Part 1 Flashcards
Epigenetics
The expression of the genome depends on the environment
Allostasis
Stability through change, our physiological systems have adapted to react rapidly to the environment
Eg. Cardio, Metabolic, Immune, CNS
Allostatic Load
Long term overtaxation of our physiological systems leads to impaired health (stress)
Salutogenesis
Favourable physiological changes secondary to experiences which promote healing and health
Emotional Intelligence
The ability to identify and manage one’s own emotions, as well as those of others
What is primary care for?
- Managing illness and clinical relationships over time
- Finding the best available clinical solutions to clinical problems
- Preventing illness
- Promoting health
- Managing clinical uncertainty
- Getting the best outcomes with available resources
- Working in a team
- Shared decision making with patients
The dangers of overprescribing antibiotics
- Unnecessary die effects
- Medicalising self limiting conditions
- Antibiotic resistance
Examples of appropriate antibiotic prescription
- Bilateral otitis media <2 years old
- Acute otitis media with otorrhoea
- Acute sore throat with 3 or more censor criteria (exudate, fever, tender cervical lymphadenopathy, absence of cough)
- Systemically very unwell
- High risk eg. comorbidities, immunosuppression, ex premature baby
- Aged >65 and 2 of the following or >80 and one of the following: hospital admission within last 12 months, congestive heart failure, glucocorticoid use
- Complications : pneumonia, mastoiditis, peritonsillar abscess/cellulitis
Public Health definition
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
Three domains of public health
Health improvement
Health protection
Improving services
What is health improvement?
Concerned with societal interventions (aimed at preventing disease, promoting health and reducing inequalities) Includes... -Inequalities -Education -Housing -Employment -Lifestyles -Family/community -Surveillance and monitoring of specific diseases and risk factors
What is health protection?
Concerned with measures to control infectious disease risks and environmental hazards Includes... -Infectious diseases -Chemicals and poisons -Radiation -Emergency Response -Environmental health hazards
What is service improvement?
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment and care
- Clinical Effectiveness
- Efficiency
- Service Planning
- Audit and evaluation
- Clinical governance
- Equity
Key concerns of public health?
- Inequalities in health
- Wider determinants of health
- Prevention
What are interventions?
Delivered at individual, community or population level. May be health/non-health interventions which have an impact on public health
Before intervening, need to assess health needs
Health Needs Assessment
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
Need- ability to benefit from an intervention
Demand- what people ask for
Supply- what is provided
Health Need
The need for health eg. measured using mortality, morbidity, socio-demographic measures
Health Care Need
The need for health care, ability to benefit from health care. Depends on the potential of prevention, treatment and care
Types of sociological perspective
Felt Need
Expressed Need
Normative Need
Comparative Need
Felt Need
Individual perceptions of variation from normal health
Expressed Need
Individual seeks help to overcome variation in normal health (demand)
Normative Need
Professional defines intervention appropriate for the expressed need
Comparative Need
Comparison between severity, range of interventions and cost
Approaches to a health needs assessment?
Epidemiological, Comparative, Corporate
What does an epidemiological approach consist of?
- Define the problem
- Size of problem (incidence/prevalence)
- Services available- prevention/treatment/care
- Evidence base- effectiveness and cost effectiveness
- Models of care- including quality and outcome measures
- Existing services- unmet need, services not needed
- Recommendations
(Sources of data: disease registry, hospital admissions, GP databases, mortality data, primary data collection)
Advantages and Disadvantages of an Epidemiological approach
Advantages
- Uses existing data
- Provides data on disease incidence/mortality/morbidity etc.
- Can evaluate services by trends over time
Disadvantages
- Quality of data variable
- Data collected may not be the data required
- Does not consider the felt needs or opinions/experiences of the people affected
What does a comparative approach consist of?
Compares the services received by a population (or subgroup) with others
- Spatial
- Social (Age, gender class, ethnicity)
May examine
- Health status
- Service provision
- Service utilisation
- Health outcomes (mortality, morbidity, quality of life, patient satisfaction)
Advantages/Disadvantages of a Comparative approach?
