Health and Society Flashcards
1
Q
What are the 3 types of ethics?
A
- meta-ethics - study moral concepts
- normative - study of deciding what is the right action
- applied ethics - application of moral theories in real cases.
2
Q
What are the 3 normative ethics?
A
Consequentialism - moral based on consequence of action e.g. act utilitarian
Deontology - morality of an action based on action’s adherence to the rules e.g. lying is wrong.
Virtue ethics - act according to the most virtuous person in the world.
3
Q
What are the 4 principles approach?
A
- Autonomy - respect patient’s as individuals to make informed choices.
- Beneficence - do good, act in ways that positively benefit patients.
- Non-malaficience - do no harm.
- Justice - treat all patients and resources fairly and equitably.
4
Q
Define medical professionalism.
A
Signifies the set of values, behaviours and relationships that underpins the trust the public has on doctors.
5
Q
Why do doctors need to be good communicators?
A
Use clinical reasoning - must sort through cluster of features presented by patient and accurately assign a diagnostic label with development of appropriate treat so communication skills are key to getting info and explaining things to patients.
6
Q
What are the consequences of good communication?
A
- accurate diagnosis
- accurate data gathering
- increased adherence to treatment
- effective doctor-patient relationship
- increased satisfaction
7
Q
What are the consequences of poor communication?
A
- inaccurate diagnosis
- non-adherence
- less recognition of ICEF
- decreased satisfaction
- more complaints
8
Q
Can communication skills be taught?
A
Yes, it leads to improvements but requires feedback and self-reflection.
9
Q
What is the basic principle of the Calgary-Cambridge model?
A
Bridges the biomedical perspective with patient perspective.
PP - every patient explains own problems within their own framework, CC enables us to communicate within their own framework.
10
Q
Why is biomedical explanations described as socially constructed?
A
Develops within social context, financed by particular interest (question of the time). Science is always a social exploration. Social factors: - funding - profit - ethical issues
11
Q
Define eugenics.
A
Based on Darwin’s ideas, illogical conclusion that humans are evolving towards the ‘perfect’ or ‘ideal’ human race and we should socially construct a society to achieve this goal.
12
Q
Where was eugenics prevalent?
A
Nazi Germany -> Jews
US -> race and immigration
UK -> class
Enacted through various laws e.g. sterilisation laws
13
Q
Define positive and negative eugenics.
A
Positive - encouraging good genetics.
Negative - discouraging through bad discourse.
14
Q
What is new genetics?
A
We are in genomic era - discover genetic factors to diseases, map human genome and have personalised genome.
15
Q
What are the issues raised by new genetics?
A
Paradigm shift -> thinking about future health instead of present e.g. Angelina Jolie and BRCA gene -> desire for mastectomies and consults increased.
Designer babies
Dangerous behaviour -> people without predisposition feel ‘let off’ and won’t be careful with nutrition and smoking.
Risk surveillance -> health insurance, employment and civil liberties (genetic passport).
16
Q
Define patient centred care.
A
Care that is responsive to needs of patient.
17
Q
What is the rationale behind PCC?
A
Social relationship has changed in the last 30 years, in Victorian times - doctors pleased the patients. In 20th century, diagnostic capabilities increased so ritualistic act of diagnosis lead to paternalistic care. Eventually treating patients as individuals came into effect.
18
Q
Define professional choice.
A
Doctor decides, patient consents.
19
Q
Define shared-decision making.
A
Info shared, both decide together.
20
Q
Define consumer choice.
A
Doctor informs, patient decides.
21
Q
List the 5 criteria of PCC
A
- Explores the patients’ main reason for the visit concerns and need for information
- Seek an integrated understanding of the patients’ world – their whole person, emotional needs, and life issues.
- Finds common ground on what the problem is and mutually agrees on management
- Enhances prevention and health promotion
- Enhances the continuing relationship between the patient and the doctor
- Is realistic
22
Q
Define sick role.
A
Illness is a form of social deviance, stops people from fulfilling their expectations in society.
23
Q
What are the patients obligations in the sick role?
A
- want to get well quickly
- must seek professional medical advice
- allowed to shed some normal activities and responsibilities of society
- in need of care, can’t get well on their own.
24
Q
What are the doctors obligations in the sick role?
A
- apply high skill and knowledge
- act for the welfare of patients and society, not for own self
- objective and emotionally detached
- guided by rules of professional practice
25
What are the rights of the doctor in the sick role?
- right to examine patients and enquire intimate physical and personal info.
- autonomy in professional practice
- position of authority
26
What are the criticisms of the sick role?
Ignores potential conflicts between patient and doctors value, best interest of individual and cost to society in allocation of resources.
27
Define uncertainty in medical practice.
Technical uncertainty - insufficient info to assist with accurate diagnosis.
Personal uncertainty - not sure what patient wants.
Conceptual uncertainty - difficult to apply available knowledge to specific patients.
28
What is the role of evidence in healthcare?
Reduces uncertainty in medical decisions.
Used to make informed decisions.
Increases efficiency and reduces variations.
29
What are the different types of decisions that doctors make?
- treatment options
| - diagnosis
30
How has evidence based decision making arisen in medicine?
Evidence can inform decisions about effectiveness of treatments. There's often gap between evidence generated and application into clinical practice.
- Variation in practice
- Increased pressure on resources
- increased consumer involvement
- lack of acceptance on expertise
31
Define evidence based decision making.
Conscientious, judicious and explicit use of current best evidence in making decisions about the care of individual patients.
32
What are the components of EBDM?
Evidence from research
Patient preference
Available resources
Clinical expertise
33
Describe the economic perspective in medicine.
Resources are scarce so economics is how people make choices about how to allocate the resources.
e. g. infertility:
- hippocratic -> infertile couples can benefit from IVF
- economic perspective -> £2 million funds 21,500 A&E attendees.
34
Define opportunity cost.
Value of what you give up when you make a treatment decision. Measured in terms of resources given up or the foregone health for another patient.
35
Why has demand for healthcare increased?
- ageing population
- technological change
- increased population size
36
How is the NHS funded?
- general taxation
- national insurance
- payments made to NHS e.g. prescriptions
37
Who manages NHS?
Department of Health
38
Who are the purchasers within NHS?
CCGs
39
What is the conventional medical model of disease?
Looks at biomedical perspective only (no social, psychological and behavioural factors).
Biomedical explanation for disease - deviations from the norm. Over-simplifies problems of illness. Enables paternalistic medicine.
40
What is disease?
What is wrong with the body, as identified by signs and symptoms and abnormal tests.
41
What is illness?
Feelings about being ill (feelings, ideas, function, expectations).
42
What are the problems that arise from failure to recognise the duality of agendas (disease & illness)?
- Patient dis-satisfaction
| - Complaints
43
How is disease and illness interrelated?
To be patient-centred, must weave between disease and illness to find common ground and mutual understanding with patient.
44
How might the patient's agenda be explored in consultation?
The Calgary-Cambridge model seeks both disease info by history and examination and illness info by ICEF.
45
Define the principle of respecting patient autonomy.
- acting with sufficient understanding
- acting free from the control of others
- acting in accordance with one's values.
