question 279

What factors influence whether someone will become addicted?

Answer 279

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.

Question 280

In what 2 ways is a variable reinforcement schedule more effective than a continuous one?

Answer 280

It creates a high steady rate of responding

It is resistant to extinction

Question 281

How are positive and negative reinforcement involved in alcohol addiction?

Answer 281

Positive reinforcement (social/ dopamine buzz) starts the alcohol addiction, negative reinforcement (relief from withdrawal symptoms) maintains the alcohol addiction.

Question 282

What was the evidence found that heroine and cocaine are innately addictive drugs?

Answer 282

Rats will repeatedly administer heroin or cocaine until death, ignoring other activities like running in their wheel or eating or drinking.

Question 283

Which pathway is responsible for dopamine release producing feelings of pleasure?

Answer 283

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.

Question 284

What factors maintain addiction?

Answer 284

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.

Question 285

What are the characteristics of end stage addiction?

Answer 285

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.

Question 286

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?

Answer 286

Drug use and addiction are highly dependent on circumstance and environment (e.g availability, peers)

Question 287

What was shown by Rat Park?

Answer 287

Severely distressed people and animals will relieve their distress pharmacologically if they can.

Question 288

Evidence shows that education campaigns have a negligible impact on addiction, what two things are are more effective?

Answer 288

Minimum unit pricing - get rid of severely discounted alcohol in supermarkets
Reduced availability

Question 289

What two things help to maintain addiction?

Answer 289

Long term memory encoding of substance taking behaviours

Reduced frontal inhibition of such behaviours

Question 290

What is a case series?

Answer 290

Follow up patients who have had the same exposure or treatment to see how they are doing.

Question 291

What are some characteristics of chronic illnesses from the patient’s perspective?

Answer 291

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

Question 292

What are some positive consequences for patients on receiving a diagnosis?

Answer 292

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

Question 293

What are some negative consequences for patients on receiving a diagnosis?

Answer 293

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

Question 294

What is the difference between felt stigma and enacted stigma?

Answer 294

Felt stigma is the fear of actual stigma, but enacted stigma means the person actually experiences stigma (and is excluded, sacked, teased etc)

Question 295

What are the 4 steps to measuring blood sugar with a glucometer?

Answer 295

Calibrate machine
Prick finger
Spread blood evenly over stix
Insert stix into machine 
Read result

Question 296

What is prognosis?

Answer 296

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…).

Question 297

What are prognostic factors?

Answer 297

Characteristics of the patient that can be used to more accurately predict the outcome of their disease.

Question 298

What are the three categories of prognostic factors?

Answer 298

Demographic (age, gender…)
Disease specific (e.g grade of tumour)
Co-morbid (any co-existing disease conditions)

Question 299

What is the difference between prognostic factors and risk factors?

Answer 299

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.

Question 300

What are the three key questions about prognosis to answer with evidence from research?

Answer 300

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)

Question 301

What are the two most appropriate study designs for looking at prognostic factors, and why is a randomised controlled trial not appropriate?

Answer 301

Case-control study, cohort study.

You can’t easily randomise people to different prognostic factors, and you don’t have equipoise.

Question 302

What are the problems with using a cohort study for looking at prognosis?

Answer 302

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.

Question 303

What are the good things about using cohort studies to look at prognostic factors?

Answer 303

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.

Question 304

What are the problems with using a case-control study to look at prognostic factors.

Answer 304

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.

Question 305

What are the three ways the likelihood of an outcome occurring over time can be presented?

Answer 305

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)

Question 306

For what two reasons is it important to know the cause of a disease?

Answer 306

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)

Question 307

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?

Answer 307

Falsifiability

Question 308

What are the three steps to trying to prove something?

Answer 308

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

Question 309

What is bias?

Answer 309

A systematic error in the collection or analysis of information

Question 310

What is confounding?

Answer 310

Both factors are not directly associated, but are linked by a third factor

Question 311

What are the 9 Bradford-Hill criteria?

Answer 311

Strength of association
Temporal association
Consistency
Specificity
Dose-response relationship
Experimental evidence
Analogy
Theoretical plausibility
Coherence

Question 312

What are the four classifications of causes?

Answer 312

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)

Question 313

What is medicalisation?

