Year One Flashcards
Typical GP day
Morning and afternoon surgeries Paperwork (letters, results etc.) and phone calls interspersed throughout the day House calls Extended hours Duty doctor/ emergencies Practice business/ staff issues
Main features of general practice
Caring for the whole person as well as their illness
The promotion of healthy lifestyles
The first point of contact
What is a GP practice
Most GPs are independent NHS contractors, owning and running the business alone or in partnership with others.
Responsibilities of a GP practice
Running the business affairs of the practice
Providing adequate premises and infrastructure to provide safe patient services
Employing and training practice staff.
Ongoing learning as a GP
Each 5 years GPs prepare for appraisal by reading literature, attending courses and performing audits.
Appraisal work is assessed so the GP can be re-validated and allowed to continue working
Effective communication improves…
Patient satisfaction Recall Understanding Concordance Outcomes of care
five core concepts associated with the SCT framework
Observational learning/ modelling Outcome expectations Self-efficacy Goal setting Self regulation
Personal factors affecting behaviour (SCT)
Self-efficacy
Perceived outcomes/ consequences
Importance of outcomes/ consequences
Perceived risk to the individual
To influence behaviour, information must be
Relevant to current goals
Easily understood and remembered
Readily available in the moment of decision/ action
Self-efficacy underpins….
Goal setting
effort investment
persistence in face of barriers
recovery from set-backs
Choice architecture
The environment in which the individual makes choices
*Changes in choice architecture can influence individual decisions
Nudges
Prompt choices without getting people to consider their options consciously
Bio-medical/ scientific view of health
Health as the absence of disease
Health as the absence of illness
Reasons for verbally checking and safety netting
To check you’ve understood the real reason the patient was there.
To chech nothing was missed
To minimise the chance of future problems
To ensure you are ready for the next consultation
5 core concepts of social cognitive theory
Observational learning/ modelling Outcome expectations Self-efficacy Goal setting Self regulation
Uncertainty definition
State of not being completely confident or sure of something
Safety netting
If uncertainty remains, this must be communicated to the patient
They must know what to look out for, how to seek help and what to expect about the time course
It may be important to arrange follow up.
Method used as a full systematic enquiry is not possible
Hypothetico-deductive reasoning
- consider diagnoses that are likely or immediately concerning.
- eliminate other diagnoses at this stage
- strengthen the case for diagnoses through brief history + examination
- extend the search if no diagnosis identified
Childhood experiences that influence adult health
Nutrition Trauma Nurture Optimism Education
Factors that influence the degree of risk
How much a person is exposed
How the person is exposed
Conditions of exposure
Where do ethical principles come from?
- duties
2. considering the benefits and harms to individual and society (4 principles)
Duty of Candour
Must be open and honest with patients when something goes wrong.
Must apologise and offer to put matters right.
Must raise concerns where appropriate.
Ethical practices
Non-judgemental approach Not imposing personal views and respecting patients' views Confidentiality Not exceeding your competency Fitness to practice
Focuses of cultural competence in health care
- eliminate misunderstandings that may arise from differences in language or culture
- Improve patient adherence
- Eliminate health care disparities
Role of the physician in eliciting the patient’s explanatory model of illness
- asking questions to elicit the patient’s understanding of their illness
- Having strategies for identifying and bridging the different communication styles
- Having skills for assessing decision-making preferences and the role of family
BELIEF model of cross-cultural communication
B-eliefs about health (what caused the illness) E-xplanation (why did it happen) L-earn (about belief) I-mpact (on life) E-mpathy F-eelings
A culturally competent doctor
Has an awareness and acceptance of difference whereby diversity is valued
Understands how their own culture influences them
Understands the dynamics of difference present when cultures interact
Is familiar with the cultures in their area
Adapts to the cultural context of the patient/client
Role of primary care
Where illness first presents,
Most illness managed,
“Gatekeeper” function,
Prevention
Secondary care
Hospitals
Consulting
Tertiary care
Regional centres
Bridging Primary and Secondary Care
Public health specialists, Occupational medicine, Some hospital specialties (e.g. mental health, palliative care), Management of long term conditions, Community Hospitals
General practice team members
Manager, IT/Admin Staff, Secretarial Staff, Reception Staff, Nurses – Junior/Senior, Advanced Nurse Practitioners/Physicians Assistants, Phlebotomists/Health Care Assistants,
Other roles of GPs
Out-of-hours responsibility,
GPs with special interests,
Portfolio careers,
Events coverage e.g. concerts, car rallies,
BASICS (British Association for Immediate Care - pre-hospital care)
Primary Care specialties
General Practice (GP), Occupational and Environmental Medicine (OEM), Public Health (PH)
Personal qualities of a good GP
Clinical competence, Organisational ability, Ability to work with others, Maintaining good practice, Relating to the public, Ability to deal with uncertainty
Ability to manage oneself,
Ability to care about patients and their relatives,
A commitment to providing high quality care,
An awareness of one’s own limitations,
An ability to seek help when appropriate,
Commitment to keeping up to date and improving quality of one’s own performance,
Appreciation of the value of team work,
Good interpersonal and communication skills,
Uses of GP IT systems
Book appointments,
Chronic disease management and recall,
Patient leaflets/resources,
Public health information,
Identify patients for screening programmes,
Electronic management of hospital letters,
Electronic management of blood/other results,
Assist in consultations (patient records), Support prescribing, Use in audit, E-consultations, Store appointments,
The four essential components of clinical competence
Knowledge,
Communication skills,
Physical examination,
Problem solving
Skills needed for successful medical interviewing
Content skills - What doctors communicate
Perceptual skills - What they are thinking and feeling
Process skills - How they do it
Types of factors Influencing the Consultation
Physical factors
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Personal factors
of the doctor and patient
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Physical Factors Influencing the Consultation
Site and environment.