46
Why is autonomy important?
Consequentialist - leads to better outcomes.
Deontology - Kant -> treating people as ends not means.
Resting autonomy is a negative and positive obligation e.g. obtaining patient's consent and respecting their confidentiality.
47
Describe the meaning of the patient's best interest.
Doctor does something they believe will provide a net benefit for the patient.
48
How is best interests related to the 4 principles approach?
Best interest is a synthesis of principles of non-malaficience and beneficence to give an all things considered approach by the doctor and the patient.
i.e. balancing side effects with the benefit of a particular treatment.
49
What are the potential difficulties of assessing best interest?
- difficulties in predicting future outcome
- patient unable to communicate info
- conflict between benefits of treatment and patients one values.
- conflict between doctor's views and patient's view on best interest.
- emotional attachment
50
How does autonomy relate to the patient's best interest?
Patients often in best position to autonomously decide what is in their best interest so for the doctor, acting in the patient's best interest will require empowering patients to make decisions for themselves.
51
What happens when autonomy and patient's best interest is not considered?
Paternalism:
Coercion - forcing pt. to eat
Misinformation - lying to save from distress
52
Do patients have the right to accept/refuse options?
Yes even if it seems irrational or for no reason at all.
53
Define epidemiology.
Study of distribution and determinants of health-related states and events in population and the application of this study to the control of health problems.
54
Define incidence.
Number of new cases in a period/number initially free of disease
Number changes due to new diagnosis and immigration of ill people.
Rate
55
Define prevalence.
Number of people with disease at a particular point in time/ total population
Number changes due to recovery, death, emigration of ill people.
56
Describe patterns of smoking across time.
```
Smoking prevalence has decreased over time in males and females.
Ethnicity:
- highest male -> Bangladesh
- lowest male -> Indian
- highest female -> Irish
- lowest female -> Bangladesh
More prevalent in deprived areas.
```
57
Describe smoking prevalence between girls vs. boys.
Ages 11-15, higher girls prevalence
Above 18, higher male prevalence
Decreasing prevalence after age 25.
58
What is descriptive epidemiology?
Tells us how things are distributed.
59
How does descriptive epidemiology help in medicine?
Knowledge of distribution of smoking in the population guides prevention action, identifies cause of disease and surveillance of populations.
e.g. Need to help people stop smoking before age 40 as health risks will reduce to that of non-smokers then.
60
What is symptom iceberg?
Most symptoms are managed in the community without people seeking professional healthcare.
Tip of the iceberg - small amount of people present to healthcare.
Submerged majority - self-care.
61
What are Zola’s triggers for help-seeking.
- Interference with work or physical activity.
- Interference with social relations
- Interpersonal crisis
- Putting time limit on symptoms
- Sanctioning by friends and relatives.
62
What are the barriers to people seeking help?
- Provision and availability of health services.
- Attitudes of staff (receptionists, doctors)
- Social/cultural distance
- Geographical distance
- Time, effort, childcare, loss of earnings
- Car ownership and transport costs
- Bad experiences and waiting times.
63
What factors influence people’s decision to seek help?
- Perception and evaluation of symptoms.
- Perceived risk of disease
- Previous experience
- Psychological factors - fear of death
- Concern about using NHS resources
- Context e.g. weekend, Christmas
64
What is the old-world model of doctor-patient relationship?
Patients don't have easy access to knowledge base of doctors.
Doctor is smartest.
65
What is the new world model of doctor-patient relationship?
Patients have as much access to the evidence base of medicine as doctors.
Patients are smarter.
66
What is medical pluralism?
Co-existence with a society of differentially designed and conceived medical traditions and systems (herbalism, acupuncture, homeopathy).
67
What is the lay-referral system?
Before attending appointments, 70% consult at least 3 lay people e.g. relatives and friends, pharmacists, internet.
68
Define illness behaviour.
Ways in which symptoms may be differentially perceived, evaluated and acted up by different kinds of people.
69
How does illness behaviour vary?
With age, ethnicity, religion, sexual orientation and disability.
70
How does illness behaviour vary with gender?
Men find cold symptoms more difficult to handle than women.
71
How does illness behaviour vary with ethnicity?
BAME more likely to delay help seeking.
72
How does illness behaviour vary with socio-economic conditions?
Working class -> symptoms part of everyday life e.g. cough and back pains.
Middle class -> seek help quicker than working class.
73
Why are symptoms differentially perceived by different people?
Depends on our life experiences.
| Socially and culturally learnt response -> multi-faceted.
74
What is evidence?
Evidence is an observation, factor or organised body of information, offered to support or justify inferences or beliefs in the demonstration of some proposition or matter at issue.
75
What is the biomedical model of health and illness?
Questions of health and illness largely solved by investigation genetics, cellular function and the impact of pharm interventions.
76
What is the social model of health and illness?
Accepts health and illness can't be entirely explained by genes, biochemistry and physiology.
The context in which people live is important.
The opportunities for a healthy life are not afforded equally to all -> health inequalities.
77
What are social determinants?
Conditions in which people are born, grow, work, live and age.
These include economic policies, development agendas, social norms, political systems.
78
How are social classes classified?
1. Professional - doctor
2. Managerial
3. Skilled - secretary
4. Partly-skilled - porter
5. Unskilled - cleaner
79
Define social inequalities.
Differences in people's health linked to social inequalities in their lives.
Health inequalities persist despite overall improvement in health.
80
What are the Black Report's explanations of health inequalities?
- Statistical artefact (illusionary)
- People's health drives their social class
- Ill health is caused by people's behaviour.
- Determined by people's position in social structure.
81
Describe the life course approach of explaining health inequalities.
Position in society from birth and throughout life -> material conditions and behavioural risk factors leads to health inequalities.
82
What other reports followed the Black Report?
Acheson report, 1998
| Marmot review, 2010
83
How are health inequalities measured?
- Household income
- Educational level
- Occupational status
- Housing tenure
- Area deprivation
84
What are the determinants of health outcomes?
Biological (ageing, genetics)
Social and economic (education, housing, employment)
Environment (air quality, water, climate change)
Lifestyle issues (diet, smoking, drugs)
Health services (delivery and access)
85
Define health promotion.
Process of enabling people to increase control over and improve their health.
Moves beyond focus on individual behaviour towards a wide range of social and environmental interventions.
86
What are the WHO's 5 aspects of health promotion?
- Health public policy -> education, income, housing.
- Supportive environment -> smoke free zones.
- Community action
- Personal skills
- Reorienting health services.
87
Define health education.
Any combo of learning experiences designed to facilitate voluntary actions conducive to health.
88
What is the aim of health education?
To give people knowledge and skills to change potentially health damaging behaviours i.e. mass media campaigns.
89
Define health protection.
Legislations to protect public health i.e. seatbelts, pollution, tracing diseases.
90
What is primary prevention?
Preventing onset of disease.
| e.g. immunisations, healthy school meals, screening risk factors.
91
What is secondary prevention?
Detecting and curing disease at an early stage.
| e.g. screening for disease.
92
What is tertiary prevention?