Answer 313

The expansion of medicine into areas of human life previously understood in other ways.

Question 314

What is meant by medical understandings of sexuality being historically specific?

Answer 314

They change throughout history.

Question 315

What types of causes of sexual problems are overlooked when sexuality is medicalised?

Answer 315

Social, cutural, relational

Question 316

Medical understandings of sexuality both REFLECT and REPRODUCE social norms, true or false?

Answer 316

True, e.g Freud saying women were asexual showed the sexism of that time

Question 317

What is sexuality?

Answer 317

All aspects of social like and subjective experience that have any erotic significance.

Question 318

What is gender?

Answer 318

Social categories of “femininity” and “masculinity” and their associated expectations, identities, conduct, and subjective experience.

Question 319

What was the one sex model at the start of the 18th century?

Answer 319

Women and men were two versions of one essential sex, and women had the same genitalia as men just internal instead of external.

Question 320

What was the two sex model developed after the enlightenment?

Answer 320

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.

Question 321

Why can the Victorians be said to have invented sexuality?

Answer 321

They first started studying it scientifically, and first introduced sexuality (particularly women’s) as a medical problem.

Question 322

what was the Victorian’s domestic ideology?

Answer 322

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.

Question 323

Why did “female hysteria” develop?

Answer 323

Emotional and mental isolation led to epidemic of depression. Fed notion of women as innately sick.

Question 324

What has contributed to the contemporary sexual liberalisation?

Answer 324

Changes in women’s rights, increasing use of contraception, rallying against sexual repression.

Question 325

Why might the problem of erectile dysfunction in men have been massively over exaggerated by big pharma?

Answer 325

They receive high profits from selling viagra, which Pfizer (a profit-driven company) discovered by accident.

Question 326

Why might viagra have a negative effect on a relationship?

Answer 326

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.

Question 327

Why was there a drive by pharmaceutical companies to define Female Sexual Dysfunction (FSD)?

Answer 327

To increase profits by selling viagra to women.

Question 328

On what 5 grounds is the biomedical model of sexuality criticised?

Answer 328

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

Question 329

What do the “New View” group state are the 4 major factors contributing to sexual problems?

Answer 329

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

Question 330

What two things are needed to prevent discrimination of LGBT staff and patients?

Answer 330

Awareness in GP practices that discrimination exists.

Determination to provide people with privacy and dignity (which can be hard to do on the wards).

Question 331

Why might LGBT people have poorer health outcomes?

Answer 331

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.

Question 332

What does it mean that there are different layers of discrimination?

Answer 332

Further discrimination can be applied to an LGBT individual if they are disabled, BAME, older/younger.

Question 333

What are some issues encountered by LGBT people?

Answer 333

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.

Question 334

What are the negative outcomes of poor communication about sex and sexuality?

Answer 334

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.

Question 335

What 3 things continue barriers to communication with LGBT people?

Answer 335

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.

Question 336

What 4 things are recommended as good practice for GPs by the National Strategy for Sexual Health and HIV (DoH 2001)?

Answer 336

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.

Question 337

What is bisexuality?

Answer 337

Having attraction to more than one gender (attraction regardless of gender)

Question 338

What did the Bisexuality Report 2010 conclude were the challenges particularly faced by bi and trans people?

Answer 338

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.

Question 339

What is queer?

Answer 339

Those who challenge the binaries of sexuality.

Question 340

What was found by the Gay Men’s Sex Survey 2003?

Answer 340

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.

Question 341

What are two reasons that sexuality is relevant?

Answer 341

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.

Question 342

What is heterosexism?

Answer 342

Discrimination against homosexuals on the assumption that heterosexuality is the normal sexual orientation.

Question 343

In what 3 ways can Genitourinary Medicine services help to pathologise sexuality?

Answer 343

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.

Question 344

What are the 4 recommendations of the sigma report to reduce discrimination against LGBT people in GP surgeries?

Answer 344

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.

Question 345

What are 4 things that highlight the scarcity of resources in the NHS?

Answer 345

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

Question 346

What is rationing in healthcare?

Answer 346

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.

Question 347

What are two criteria for something to be considered rationing in healthcare?

Answer 347

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.

Question 348

Before the NHS started, how was healthcare rationed?