Advantages
- Quick and cheap if data available
- Indicates whether health or service provision is better/worse than comparable areas (gives measure of relative performance)
Disadvantages
- May be difficult to find comparable population
- Data may not be available/high qualaity
- May not yield what the most appropriate level should be (Eg. provision or utilisation)
What does a corporate approach consist of?
- Asks the local population what their health needs are
- Use focus groups, interviews, public meetings
- Wide variety of stakeholders eg. teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians
Advantages/Disadvantages of a corporate approach
Advantages
- Based on the felt and expressed needs of the population in question
- Recognises the detailed knowledge and experience of those working with the population
- Takes into account wide range of views
Disadvantages
- Difficult to distinguish ‘need’ from ‘demand’
- Groups may have vested interests
- May be influenced by political agendas
Consequentialism and types of consequentialism
“The end justifies the means”- the morality of an action is judged solely by the outcome. So the morally right action is the one that gives rise to the best consequences or actions. Eg. lying is okay in some situations if it promotes a better outcome than the truth
Types of consequentialism…
Utilitarianism (the best course is the one that promotes the most happiness/pleasure and absence of pain for all- lesser of two evils)
Egoism (the best course is what’s best for you- which may be positive, negative or neutral for others)
Altruism- the best course is what’s best for others’ wellbeing.
Deontology
“The study of the nature of duty or obligation’ Relates to duty-based theories. There are fundamental rules and duties to follow- some acts are seen as wrong no matter the consequences.
Principilism
The four principles
- Autonomy (Freedom for the patient to choose and advocate for their own health)
- Beneficence (what is considered the patient’s best interests)
- Non-maleficence (“do no harm”- balance the benefits against the harm)
- Justice (equity and avoiding discrimination at both an individual and societal level)
Dynamism
Situations are almost always dynamic and a decision taken at one time may not be appropriate at a later stage.
The 6 principles of good safeguarding practice
Relevant to protecting and promoting the health of individual patients including vulnerable groups
Empowerment (person-led decisions/informed consent)
Protection (support and representation for those in greatest need)
Prevention (it is better to take action before harm occurs)
Proportionality (proportionate and least intrusive response appropriate to the risk presented)
Partnership (local solutions through services working with their communities)
Accountability (accountability and transparency in delivering safeguarding)
The Care Act 2014
Sets out a legal framework for how local authorities and other parts of the health and care system should protect adults at risk of abuse or neglect
Primary Prevention
Preventing disease before it has happened
Secondary Prevention
Catching disease in the pre-clinical or early phase
Tertiary Prevention
Preventing complications of disease
Approaches to prevention
Population Approach (preventative measure eg. dietary salt reduction to reduce bp)
High risk approach (identify individuals above a chosen cut off and treat eg. screening for high bp)
Prevention paradox
A preventative measure which brings much benefit to the population often offers little to each participating individual
Screening
A process which sorts out apparently well people who probably have a disease (or precursors or susceptibility to a disease) from those who probably do not
Types of Screening
- Population-based screening programmes
- Opportunistic screening
- Screening for communicable diseases
- Pre-employment and occupational medicals
- Commercially provided screening
Disadvantages of screening
- Exposure of well individuals to distressing or harmful diagnostic tests
- Detection and treatment of sub-clinical disease that would never have caused any problems
- Preventative interventions that may cause harm to the individual or population
Wilson and Junger Criteria
The condition (important health problem, with a latent/preclinical phase, natural history unknown)
The screening test (suitable- specific, sensitive, inexpensive), acceptable
The treatment (Effective, agreed policy on whom to treat)
The organisation and costs (Facilities, costs of screening should be economically balanced in relation to healthcare spending as a whole, should be an ongoing process)
Sensitivity and Specificity
Sensitivity
The proportion of people with the disease who are correctly identified by the screening test (true positive/false neg + true pos)
Specificity
The proportion of people without the disease who are correctly excluded by the screening test (true negative/false pos + true neg)
Positive and negative predictive values
Positive predictive value
The proportion of people with a positive test result who actually have the disease (true pos/true pos +false pos)
Negative predictive value (the proportion of people with a negative test result who do not have the disease (true neg/true neg+false neg)
Lead time bias and length time bias
Lead time bias
When screening identifies an outcome earlier than it would otherwise have been identified, this results in an increase in survival time, even if screening has no effect on outcome
Length time bias
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
Social Determinants of Health
Environment Economics Food Social Health Care Education
Social Capital
The networks of relationships among people who live and work in a particular society, enabling that society to function effectively
Types of Study design
Can be observational or experimental/interventional
Case Reports
Study individuals
Ecological Studies
Use routinely collected data to show trends in data and thus is useful for generating hypothesis.