Minimising effects or reduce progression of irreversible disease.
e.g. hip replacements, palliative care, dentistry.
93
What are Beattie's typologies of health promotion?
1. Health persuasion - experts inform individuals about what to do e.g. mass campaigns, smear tests. Cheap but not cost-effective.
2. Legislative action - upon experts advice, governments intervene e.g. smoking ban, fluoride in water. Limits autonomy and freedom.
3. Personal counselling - opportunistic prevention in consultations e.g. youth or community workers.
4. Community development - locally based initiatives e.g. food cooperatives.
94
What should doctors be aware of when giving opportunistic advice?
Awareness of patient's receptiveness.
Respectful - listening to patient's views
Avoid preaching
Caring not scaring
95
Outline the arguments for and against smokers receiving coronary bypass surgery.
For:
- doctors have ethical obligation to treat on basis of clinical need and best available treatments
- slippery slope
- poor people smoke more than rich
- value judgements - deserving and undeserving
Against:
- smoking led to disease in first place
- smoking limits effectiveness of surgery
- poor outcome -> higher failure rate
- expensive when resources limited.
96
Define preventative paradox.
Large no. of people must participate in a preventative strategy for direct benefit to relatively few.
97
What are the two systems of health knowledge?
1. scientific medicine
| 2. lay medicine
98
What are common GI symptoms?
- difficulty swallowing
- nausea
- vomiting
- constipation
- tummy ache
- stomach ache
- diarrhoea
- changes in bowel movements
99
Why do doctors need to use lay talk?
Doctors have to deal with both systems to make their specialist knowledge understandable to their patients.
100
What are the advantages and disadvantages of lay-referral and self-care?
+ reduces pressure on GPs & NHS
+ reduces costs
- delays diagnosis
- delays treatment
101
Why is CAMs used?
- focuses on health, wellness and wellbeing
- emphasises subjective experience of the whole person
- less hierarchical than medicine
- natural, safer, non-invasive
- less costly
102
What are the positive and negative reasons why patients use CAMs?
```
+ perceived effectiveness and safety
+ control over treatment
+ non-invasive
+ good experience
+ accessible
- dissatisfaction with conventional healthcare
- waiting lists
- poor doctor-patient relationship
- rejection of conventional science
- desperation
```
103
What are the consequences of poor doctor-patient relationship?
- inaccurate diagnosis
- less recognition of ICEF
- non-adherence
- decreased satisfaction
- more complaints
104
Define medicalisation.
Process of defining an increasing number of life's problems as medical problems.
e.g. sexuality
105
Define pharmaceuticalisation.
Transformation of human condition/capabilities into opportunities for pharmaceutical intervention.
106
Why does gender matter in health care?
Women more likely to report health problems than men:
women - soft
men - hard
107
Define diagnosis.
Process of determining the nature of a disorder by considering the patient's signs and symptoms, medical background and results of tests.
108
Define prognosis.
Assessment of the future course and outcome of a patient's disease based on knowledge of the course of disease from other patients + patient's general health, age and sex.
109
Define treatment.
Choice of what action to take to treat patient.
110
What are the 3 theories of decision making?
Normative - what should you be doing?
Descriptive - what are you doing?
Prescriptive - how can we improve what you are doing?
111
Why is hypothetic-deductive model more common in the less experienced?
Used for diagnostic problems that are less familiar.
| Experienced doctors more likely to use pattern matching and deliberative reasoning.
112
Describe hypothetic-deductive model of decision making.
Cue acquisition -> hypothesis formation -> cue interpretation -> hypothesis evaluation.
113
What are the 2 phases in the choice process?
1. framing and editing - preliminary analysis of decision problem.
2. phase of evaluation - framed prospects evaluated and prospect with highest value selected.
114
Describe how framing a problem differently changes the patients choice.
If treatment is framed according to relative risk reduction, more will agree. If framed to absolute risk reduction, more will say no.
115
Define evidence.
Any factor that can and should influence clinical decision making.
Result of rigorous clinical trials and observational studies.
116
List the hierarchy of evidence.
1. Systematic reviews and meta-analysis
2. RCTs
3. Cohort study (controlled observational study)
4. Case control studies (controlled observational study)
5. Case series
6. Case report (uncontrolled observational study)
7. Ideas and opinions
8. Animal research
9. In vitro research
117
What is the quality of evidence based on?
Quality is associated with level of potential bias in a study.
118
What does a higher position on the pyramid say about the research?
- better quality
- less potential for research bias
- more predictive power
119
What are the negatives of the hierarchy of evidence?
- study designs are suited to different questions
- good and bad studies of any type
- pyramid doesn't include qualitative research.
120
What are the 5S levels of organisation of evidence?
Studies -> synthesis (systematic review) -> synopses (journal abstract) -> summaries (textbooks) -> systems (computerised database).
121
How is evidence used to inform diagnosis decision-making?
- identify most likely hypothesis
- evaluate likelihood of hypothesis of being correct
- accuracy of diagnostic tests
122
How is evidence used to inform prognosis decision-making?
Evaluate what happened to other patients with same condition.
123
How is evidence used to inform treatment decision-making?
- evaluate likelihood of different options having an effect
- evaluate likelihood of adverse events
- likely acceptability of treatment by patients
124
Define consent.
Properly informed and freely given decision of a competent patient.
125
List the forms of consent.
- oral
- written
- expressed (a way which is clearly articulated)
- implied (holding out arm for BP check)
126
When is consent required?
Required before examination, treatment, care, disclosure of confidential info, screening, teaching and research.
127
Why is consent needed?
- To maintain trust
- Failure -> harm
- Respects patients autonomy and right to self-determination
- Professional requirement
- Legal requirement
- Failure -> serious professional and personal repercussions.
128
Define battery.
When a person touches another person without his/her consent.
129
Define negligence.
Causal connection between failure to inform adequately and the resultant harm.
130
Differentiate between reasonable doctor standard and reasonable patient standard.
Doctor - practitioners are not negligent if they act in accordance with the practice accepted by a responsible body of medical opinion.
Patient - if there is significant risk which would affect the patients decision about a treatment then its the doctor's responsibility to inform the patient and allow them to decide.
131
Define informed consent.
Patients making an informed choice.
132
How should info given to patients be tailored for consent?
Tailored to:
- needs, wishes and priorities
- level of knowledge and understanding
- nature of their condition
- complexity of treatment
- nature and level of risk associated with the treatment.
133
What sort of info should be given to patients?
- diagnosis and prognosis
- uncertainties and options for further investigations
- options
- purpose
- benefits, risks, likelihood of success
- people responsible
- right to seek 2nd opinion.
134
Define voluntary consent.
Patient must be acting according to their own free will and not under pressure from other parties.
135
Define capacity.
Legal term, describes patients with legally recognised decision-making authority.
136
Define competency.
Patients cognitive faculties are such that they are able to make a decision with respect to given situation.
137
Describe the Mental Capacity Act 2005.
Test of capacity:
- understand
- retain
- weigh up
- communicate
138
Define Gillick competence.
Children under 16 is able to consent to their own treatment, without the need for parental consent.
139
Describe Frasier guidelines on contraceptions.