Answer 348

Healthcare was rationed by price

Question 349

At what 3 levels in the organisation of funding of the NHS is healthcare rationed?

Answer 349

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)

Question 350

Why might it not be a good idea to ration healthcare by price?

Answer 350

It excludes the poorest and discourages the rest from using healthcare, so leads to a reduction in population health.

Question 351

What are need, demand and utilisation?

Answer 351

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.

Question 352

What two things are looked at in NICE appraisals?

Answer 352

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.

Question 353

What are the two types of appraisals NICE carry out?

Answer 353

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)

Question 354

What is the problem with rationing healthcare by need?

Answer 354

Rationing by need is defined by cost per QALY, which assumes a QALY is of equal value to all citizens.

Question 355

What are the three principles to guide rationing?

Answer 355

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

Question 356

What are the characteristics of long term conditions?

Answer 356

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)

Question 357

What sort of demographic are more likely to develop a long term illness?

Answer 357

People with a lower income
Older people
Economically-inactive people (so can’t receive benefits)
People living in Wales

Question 358

What are the challenges posed to a health care professional by a patient with a long term condition?

Answer 358

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

Question 359

For what reasons does the Sick Role apply better to acute illness than chronic illness?

Answer 359

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.

Question 360

For what 5 reasons could diagnosis of a chronic condition be seen as positive in the short term?

Answer 360

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

Question 361

Why might diagnosis of a chronic condition change to being seen as something more negative in the long term?

Answer 361

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

Question 362

What is Biographical Disruption?

Answer 362

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.

Question 363

What are the three aspects of biographical disruption?

Answer 363

Disruption of taken-for-granted assumptions and behaviours
Disruption to biography (identity, re-examine future plans)
Response to disruption (mobilise resources)

Question 364

What is it called when people receive a diagnosis of a chronic condition, and look for explanations for it rooted in their biography?

Answer 364

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)

Question 365

What are the two types of Meaning Making when faced with biographical disruption?

Answer 365

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

Question 366

What are the three areas of work involved in self-management of a long term condition?

Answer 366

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

Question 367

The concept of biographical disruption doesn’t apply everyone, what will people who have had the long term condition from birth see it as?

Answer 367

Biographical continuity

Question 368

For what two reasons does the concept of biographical disruption not apply to everyone with a LTC?

Answer 368

It is adult centred, and assumes the life had aspirations and a planned trajectory

Question 369

The concept of biographical disruption doesn’t apply everyone, what are elderly people and working class people more likely to see it as?

Answer 369

Normal crisis

Question 370

What is a Normal Crisis?

Answer 370

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.

Question 371

What is an example of an LTC being seen as biographical reinforcement?

Answer 371

The HIV crisis being seen as part of their political struggle and identity by gay men.

Question 372

What is biographical re-invention in terms of an LTC diagnosis?

Answer 372

Seeing the diagnosis as positive in a “whatever-doesn’t-kill-you-makes-you-stronger” attitude.

Question 373

For what 5 reasons would patients with a LTC not comply to medication?

Answer 373

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

Question 374

What are the reasons that a patient with a LTC would comply to medication?

Answer 374

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

Question 375

Why would a patient with a long-term condition be a self-regulator in terms of their medication (alter their doses themselves)?

Answer 375

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…

Question 376

With diabetes, self-management of diet is required. What were the 4 types of diet it was found that patients followed?

Answer 376

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

Question 377

What was the difference found between how girls with diabetes coped at school and how boys with diabetes coped at school?

Answer 377

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.

Question 378

How do family relationships affect the management of chronic disease in children?

Answer 378

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.

Question 379

Which person in a multidisciplinary team will care for people with depression?

Answer 379

General Practitioner

Question 380

Which person in a multidisciplinary team will screen people with chronic disease for depression?

Answer 380

Practice nurse

Question 381

Which person in a multidisciplinary team will act as a care programme coordinator for people with severe mental health problems?

Answer 381

Psychiatric social worker

Question 382

Who at the GP practice coordinates the care for patients from the practice who attend the consultant diabetologist?

Answer 382

Specialist diabetes nurse

Question 383

Who in the GP practice performs medicine reviews and checks on treatment compliance?

Answer 383

Community pharmacist