Shows prevalence and association, not causation
Cross sectional study/survey
Divides the population into those without the disease and those with the disease and collects data on them once at a defined time to find associations at that point in time.
Advantages
Quick/cheap, provide data on a single point in time, large sample size, good for surveillance and public health planning
Disadvantages Risk of reverse causality (did exposure or outcome come first) Cannot measure incidence Risk recall bias and non-response Prone to bias, no time reference
Case-control studies
Retrospective, analytical studies that take people with a disease and match them to people without the disease for age/sex/habitat/class etc and study previous exposure to the agent in question.
Advantages
Good for rare outcomes
Quicker than cohort or intervention studies
Can investigate multiple exposures
Disadvantages
Difficulties finding controls to match with cases
Prone to selection and information bias
Cohort Studies
Start with a population without the disease in question and study them over time to see if they are exposed to the agent and develop the disease or not.
Advantages
Can follow-up a group with a rare exposure
Good for common and multiple outcomes
Less risk of selection and recall bias
Can distinguish preceding causes from concurrent associated factors
Disadvantages
Takes a long time
Loss to follow up- people drop out
Need a large sample size
Randomised Control Trial
Patients are randomised into two groups, one group is given an intervention, the other is given a control and the outcome is measured.
Advantages
Low risk of bias and confounding
Can infer causality (gold standard)
Disadvantages
Time consuming
Expensive
Specific exclusion/inclusion criteria may mean the study population is different from typical patients (eg. very elderly people)
Ethical issues- ethical to withhold a treatment
Non-randomised control trial
Same as RCT but no randomisation. Very subject to bias
Independent/Dependent variable
Independent variable- can be altered in a study
Dependent variable- cannot be altered, dependent on the independent variable
Odds
The odds of an event is the ratio of the probability of an occurrence compared to the probability of a non-occurance
Odds = probability/(1-probability)
Odds Ratio
The ratio of odds for exposued group to the odds for the not exposed group
OR = (Pexposed/1-Pexposed) over (Punexposed/1-Punexposed)
Can be interpreted as a relative risk when the event is rare.
Epidemiology
The study of the frequency, distribution and determinants of diseases and health related states in populations in order to prevent and control disease.