- young person understands the professionals advice
- young person can't be persuaded to inform parents
- unless patient receives treatment, patient suffers
140
Define self-medication.
Ability to select and use medication to treat self-recognised illness or symptoms.
Element of self-care.
141
Define self-care and e.g.
Individual taking responsibility for their own health and wellbeing.
- staying fit
- maintaining good physical and mental health
- meeting social and psychological needs
- prevent illness and accidents
142
Define over the counter medicines.
Medicines purchased without a prescription.
143
What is the advantage of OTCs.
Saves the NHS £2 billion as 57 million GP appointments are wasted on minor ailments.
144
What do people self-medicate with?
- pharmacy medicines
- general sales list medicines
- herbal
- vitamins, minerals, food supplements
- illicit substances
145
Where can OTCs be accessed?
- doctors
- community pharmacy
- lockable shop premises
- health food shop
- internet
- black market
146
How are drugs regulated?
Medicines and Healthcare products Regulatory Agency
147
Define POM, P and GSL.
POM - prescription only
P - supervision of pharmacists
GSL - general sale
148
What is the criteria for POM -> P?
- not likely to present direct/indirect danger to human health
- not frequently used or used incorrectly to present direct/indirect danger
- causes adverse events that require further investigations
- doesn't need doctors prescription
149
What is the criteria for P -> GSL?
Reasonably safe to be sold or supplied otherwise than by or under the supervision of a pharmacists.
150
Outline community pharmacy schemes.
- minor ailment schemes
- emergency contraception and sexual health advice
- health education and promotion
151
Describe the role of prescriber.
What OTC/herbal/internet medicines are you taking?
Prevent re-prescribing ineffective drugs and doses.
Prevent drug interactions.
152
Define continuous data.
Numerical value with an infinite number of intermediate values.
153
Define discrete data.
Numerical value that cannot be intermediate i.e. no. of children not 1.5
154
Define categorical data.
Given a label i.e. marital status.
155
What is normal distribution?
Mean=median=mode
156
Describe positive skew data.
Tail to left side
157
Describe negative skew data
Tail to right side
158
Define mean.
Sum of numbers/number of data
159
Define median.
Central value when data is ordered.
160
Define mode.
Value occurring most.
161
Define range.
Largest to smallest value.
162
Define inter-quartile range.
25% - 75% of the data set.
163
Define hypothesis.
An idea that can be tested.
164
Define null hypothesis.
Hypothesis stating there is no relationship between two variables.
165
Define alternative hypothesis.
Hypothesis stating there is a difference between two variables.
166
Define p-value.
The probability of obtaining our results, or something more extreme, if the null hypothesis is true.
The probability the results are due to chance.
The smaller the p-value, the stronger the evidence against the null hypothesis.
167
Define statistical power.
The probability of rejecting a null hypothesis when it is false. Increases with sample size.
168
Define type I error.
False positive
| Rejecting null hypothesis when there is no relationship between variables.
169
Define type II error.
False negative
| Accepting null hypothesis when there is a relationship.
170
Describe interval data.
Quantitative, discrete, where only certain values are possible.
e.g. number of falls
Mean
171
Describe ordinal data.
Qualitative but ordered, where we have more than 2 categories which have a logical order.
e.g. physical condition.
Median
172
Describe nominal data.
Qualitative, multinomial, with more than 2 categories which are not ordered.
e.g. single, married.
Mode
173
In a normal distribution, what is 1 SD and 1.96 SD?
68%
| 95%
174
What are the measures of location vs. dispersion?
```
Measures of location:
- mean
- median
- mode
Measures of dispersion:
- standard deviation
- interquartile range
- range
```
175
Describe the process of hypothesis testing.
1. set up null and alternative hypothesis
2. define and evaluate a test statistic
3. calculate p-value
4. interpret results
176
Define clinical significance.
Practical importance of the treatment effect, whether it has a real, palpable, noticeable effect on daily life.
177
Define confidentiality.
Principle of not divulging information about patients to others without that patients consent.
Legal requirement by the Human Rights Act 1998.
178
Why is confidentiality important and required?
```
Maintain trust between patient and doctor.
Respects autonomy
Legal requirement
Prevents patient harm
GMC requirement
```
179
Outline circumstances in which info can be shared with other people without breaching confidentiality.
Consent - if obtained from patient to share info
| Encoded - remove any patient identifiable data when discussing cases
180
When can confidentiality be breached, justify?
- STDs when others are at risk, if possible not revealing patients identity
- infectious diseases need reporting
- to prevent serious harm to competent adults when seeking consent is impractical
- patients lack capacity/is a child
- disclosure is in public's interest
- demanded by court
- risk of serious harm to patients or others
181
What are the current guidelines in GMC regarding confidentiality?
Make care of your patient your first concern.
Protect and promote health
Should still seek consent nonetheless
182
Define race and ethnicity.
Race - genetic and biological factors
| Ethnicity - socially/self-determined, linked with countries of origin and residence, religion and social networks.
183
Why is ethnicity important in medicine?
- Look at patients according to their own cultural influences.
- Disease prevalence varies with ethnicity.
- Approaches to best treatment vary with ethnicity.
- Ethnicity affects behaviour of people (stereotypes)
184
What are the consequences of genetic anaemias?
```
Consequences to individuals:
- impacts actitivites i.e. school, work
- impacts relationships
- reduced lifespan
Consequences to family dynamic:
- different dynamic i.e. particular routine around appointments
- future pregnancy
```
185
Describe the genetic implications of thalassemia and sickle cell anaemia.
Thalassemia - reduction in quantity of a or b-globin chains (Mediterranean).
Sickle cell - change in quality of b-globin chain (HbS) (African).
186
Describe the potential for racism in the diagnosis and treatment of genetic anaemias.
Basing screening on ethnicity could stigmatise.
Ethnic minorities may be perceived to be sicker - bring sickness into country.
Resent resources going to minorities.
187
Differentiate between descriptive and analytical studies.
Descriptive - What's it like? Don't need control, point in time e.g. survey, case report, case series.
Analytical - Why it is like this? Requires control, over time e.g. experimental - trials, observational - cohort and case-control.
188
Describe cross-sectional studies.
Descriptive, surveys - look at a particular point in time.
Major challenge - how well study represents the population.
Impossible to judge cause-effect relationships.
189
Describe randomised trials.
Analytical, experiment:
- investigator in control
- interventions assigned by investigator
- if groups differ in intervention only then changes observed are a consequence of the intervention
But not all interventions are acceptable -> must do observational studies.
190
Describe case control and cohort studies.
Analytical, observational:
- no intervention by investigator
- analysis of spontaneously occurring events i.e. diseases that have accrued
- group assignments not random
- used to explore aetiology (cause)
191
Differentiate between case control and cohort studies.
Case control - start with outcome i.e. disease already present - compare exposures in the past.
Cohort - start with exposure and compare outcomes (present).
192
Define risk.
Probability that an event will occur during a specified time.
193
How do you calculate risk?
Risk = number with disease / number in group
194
Define relative risk.
Ratio of the probability of developing, in a specified period of time, an outcome among those receiving the treatment of interest or exposed to a risk factor, compared with the probability of developing the outcome if the risk factor or intervention is not present.