The epidemiology of a disease is described by time, place, person- age gender class ethnicity
Incidence v Prevalence
Incidence= new cases, denominator, time Prevalence = existing cases, denominator, point in time
Person time
Measure of time at risk ie time from entry to a study to i) disease onset ii) loss to follow-up iii) end of study
Used to calculate incidence rate which uses person time as the denominator
Incidence Rate
No. of persons who have become cases in a given time period, over the total person-time at risk during that period
Absolute risk, Attributable risk,
Absolute Risk
Gives a feel for the actual numbers involved (has units)
Attributable risk (a type of absolute risk)
The rate of disease in the exposed that may be attributed to the exposure ie. incidence in exposed minus incidence in unexposed (the size of effect in absolute terms)
Gives a feel for the public health impact- good if causality is known/assumed
Relative Risk
Relative risk
The ratio of risk of disease in the exposed to risk in the unexposed ie. incidence in exposed divided by incidence in unexposed
RR=1 means no difference between the two groups, RR>1 means the intervention increased the risk of the outcome, RR<1 means the intervention decreased the risk of the outcome
Tells us about the strength of association between a risk factor and a disease
Relative Risk Reduction
The reduction in rate of the outcome in the intervention group relative to the control group
Absolute Risk Reduction (ARR)
The absolute difference in the rates of events between the two groups and gives an indication of the baseline risk and intervention effect
Number Needed to Treat
NNT tells us the number we need to treat to prevent one bad outcome (1/ARR or 100/ARR)
An association between an exposure and an outcome can be due to…
Bias Chance Confounding Reverse Causality A true causal association
Bias and types of Bias
A systematic deviation from the estimation of the association between exposure and outcome
Selection Bias
Information Bias
Publication Bias
Selection Bias
A systematic error in
- the selection of participants
- the allocation of participants to different study groups
(eg. non-response, loss to follow up, differences between intervention and control group)
Information Bias
A systematic error in the measurement of classification of exposure or outcome
Sources include…
Observe (observer bias)
Participant (recall bias, reporting bias)
Instrument (wrongly calibrated instrument)
Confounding
A situation in which the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome
Reverse Causality
Refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
Criteria for causality (Bradford-Hill)
- Strength of association (The magnitude of RR)
- Dose-response (the higher the exposure, the higher the risk of disease)
- Consistency (similar results from difference researchers using various study designs)
- Temporality (does exposure precede the outcome)
- Reversibility (removal of exposure reduces risk of disease
- Biological plausibility (biological mechanisms explaining the link)
- Coherence (logical consistency with other information)
- Analogy (similarity with other establish cause-effect relationships
- Specificity (Relationship specific to outcome of interest
Addiction
Craving
Tolerance
Compulsive drug-seeking behaviour
Physiological withdrawal state
Effects of dependent drug use
Bio Acute... -Complications of injecting (DVT, abscesses, SBE) -Overdose (resp depression) -Poor pregnancy outcomes -Side effects of opioids Chronic... -blood-borne virus transmission -effects of poverty -side effects of cocaine (vasoconstriction, local anaesthesia)
Social
- Effects on families
- Drive to criminality
- Imprisonment
- Social exclusion
Psychological
- Fear of withdrawal
- Craving
- Guilt
Heroin management
Modalities of treatment
- Harm reduction (prevention of deaths, prevention of blood borne virus transmission, referral where appropriate)
- Detoxification (buprenorphine, lofexidine)
- Maintenance (methadone, buprenorphine
- Relapse Prevention (naltreoxne)
- Psychological interventions and alternative therapies
- Referral for allied problems (Hep C, STIs)
Cocaine management
Principles of treatment
- Harm reduction (Advice on risky behaviour, same sex advice, blood borne virus advice, Hep B/C testing and vacc, contraceptive advice)
- Brief intervention (Exxplanation of effects, risks, advice on controlled use, setting limits, cognitive based approaches)
- Team working (referral to sex health, infectious diseases, voluntary agency, specialist advice
Aims of treatment of drug misuse
To reduce harm to user, family and society
To improve health
To stabilise lifestyle and reduce the amount of illicit drug use
To reduce crime
Health psychology
Emphasises the role of psychological factors int he cause, progression and consequence of health and illness
Health behaviour
Illness Behaviour
Sick Role Behaviour
Health behaviour is a behaviour aimed to prevent disease (eg. eating healthy)
Illness behaviour is a behaviour aimed to seek remedy (eg. going to the doctor)
Sick role behaviour is any activity aimed at getting well (eg. taking medications, resting)
Theory of planned behaviour and intention
Proposes the best predictor of behaviour is ‘intention’ (eg. I intend to give up smoking)
Intention is determined by
- A persons attitude to the behaviour
- The perceived social pressure to undertake the behaviour, or subjective norms
- A persons appraisal of their ability to perform the behaviour, or their perceived behavioural control
5 Stages of change
Precontemplation Contemplation Preparation Action Maintenence
Motivational Interviewing
A counselling approach for initiating behaviour change by resolving ambivalence
Nudge Theory
‘Nudge’ the environment to make the best option the easiest eg. opt-out schemes such as pensions, placing fruit next to the checkouts
Factors to consider in regard to health behaviour
- Impact of personality traits
- Assessment of risk perception
- Impact of past behaviour/habit
- Automatic influences on health behaviour
- Predictors of maintenance of health behaviours
- Social norms
NCSCT
The national centre of smoking cessation and training
A social enterprise to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services
- Training and assessment programmes
- Support services for local and national providers
- Research into behavioural support
How do NCSCT programmes provide a measure of quality assurance for stop smoking services?
- Confirming that stop smoking practitioners have the necessary knowledge and skills to deliver stop smoking interventions
- Ensuring that the interventions that stop smoking practitioners deliver are evidence-based
- Committing stop smoking practitioners to providing evidence of clinical effectiveness and ongoing continual professional development.
Communicable disease- why notify?
So HPA can take urgent control measures
May be the only one who can tell HPA
Duty of registered medical practitioners
Duty to notify if…
- Notifiable disease
- Infection or contamination which could present (or have presented) signifiant harm to human health
Timescale for notifying causative agents found in human samples
From laboratory, in writing within 7 days, orally as soon as practicable
To the HPA within 3 days of request
Notifiable Diseases?
Acute Encephalitis Acute Meningitis Acute poliomyelitis Acute infectious hepatitis Anthrax Botulism Brucellosis Cholera Diptheria Enteric Fever HUS Infectious blood diarrhoea Invasive group A strep, scarlet fever Legionnaires Disease Leprosy Malaria Measles Meningococcal Septicaemia Mumps Plague Rabies Rubella SARS Smallpox Tetanus Tuberculosis Typhus VHF Whooping Cough Yellow fever
Local authority powers in notifiable disease
Requirement to keep children away from school, school must provide list of attendees
Local authority may request a person/group to do or refrain from doing anything to prevent, protect and control public health response if sig harm to health is a risk.
Magistrate Order for notifiable disease may require…
People (medical exam, hospital isolation, disinfection, protective clothing, provide information, monitor, attendance at training, prohibition from working)
Things (seizure or retention, isolation, decontamination, destruction)
Premises (closure, detention, disinfection, destruction)
Role of the consultant in notifiable disease control
Surveillance (using notification, lab and other data to monitor disease)
Prevention (trying to stop people getting it in the first place)
Control (what to do when routine cases and outbreaks occur)
Managing outbreaks of disease
- Clarify the problem (make a diagnosis)
- Decide if it is an outbreak (2 or more related cases of the disease)
- Get whatever help is needed (microbio, health visitors, consultant, nurse)
- Outbreak meeting
- Identify the cause
- Initiate control measures
Modes of transmission
- Foodborne
- Foecal-oral spread
- Respiratory route
- Direct physical contact (contagion- includes STIs)
- Acquired from animals (zoonoses)
Maslow’s Hierarchy of needs
Self-actualization (morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts)
Esteem (Self-esteem, confidence, achievement, respect of others and respect by others)
Love/belonging (friendship, family, sexual intimacy)
Safety (Security of body, of employment, of resources, of morality, of the family, of health, of property)
Physiological (breathing, food, water, sex, sleep, homeostasis, excretion)
Causes of homelessness
Relationship breakdown, caused by mental illness, domestic abuse, disputes with parents, bereavement
Health problems faced by homeless adults
- Infectious diseases (includes TB and hepatitis)
- Poor condition of feet and teeth
- Respiratory problems
- Injuries following violence, rape
- Sexual health, smears, contraception
- Serious mental illnesses
- Poor nutrition
- Addiction/substance misuse
Barriers to healthcare for travellers/gypsies
- Reluctance of GPs to register them and to visit sites
- Poor reading and writing skills, many are illiterate
- Communication difficulties
- Too few permanent and transient sites
- Mistrust of professionals
- Lack of choice
Barriers to healthcare for homeless people
Difficulties with access (due to opening times, appointment procedures location and perceived/actual discrimination)
Lack of integration between mainstream primary care services and other agencies (housing, social services, criminal justice system and voluntary sector)
Other things on their mind (more immediate survival issues so don’t prioritise their health)
May not know where to find help
Asylum Seeker
A person who has made an application for refugee status
Refugee
A person granted asylum and refugee status. Usually means leave to remain for 5 years and then reapply
Humanitarian protection
Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years and then reapply
How do asylum seekers live?