195
Define absolute risk.
Observed or calculated probability of an event occurring.
196
Define absolute risk difference.
The difference in the risk for disease or death between an exposed population and an unexposed population.
197
Define absolute risk reduction.
The difference in the rates of adverse events between study and control populations.
i.e. difference in risk between control and treated group ARR = CER - EER
198
Define risk ratio.
Risk ratio = risk in exposed/risk in non-exposed
199
Define odds ratio.
The ratio of odds of exposure amongst subjects with disease compared to the odds of exposure amongst a control group.
OR = odds in exposed / odds in non-exposed
200
What does the risk difference and risk ratio tell us?
Impact
| Strength of relationship
201
What are risk and odds ratios?
Relative measures
202
What are risks and odds and risk differences?
Absolute measures
203
Explain the demand for blood.
- transfusion necessary when blood loss >2-3 pints
| - high demands from surgery, medicine, blood diseases
204
Explain the supply of blood.
Voluntary system of giving, 2 mill donors/year.
Publicly funded system, some privatisation of storage and distribution.
Normally, adequate stock levels unless significant events.
205
What are the arguments for and against market for blood?
For (Titmuss):
- blood is no different than any other tradable product
- increase supply by removing obstacles from donors
- can offer financial rewards to improve donation
Against (Cooper and Culyer):
- represses altruism
- lose sense of community
- subjects medicine to market place rules
- increased supply from poor, unemployed, commercialisation may increase infection risk.
206
What are the alternatives to transplant?
Mechanical maintenance e.g. dialysis
| Heart valves - metal, but require more medication.
207
What are the benefits of increasing transplants?
Improves quality of lives for patients.
| Saves NHS money e.g. 200 transplants/year saves £50mill.
208
How can we increase supply of organs?
- opt out scheme instead of opt in
- transplant coordinators in hospitals
- financial incentives
209
What are the arguments for paying for organs?
Increases supply
Reduces transplant tourism
Saves money in long run
210
What are the ethical dilemmas of transplantations?
- who to prioritise?
- age
- behaviour
- family circumstances
- social class
211
Define activities of daily living.
- everyday tasks
- functional activities
- essential part of life
- personal, locomotion, domestic/work, leisure
212
List range of ADLs.
Showering, making cup of tea, getting dressed, brushing teeth, cooking.
213
Common MSK conditions affecting ADLs.
Arthritis, back pain, neck pain, tennis elbow, frozen shoulder, fractures.
214
Common neurological conditions affecting ADLs.
Parkinson's, stroke, cerebral palsy, MS, motor neurone disease, brain trauma.
215
What are the roles of physiotherapists in helping ADLs?
Assessment of impairment.
| Management of condition - exercise therapy, acupuncture, injection therapy.
216
How is ADLs assessed?
Observation - difficulty in performing particular tasks.
History taking - subjective exam
Clinical examination
Specific tests for certain conditions
Nottingham health profile.
Barthel index - global disability/ADL measure, looks at feeding, bathing, mobility.
217
What are the effects of pain on ADLs?
- loss of function more relevant than damage
- subjective -> assessment difficult
- doesn't always result in disability
- severity of pain and degree of disability not in proportion
- not clinical diagnosis/disease
- focus on limitation of activity rather than pain itself.
218
Describe the biopsychosocial model as an approach to disability.
Individual active in their own rehabilitation and recovery.
Management must relieve pain and prevent disability.
Involves healthcare professionals and the patient themselves.
Bio - impairment and function
Psycho - attitudes, psychological distress, coping strategies, illness behaviour
Social - occupational demands, economic incentives and controls, cultural attitudes.
219
Define impairment.
Any temporary/permanent loss/abnormality of a body structure/function whether physiological or psychological.
e.g. amputation
220
Define disability.
Restriction/lack of ability to perform an activity in the manner or within a range considered normal mostly resulting from impairment.
221
Define handicap.
Disadvantage due to impairment or disability that limits the fulfilment of a role that is normal for that individual.
222
What is the role of occupational therapist in helping ADLs?
Functional assessment - i.e. kitchen assessment, are they are to cook?
Quality of life assessments
Occupational isses - providing specific equipments to help around house
Goal setting
223
Describe the medical model of disability.
Emphasises what is wrong with the person, abnormality, with goal of improving impairment and working to normality.
Exclusion from society - have separate education, employment and living situation.
Language of impairment - confined to wheelchair.
224
What are the criticisms of the medical model of disability?
Views disability as individual's tragedy.
Doesn't account for wider social causes that makes person unable to be normal in society.
Puts disability between patient and doctor - patient is disabled and doctor has the cure, otherwise patient enters sick role.
225
Describe the social model of disability.
Discrimination against disabled people arises because of the organisation of society.
Society fails to make things accessible, fails to remove barriers and outlaw unfair treatment e.g. education, work, public services.
Society is built for able bodied people and doesn't recognise the range of human bodies that exist.
226
What are the criticisms of the social model of disability?
Says that impairment doesn't cause the individual problems, only society does.
Impairment does impact on people's daily lives that goes beyond social processes.
It is idealised.
227
Describe the interaction model.
Interaction between peoples impairment and the environment they live in.
Person-centred -> recognises disabled people as individuals and social inputs.
228
Discuss the prevalence of impairment and disability globally.
15.3% moderate to severe disability
2.9% severe disability
Highest rates in developing countries due to poorer healthcare, malnutrition, civil unrest, land mines.
229
Describe the disability discrimination act 1995.
Gives new rights to people who have had disability, which makes it difficult to carry out normal day to day activities. Disability can be physical, sensory or mental.
230
Describe the equality act 2010.
You're disabled if you have a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities.
231
Describe radical disability.
Argues that disability is simply those who are externally identified as disabled and those who self-identity as disabled.
232
What are the factors leading to disability?
Social - poor provision by society leads to exclusion of those with impairment and the attitudes of the population.
Biological - medical impairment and loss of function.
Political - legislation concerning impairment and provision.
233
Define justice and distributive justice.
Justice - treat people in a fair and equitable way.
| Distributive justice - distribution of services and resources fairly.
234
Distinguish between justice and equality.
Equality - being the same in quantity, amount, value, intensity.
Equity - fairness or impartiality.
An act can be equitable but not equal, vice versa.
235
Describe the needs based assessment for delivery healthcare.
+ resource allocation should be made on basis of needs
+ most equitable system -> healthcare is distributed according to who needs it most
- difficult to assess needs and preferences
- worst off will absorb almost all healthcare
236
Define difference principle.
Social order is not to establish and secure the more attractive prospects of those better off unless doing so is to the advantage of those less fortunate.
237
What are the possible options for judging healthcare delivery?
- quality adjusted life years (QALY)
- position in waiting list
- how likely to comply with treatment
- lifestyle choices may by patient e.g. smoking
- ability of patient to pay
238
Describe the concept of lifestyle-based assessments.
Decisions about health care should take into account lifestyle choices of patient.
Those who harm their health through behaviour are less deserving of treatment.
Those who have damaged health have forfeited their right to receive treatment.