No choice dispersal Vouchers, 70% of income support sum NASS support package Access to NHS Not allowed to work
Health problems in asylum seekers/refugees
Physical
- Illness specific to country of origin
- Injuries from war/travel
- No previous health surveillance/neonatal screening/immunisations
- Malnutrition
- Torture and Sexual Abuse
- Infestations and debilitation
- Communicable disease / blood borne disease
- Untreated chronic disease/ congenital problems
Mental Health
- PTSD
- Depression
- Sleep disturbance
- Psychosis
- Self-Harm
Why is safety compromised so often?
- Healthcare is a complex, high risk environment
- Resource intensive
- System, patient and practitioners interaction
- Responsibilities are often shared
- Practitioners often take risks unknowingly
Common errors made in healthcare
Wrong diagnosis leads to wrong plan Medication reconciliation High concentration medicine solutions Patient identification Patient care handovers
Ways of classifying error
Classification based on…
- Intention
- Action
- Outcome
- Context
Classification of error based on intention
Failure of planned actions to achieve desired outcome…
-Skill-based errors
-Rule based mistakes
Knowledge-based mistakes
Automatically makes us prone to actions not as planned, limited attentional resources, knowledge-based mistakes
Classification of error based on action
Generic Factors (omission, intrusion, wrong order, mistiming)
Task specific factors (wrong blood vessel, verve, organ, side, bad knots)
Classification of error based on outcome
- Near miss
- Successful detection and recovery
- Death/injury/loss of function
- Prolonged in intubation/stay in ICU
- Cost of litigation
- Unplanned transfer
Classification of error based on context
- Anticipations and preservation
- Interruptions and distractions
- Nature of procedure
- Team factors
- Organisational factors
- Equipment and staffing issues
- Accumulation of stressors
Perspectives on error
The person approach (focus on the individual)
- Errors are the product of wayward mental processes
- Focusses on the unsafe acts of people on the frontline
- Shortcomings- anticipation of blame promotes ‘cover up’ need detailed analysis to prevent recurrence.
The system approach (focus on the working conditions)
- Errors are commonplace-adverse events are the product of many causal factors
- Sharpenders are more likely to be inheritors than instigators
- Remedial efforts directed at removing error traps and strengthening defences
- Interaction between active failures and latent conditions (proactive risk management- remedy latent factors)
Tools of risk identification
Incident reporting
Complaints and claims
Audit, service evaluation and benchmarking, external accreditation
Active measurement/compliance
Strategies to reduce errors and harm
- Simplification and standardisation of clinical processes
- Checklists and aide memoires (SBAR)
- Information technology
- Team training
- Risk management programmes
- Mechanisms to improve uptake of evidence based treatment patterns
Never events
Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
(eg. surgery- wrong site/implant, retained item. Medication- wrong preparation/route. Mental health- suicide)
Leadership styles
Inspirational, Transational, Laissez-faire, Transformational
Mechanisms underlying inhumane behaviour
Bystander effect- no. of bystanders (leadership), ambiguity, similarity of bystander to victim
Pressing situational factors can override explicitly annouced value systems
Unwillingness to speak out against prevailing view
Error: Sloth
Error: Not bothering to check results/information for accuracy. Incomplete evaluation. Inadequate documentation
Skill/behaviour/attribute… conscientiousness
Eg. attention to detail, completeness, not assuming that information presented to you is correct. Full documentation
Error: Fixation and Loss of perspective
Error: Early, unshakeable focus on a diagnosis. Inability to see the bigger picture. Overlooking warning signs
Attribute… lack of open mindedness, situational awareness
Eg. recognition of the clinical patterns but considering facts that don’t fit. Re-evaluation if deviation from the expected.