May not change their behaviour and waste their treatment.
- people may not be responsible for their decisions as lack of knowledge
- unfair to punish people
239
Define rights.
Justified claims on others, entitled to something.
240
Distinguish between legal, moral and human rights.
Legal - right to vote (given by law)
Moral - right to autonomy (independent of law)
Human - right to life (combo of two)
241
What are the types of rights?
Positive rights - duty to do something e.g. right to healthcare
Negative rights - duty to refrain from certain behaviours/actions e.g. right not to be assaulted
Active rights - allows people to act or not as they choose e.g. right to travel abroad
242
Why are rights important?
- protective boundaries i.e. limits actions of others
- conductive to goods i.e. dignity, respect, equality
- minimum standards i.e. expectations
- ideal directives i.e. what should be the case
243
Define human rights acts (HRA).
Legal instruments which represent fundamental human interests and are therefore closely aligned with ethical practice.
Achieves aims through legislation, regulation of relationships between individuals and public bodies, education.
244
What are the aims of the HRA?
- to bring most of the rights contained in the ECHR into UK law -> make it possible for people to directly raise or claim their human rights within complaints and legal systems.
- to bring new culture of respects for human rights in UK
245
What are the rights relevant to healthcare?
Article 2 - Right to life
Article 3 - Prohibition of torture (or inhuman or degrading treatment or punishment)
Article 5 - Right to liberty and security
Article 6 - Right to a fair trial
Article 8 - Right to respect for private and family life
Article 9 - Freedom of thought, conscience and religion
Article 10 - Freedom of expression
Article 12 - Right to marry and found a family
Article 14 - Prohibition of discrimination
246
Define absolute rights.
No derogation is permitted, although even these rights are open to interpretation (article 3).
247
Define limited rights.
Limitations are explicitly stated in the wording of the article (article 2, 5 and 6).
248
Define qualified rights.
Derogation is permitted but any action must be: based in law, meet convention aims, necessary in a democratic society and proportionate (article 8, 9, 10, 11 and 12).
249
Define carer.
Someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour who can't manage without help.
Informal carer - unpaid
Formal carer - statutory services or voluntary organisations -> paid basis.
250
Discuss the numbers of carers.
6.5 mill UK, 1/10 people
Most carers located in areas with higher levels of deprivation and long-term illness.
More female than male carer.
Pakistani and Bangladeshi more likely to be carers.
Carers are usually 50-64yrs.
251
What are the effects of caring on heath?
- high levels of physical and mental health problems reported by carers
- problematic to establish direct causal relationship between caring and ill health
- carers often do not have enough time to look after their own health
- co-resident carers more likely to report problems than extra-resident.
252
What are the rights of the carers?
- assessment of needs in their own right
- carers special grant
- made aware of their entitlement in assessment
- assessments must consider carer's wishes about employment and training.
253
What are the unmet needs of carers?
```
Info and advice e.g. available services
Support
Training in caring activities
Respite care and short breaks
Finance
```
254
What are the issues for carers?
Parents of disabled children - access of mainstream services
Rural carers - info and advice, transport
Black and ethnic minority carers - language issues, culturally sensitive services
Young carers - info and advice, help with transition into adulthood.
255
What are the challenges of a carer?
Employment - juggling work and care, time off work, being contacted
carers of dementia patients - help with emotional stress, respite care
Carers of mental health patients - stigma and discrimination, confidentiality, respite care.
256
Describe the legislations that support carers.
```
Carer’s bill/children and family bill 2014
Carers Act 1995
National strategy for carers 1999
Carers and disabled children act 2000
Carers Act 2004
```
257
What is the carers allowance criteria?
```
Carers allowance - benefit, taxable.
£62.70/week
Criteria:
- >35 hours/week
- 16 or over
- working -> 21 hours
- only caring for 1 person
- ends at 65 (pensionable age)
```
258
Define randomised control trials.
An experiment in which participants are randomly allocated into groups: interventions and control groups.
Gold standard of primary research aimed at testing different interventions.
259
Describe a typical clinical trial.
Phase 1 - clinical pharmacology and toxicity, healthy volunteers.
Phase 2 - initial investigating of efficacy, patients.
Phase 3 - full scale evaluation, comparison with standard, randomised, prospective, gold standard.
Phase 4 - post-marketing surveillance.
260
Define temporal change.
Most people get better or worse irrespective of medical intervention so difficult to distinguish if medical action or temporal change is responsible for improvement or deterioration.
261
What does randomisation do?
Randomly selecting 2 groups ensures characteristic of both groups are balanced.
Ensures only difference between groups is intervention so that differences can be attributed to the intervention.
262
Define regression to the mean.
Phenomenon that occurs when a group are measured with an inexact measurement tool and then re-measured. Individuals with extreme values will have a high probability of regressing towards the mean on the second measurement.
263
Why randomise?
- eliminates selection bias
- controls for temporal effects
- controls for regression to mean
- basis for statistical inference
- randomisation is best method of proving causality
264
Define stratification.
Process to ensure that important factors that affect outcome are balanced across the groups.
265
Define bias.
Systematic distortion of the estimated intervention effect away from the truth, caused by inadequacies in the design. conduct or analysis of trial.
266
Define selection bias.
Systematic error in creating groups - they differ in measured and unmeasured baseline characteristics due to the way participants were selected or assigned.
Participants are not representative of population.
267
Define ascertainment (detection) bias.
Systematic distortion of the results due to knowledge of group assignments by the person assessing outcome.
268
Define performance bias.
Systematic differences in the care provided to the participants.
269
Describe methods of allocation.
- alternative allocation
- odd/even DOB
- sealed envelopes
- coin toss
- using independent organisations who randomise via computer program
270
Define blinding.
Doctors and patients don't know which treatment they have been given.
Blind:
- interventions
- outcomes
271
Identify ways in which professionalism can be demonstrated by doctors.
Putting others before yourself, high ethic/moral standards, integrity, compassion, self-reflection, probity, insight.
272
Define professionalism.
Signifies a set of values, behaviour and relationships that underpins the trust the public has in doctors.
273
What do the GMC require students to do?
- reflect
- learn and teach others
- behave accordingly with legal and ethical principles
- learn and work effectively in a team
- protect and promote health of patients and public
- improve care
- maintain confidentiality
274
Define health behaviour.
Any activity people perform to maintain or improve their health, regardless of their perceived health status or whether the behaviour actually achieves that goal.
275
What are the two categories of health behaviour?
1. Health-protective/enhancing -> exercise + eat well + attend check-ups.
2. Health-impairing -> smoking + drinking.
276
Why study health behaviours?
- Treatment protocols involves behaviours
- Relation with life expectancy
- Ageing population in many developed countries
- Rising medical costs
- Lifestyle changes involves behaviour
277
Describe the health belief theory - locus of control.
People differ to the degree in which they believe they can control their lives.
From within themselves (didn't work hard enough) vs. controlled by forces outside (shitty lecturers, luck, God).
Behavioural control - ability to take concrete action to reduce X.
Cognitive control - ability to use thought processes to modify impact of X.
278
Describe the health belief theory - self efficacy.
People's beliefs in their capability to exercise some measure of control over their own functioning and over environmental events.
Belief that we can succeed at anything we want to:
- outcome expectancy -> behaviour will lead to favourable outcome
- self-efficacy expectancy -> one can perform the behaviour properly.
279
Describe Leventhal's model of illness representation.
Identify - sprain or fracture?
Timeline - how long has it been?
Consequence - is there bleeding?
Cause - got it from someone?
Control - can I self-medicate?
Provides framework to guide understanding how patients psychological represent illness.
Impacts on: treatment options, visiting GP, monitor condition.
280
Describe the theory of predictors of health behaviour - health belief model.
The likelihood of behavioural change is impacted by:
- individual perceptions -> perceived susceptibility/seriousness
- modifying factors -> age, sex, ethnicity, personality, socio-economics, internal cues (symptoms) and external cues (education, media)
- perceived benefits and identify few barriers to behavioural change.
281
Describe the theory of predictors of health behaviour - theory of planned behaviour.
Attitudes + social norms + perceived behavioural control all interact with each other and form intentions, which leads to behaviour.
282
Describe the theory of predictors of health behaviour - stages of change model.
1. pre-contemplation -> conscious raising
2. contemplation -> self re-evaluation
3. determinism
Can exit the cycle at this point
4. active changes -> putting decisions into practice
5. maintenance -> of new behaviour
Can exit the cycle at this point
6. relapse
Cycle repeats
283
Define medically unexplained symptoms.
Physical symptoms not explained by organic disease which cause distress and impair functioning and for which there is a positive evidence or strong assumption that the symptoms are linked to psychological factors.
284
Describe the epidemiology of MUS.
20% primary care
| 30-50% secondary care
285
What are the common presentations of MUS?
Palpitation, chronic fatigue, pelvic pain, chest pain, abdominal pain, headache, muscle and joint pain.
286
Define somatisation.
Physical expression of emotional distress.
287
Describe how illness behaviour leads to MUS.
Illness behaviour - the ways in which given symptoms may be differentially perceived, evaluated and acted upon.
Abnormal illness behaviour -> inappropriate and maladaptive:
- illness denial -> behaviours to avoid the stigma/inability to accept physical/mental illness
- illness affirmation -> behaviours which inappropriately affirm illness, invalidism.
288
What are the factors that lead to MUS?
Misinterpretation of symptoms (symptom catastrophising), childhood experiences (early insecure attachment), personality and mental state, stress, indirect - poor compliance + lifestyle, direct - increased GI secretion.
289
What are the reasons for MUS?
- reduce stigmatisation of mental illness
- allows people to assume sick role
- physical expression of distress -> reduces internal emotional conflict
290
Describe the biopsychosocial model of MUS.
Bio - minor pathology, physiological symptoms, side effects of medications at same time as stress.
Psycho - cognitive processes, mental illness
Social - illness beliefs and childhood factors
All leads to misinterpretation -> functional symptoms.
291
What are the common assumptions about MUS?
- explanation for MUS lies in the patients
- 50% deny psychological factors and somatise psychological distress
- seek cure and diagnosis
- demand physical interventions
- to avoid physical interventions, doctors should help patients appropriate psychological factors.
292
How is MUS managed?
- Acknowledge symptoms genuine, avoid implying that symptoms are in their head, explain about investigations and results clearly, avoid more investigations or referrals.
- Explanatory model - tailored to their MUS e.g. your NS isn't damaged but its not working properly hence why you can't move your legs but this means that it can get better.
- Link with psychological factors e.g. sometimes these problems can be linked to stress or conflicts.
- symptom management i.e. analgesics, laxatives, exercise, physiotherapy
- initiate treatment for depression and anxiety if present
- psychotherapies
293
Define exculpation.
Recognise the reality of suffering and exculpate the symptoms by confirming that they are not the patient's responsibility.
294
How are mental health problems classified?
Neurotic conditions - related to normal emotions, most common e.g. depression, anxiety.
Psychotic conditions - unrelated to normal emotions e.g. psychosis (schizophrenia, bipolar) -> symptoms cause patient to not experience reality like most people.
295
What are the challenges of measuring psych disorders?
Scale of exercise (large), diagnosis vs. classification, subgroups in population varies.
296
What are people with neurotic disorders more likely to be?
- female
- middle-aged
- separated and divorced
- live alone or lone parent
297
What are people with psychotic disorders more and less likely to be?
```
More likely:
- separated or divorced
- live alone
- low education
- social class IV to V
Less likely:
- married
- homeowner
```
298
Describe the pathways to care model.
Describes how to access care in a primary setting.
1 - General population -> filter those with illness behaviour
2 - Psychiatric disorder in primary care -> filter those recognised by primary care clinician
3 - Conspicuous psychiatric morbidity -> filter those with referral to specialist care
4 and 5 - Specialist care
299
Differentiate between descriptive and inferential statistics.
Descriptive - data collected, summarised and described using means and SDs.
Inferential - using stat tests and confidence intervals to make generalisations about a population.
300
Define p-value.
Probability that we say there is a difference when no difference exists.
Usually 0.05 - 1/20 times we would say there is a difference between groups, when no different exists.
301
Define confidence interval.
Communicates how accurate the estimate is likely to be. Range of values that probably contains the population mean or proportion.
e.g. 95% confidence - 95% of such intervals will include the population mean, 5% will exclude it.
Greater variation in population = wider confidence interval.
302
Define confidence limits.
Values that state the boundaries of the confidence interval - calculate the upper and lower limits, which should contain the true value.
303
Define standard error.
Determines how good our estimate is of the population, comes from sampling distribution.
Is the SD of the sampling distribution - tells us how good our sample statistic is as an estimate of the population value.
304
Differentiate between standard error and standard deviation.
SD - how spread out is the data?
| SE - how accurate is the estimate?
305
What is the equation of the SE?
SE = SD/√ (n)
SE = √ p(1 - p)/n
306
In a normal distribution, what do 90%, 95% and 99% correlate to?
90% - 1.65
95% - 1.96
99% - 2.58 SD of the mean
307
How to narrow confidence intervals?
Increase sample size.
308
Discuss significance tests and confidence intervals.
If CI doesn't include the null hypothesis value, the difference is significant.
If 95% CI contains 0, difference is not significant.
If 95% CI doesn't contain 0, difference is significant.
309
Describe the prevalence of common mental disorders in Europe.
Men - prevalence of major depression and panic syndrome highest in UK.
Highest prevalence of depression men - age 30-50.
Highest prevalence of depression women - age 18-30.
310
What is Freud and Abraham's model of grief?
Grief is an 'interject' and a block to healthy living - only by letting go, moving and not dwelling on it can grief be removed.
311
Describe the attachment theory of Bowlby.
Suggested link between the way child is distressed when mother is absent and the way we become distressed when we lose a loved one.
312
What are the stages of grief as modelled by Bowlby?
1. numbness
2. yearning and searching
3. despairs and disorganisation - depression
4. reorganisation - rebuild life
313
What did Worden think about grief?
Grief is a task to be worked through in stages - prescriptive process.