Error: Communication breakdown
Error: Unclear instructions or plans. Not listening to or considering others opinions.
Attribute… lack of Effective communication
Eg. being approachable and open. Listening. Clear explanation with appropriate terminology and reinforcement
Error: Poor team working
Error: Team members working independently. Poor direction. Some individuals out of depth, others underutilised.
Attribute…Lack of good team working
Eg. clear team structure and roles with sharing of views, concerns and management plans, clear logical leadership
Error: Playing the odds
Error: choosing the common and dismissing the rare event
Attribute.. probability assessment
eg. evaluation based on scenario features as well and likelihood
Error: Bravado (timidity)
error: working beyond your competence or without adequate supervision. A show of confidence to hide underlying deficiencies (not taking on that which you should)
Attribute… humility
Eg. accurate self-evaluation, open communication of mistakes
Error: Ignorance
Lack of knowledge. Unconscious incompetence. Not knowing what you don’t know.
Attribute… Self-awareness
Eg. aware of your own abilities and limitations. Consideration of factors which may affect your judgement (Stress, fatigue)
Error: Mis-triage
Error: over/underestimating the seriousness of a situation
Attribute… prioritization
Eg. appreciation of the relative importance or urgency of each situation.
Error: lack of skill
Error: lack of appropriate skills, teaching or practice
Attribute… Effective technical skills
Eg. being properly trained in your role
Error: system error
Error: Environmental, technology, equipment or organisational features. Inadequate built in safeguards
Attribute… system design
Eg. A system designed to be easy to use, complete, and with design features that identify potential risk.
Negligence- Why do things go wrong?
System failure
Human failure (personal, teamwork problems, environment)
Judgement failure (analytical or intuitive, wrong amount or type of info, wrong strategy, bias)
Neglect (insufficient care, below expected standard, often a chain of minor failures)
Poor performance (repeated minor mistakes, not learning from mistakes)
Misconduct (deliberate harm, covering up errors, fraud/theft/abuse)
The swiss cheese model
The holes in each slice represent weaknesses in individual parts of the system, varied in size and position. Failures are produced when a hole in each slice momentarily aligns, permitting a ‘trajectory of accident oppurtunity’
Negligence
-Is there a duty of care?
-Was there a breach in that duty?
(are your actions supported by others? Would a group of reasonable doctors do the same- Bolam test? Would it be reasonable for them to do so- Bolitho test?)
-Did the patient come to any harm?
-Did the breach cause the harm?
(Patient must demonstrate that it was your action/inaction that caused the harm)
If claim is successful- amount depends on loss of income, cost of extra care, pain and suffering
Tripartite Model
Surface (fear of failure, desire to complete a course. Learning by rote and focus on particular tasks) Strategic (desire to be successful, leads to patchy and variable understanding- well organised form of surface learning) Deep Approach (intrinsic, vocational interest, personal understanding- making links across materials, search for deeper understanding of material, look for general principles)
Kolb’s learning cycle
Experience (Activist) -> Review, reflect on experience (Reflector) -> Conclusions from experience (theorist) -> What can I do differently next time (pragmatist)
Types of learner
Activist (new experiences, extrovert, likes deep end, leads)
Reflector (watches others, reviews work, analyses, collects data)
Theorist (complex situations, can question ideas, offered challenges)
Pragmatist (wants feedback, purpose, may like to copy)
Teaching a skill
Breaking task down into smaller components
Utilizing an internal commentary
Key responsibilities of small group tutors
- Managing the group: the activities, and the learning
- Facilitator of learning: leading discussions, asking open-ended questions, guiding process and task, enabling active participation of learners and engagement with ideas
Four fundamental questions of teaching
- Who am I teaching? Numbers, level
- What am I teaching? Topic, subject, type of expected knowledge
- How will I teach it?
- How will I know if the students understand/understood?
Question strategies for teaching
Evidence (how do you know that?)
Clarification (Can you give me an example?)
Explanation (why is that the case?)
Linking and extending (how does this idea support what we said earlier?)
Hypothetical (what would happen if…?)
Cause and effect (how is this response related to the management?)
Summary and synthesis (what remains uncertain? what do we need to know to understand better?
Why teach diversity?
Better health outcomes for patients (Doctors identify problems more accurately, patients are more likely to adhere to treatment, fewer diagnostic tests and referrals, patient symptom burden reduced)
More satisfying doctor-patient encounters (doctor is more time efficient, doctors own well-being is improved, patients are more satisfied with their are, better able to understand their problems, investigations and treatment options, fewer complaints
Iceberg model of culture
Gender Age Ethnicity Nationality
Socio-economic status, occupation, health, religion, education, social groupings, sexual orientation, political orientation, cultural beliefs, expectations and behaviours
Culture
A socially transmitted pattern of shared meanings by which people communicate, perpetuate and develop their knowledge and attitudes about life. An individuals cultural identity may be based on heritage, as well as individual circumstances and personal choice, and is a dynamic entity.
Ethnocentrism
The tendency to evaluate other groups according to the values and standards of one’s own cultural group, especially with the conviction that one’s own cultural group is superior to the other groups
Stereotype
Involve generalisations about the ‘typical’ characteristics of members of a group
Predjudice
Attitude towards another person based solely on their membership of a group
Discrimination
Actual positive or negative actions towards the objects of prejudice
Kleinman’s explanatory model of illness
- what do you call your illness? What name does it have?
- What do you think has caused the illness?
- Why and when did it start?
- What do you think the illness does? How does it work?
- How severe is it? Will it have a long or short course?
- What kind of treatment do you think you should receive? what are the most important results you hope to achieve from treatment?
- What are the chief problems the illness has caused?
- What do you fear most about the illness?
Rationing needs for resource allocation have increased because…
- Shift from acute illness to chronic long term
- Normal physiological events medicalised
- Increase in choice and increase in expensive drugs
The Nicholson challenge
To derive by 2015 £15-20 billion more value from overall budget to meet rising demand without corresponding increase in funding
Rationing
Resource is refused because of lack of affordability rather than clinical ineffectiveness
Allocation theories
Egalitarian principles (provide all care that is necessary and appropriate to everyone- challenge is tension between egalitarian aspirations and finite resources) Maximising principles (criteria that maximise public utility) Libertarian principles (Each is responsible for their own health, well being and fulfilment of life plan)
Health Incentive Schemes
In Germany- reduced cost for people who participate in screening/check ups/health promotion
Problem.. programmes attract/retain higher income groups
Rights that are frequently engaged in healthcare
Art 2 (the right to life- limited) Art 3 (the right to be free from inhuman and degrading treatment- absolute) Art 8 (the right to respect for privacy and family life- qualified) Art 12- the right to marry and found a family
Benefits and risks of social media
Benefits
- establishing wider/more diverse social and professional networks
- engaging with the public and colleagues in debates
- facilitating public access to accurate health information
- improvement of patient access to services
Risks
- loss of personal privacy
- potential breaches of confidentiality
- online behaviour might be perceived as unprofessional, offensive, or inappropriate by others
- risks of posts being reported by the media or sent to employers
GMC Duties of a Doctor
- Make the care of your patient your first concern
- Protect and promote the health of patients and the public
- Provide a good standard of practice and care (up to date knowledge, work within limits)
- Treat patients as individuals and respect their dignity
- Work in partnership with patients (listen to them and respond to concerns)
- Be honest and open and act with integrity (never discriminate, never abuse trust)