Led to counsellors taking clients through the stages to complete grief process. Some people may get stuck on certain phases.
314
How does fMRI scanning support the stages of Bowlby?
Grief - shows increased activity in the nucleus acumbens -> associated with reward and motivation (addiction)
e.g. show picture of loved one, NA lights up, which confirms yearning stage.
315
What does evolutionary biology say about grief?
Not until yearning gives way to despair will the bereaved person stop searching. Depression from despair stops bereaved from exhausting themselves.
So can offer bereavement counselling too - better to wait until despair phase.
316
Define grief work.
Process of confronting loss emotionally and working towards detachment.
Failure to complete grief work - maladaptive.
- grief work is not universal i.e. Islam.
317
Describe the dual process model.
Emphasises need for grief work and need to take time out from grief.
2 aspects of grieving:
- loss oriented -> grief work, focusing on lost love
- restoration-oriented -> keep busy, attending to life
Best - switch between the two e.g. LO risks downward spiral and RO risks pt. burnout.
318
How does the dual process implicate counsellors?
Reducing contact with pt. in LO phase to discourage dwelling on loss.
Deliberately encouraging tearfulness with pt. in RO phase to make them dwell on their loss.
319
Describe the assumptive world theory of grief.
Live in a world with 3 basic assumptions:
- world is benevolent
- world is meaningful
- self is worthy
Grief rocks these assumptions.
This theory hones in on helping people rebuild their lives without their loved one by making a new assumptive world.
320
Describe meaning-making theory of grief.
People need to make sense of their bereavement by finding meaning in the lost love's life and death:
- life -> they lived a full life
- death -> they're not suffering anymore
321
Describe the continuing bond theory of grief.
People hold on to a symbolic bond with their lost love, which allows the dead to keep influencing their lives i.e. "he would have wanted this".
This is not denial and contradicts Freud's theory of moving on is key.
322
Describe family grief.
The whole family needs to be worked on rather than individuals in grief counselling.
No one in family can be understood in isolation.
Each member has their role in the grief process and members bounce off each other.
323
Define stigma.
Mark of disgrace associated with a particular circumstance, quality or person.
Exists through social relations, doesn't exist in/of itself but it's about behaviours/responses to those characteristics.
324
Describe the social processing of labelling.
Human tendency to reclassify world by demarcating 'selfhood' and 'otherness' (them-and-us schemes).
Helps us feel secure and part of the 'in' group.
325
Describe social constructionism in stigma.
The enactment of stigma is about social interaction - about people's responses to behaviour or physical appearance.
Not about the actual nature of the stigma but the audience watching it.
Meaning changes over time e.g. what appears as good science and treatments are reflections of current social zeitgeist.
326
Define foucault.
We discriminate as 'mad' to fill the gap in our imagination left by 'lepers'. Therefore, socially confining them to asylums/institutionalising and removing them from society.
327
Define szasz.
Better to be 'bad' than 'mad' as you can be redeemed for being bad.
328
Describe the labelling theory.
Process which describes labelling of people to control and identify deviant behaviour.
Labelling mostly negative i.e. 'criminals' but can be good i.e. 'Drs'.
Labelling has a functional role as it allows us to ascribe certain behaviour as social deviance and satisfies the society's need to control the behaviour.
329
Describe secondary deviance.
Labelling = 2 way process - some is given a label, which affects how they conceive themselves.
Our self-image is constructed by ideas of what others think about us.
Therefore, not the actual identity of the stigmatised persons but the attitudes, behaviours and inequalities that arise from the way people are labelled.
330
List the different types of stigma.
Discreditable vs. discrediting - visible and hidden e.g. AIDS vs. being in wheelchair.
Ascribed vs. achieved - ascribed -> sex, race, achieved -> deviances that you enact i.e. joining a gang.
Felt stigma - shame you feel due to stigma.
Enacted stigma - discrimination by others.
Courtesy stigma - felt by some with a stigmatised person.
Cultural stereotyping - impairment and learned helplessness.
331
Why is stigma a process and not a static category?
Those who feel stigma have a choice of displaying or not displaying.
To display stigma is to disclose potentially damaging aspect of one's identity -> can lead to discrimination.
332
What is passing?
Not disclosing leads to passing e.g. alcoholic concealing drinking behaviour at work.
Can still experience 'felt stigma' when 'passing and covering' e.g. blind person wearing sunglasses - condition is acknowledged and solution is sought.
333
Outline the social patterning of mental health and illness by gender.
- 19% women and 12% men have CMD in UK
- Men -> psychosis, women -> neurosis
- No gender - > schizophrenia
- Female -> post-natal depression, post-partum psychosis, anxiety, depression, PTSD, dementia
- Male -> personality disorder, sex offenders, substance misuse.
334
Describe suicide rates by gender.
Men successfully commit suicide >3x more than women UK.
Leading cause of death aged 20-34 and most venerable men age 45-59 and 30-44.
Due to unemployment, economic hardship, lack of family, influence of historical culture of masculinity, personal crises.
335
Describe men and masculinity culture.
Men unwilling to express emotions (hiding anxiety and suppressing feelings) and construct identity through work.
Men become disconnected from their bodies.
336
Describe social pattern of mental health in LGBT.
LGBT people - higher rates of suicide, substance abuse, depression, anxiety, cancer, immune dysfunction relative to heterosexual people.
337
Describe the social pattern of mental health by ethnicity.
Chinese - low rates of mental illness as close knit families -> strong support system.
Irish - high rates of hospital admissions for depression and alcoholic problems.
Black - 10x more schizophrenia/psychosis, more likely to be detained and hospitalised by police.
338
Why are there ethnic differences in mental health?
- stigma and help seeking behaviour may be different in different communities
- support or lack of support
Beliefs about distress: seen as a test ' given only what we can cope with'.
339
Describe the minority stress model.
Focused on race and sex:
- exposure to external stress
- increased exposure to internal stress -> by-product of distal stress, vigilance and negative feelings
Leads to adverse health issues - hypertension.
Stress caused by environment - lack of social support, prejudice and discrimination create a hostile and stressful social environment that causes mental health problems.
340
Outline the history of classification of mental illness.
Religion (witchcraft) -> C18th moral (social control) -> C19th scientific (located in brain):
- medical (mental illness)
- social (ab/norms)
341
Define occupational stress.
Mismatch between individuals skills + capabilities and job demands.
342
Why is medicine stressful?
Unrealistic expectations, long hours, limited resources, uncertainty, exhaustion, difficult teams, making mistakes, emotional responses to patients.
343
Outline the CBT model of occupational stress.
Each individual brings with them a unique set of personal attributes and needs, temperament, beliefs and summations, behavioural coping strategies, energy level, knowledge, intelligence and skills to the job.
In turn, the job has particular characteristic demands on employees.
If the individuals attributes are significant enough to meet the demands of the job and work environment also meets the individuals needs = job satisfaction -> positive mental health and low stress.
If no then = occupational stress.
344
Outline ways to maintain psychological well-being.
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Develop alternative thoughts i.e. am I thinking in an extreme way?
Mindfulness
Healthy lifestyle
Relaxation and hobbies
Modify type A personality
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