Adequacy of medical records.
Time constraints.
Patient status (new/known)
Personal Factors Influencing the Consultation
Age, Sex, Backgrounds and origins, (e.g. social class/ ethnicity) Knowledge and Skills Beliefs, The Illness,
Types of doctor-patient relationships
Authoritarian or paternalistic relationship,
Guidance/co-operation,
Mutual participation relationship.
Parts of the medical consultation
Talking together- always
Doctor examining the patient - often
Performing procedures - sometimes
Interviewing techniques in taking the history
The open-ended question,
Listening and Silence,
Facilitation - manner that encourages communication
Types of questions
Open-ended question, Direct question - specific, Closed question - yes or no, Leading question - best avoided, Reflected question (allows the doctor to avoid answering a direct question, e.g. "you want to know the cause of the pain?)
Types of non-verbal communication
Instinctive, e.g crying. laughter, expressions of pain
Learned - From life experiences (depends on culture) or from training
Clinical - e.g. abnormal movement in response to pain
Factors to consider when reading body language
Culture,
Context,
Gesture Clusters (a cluster of gestures reinforces the message)
Congruence (if body language agrees with what is being said)
Aspects of body language
Gaze behaviour,
Posture,
Specific gestures
Main Risk factors for chronic disease
Smoking, Obesity, Poor diet, Lack of physical activity, Excessive alcohol consumption,
types of factors influencing behaviour according to social cognitive theory
Personal factors - beliefs, knowledge, attitudes, self efficacy
The behaviour itself - habit, pattern
The environment - culture, location, income
WHO definition of health
”A state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity.”
Types of normality
Statistical,
Cultural - depends on the expectations and standards of the society
Lay definitions of health
Absence of disease,
Physical fitness,
Functional ability,
Aims of a GP Consultation
Calgary Cambridge Model
Initiating the Session, Gathering Information, Providing Structure, Building Relationship, Explanation and Planning, Closing the Session,
Roger Neighbour’s tasks of a consultation
To Connect with the patient,
To summarise and verbally check that the reasons for attendance are clear*
To hand over and bring the consultation to a close*
To ensure that a safety net exists in that no serious possibilities have been missed*
To deal with the housekeeping of recovery and reflection*
.
.
*Ways in which risk can be minimised
Sources of guidance to deal with risk and uncertainty
National (e.g. SIGN) Local Immediate guidance/ protocool Colleagues Peer group Reflection
Strategies for managing risk and uncertainty
Use external evidence, Respect the internal evidence, Good organisation, Be aware of your feelings, Apply reflective practice, Developing a good doctor-patient relationship, Consider each patient as an individual, Consider the use of a checklist for diagnosis, Peer group discussions
Reasons for the social and economic gradient of health
Access to health care,
Environmental exposures (physical and social)
Health behaviours,
Life course factors,
Factors affecting access to healthcare
Affordability
Accessibility
Acceptability
Physiological response to psychological distress
Increased blood pressure
Impaired glucose tolerance
Immune dysregulation
Oxidative cellular stress with accelerated aging
Health is determined by…
Where you are born, Where you live, How you are brought up, Your life chances, Your political voice, Your family support,
The roles of government in reducing exposure to health risks
Legislation
Regulation
Taxation
Hazard
Something with the potential to cause harm
Risk
The likelihood of harm occurring and the severity of the harm involved
Risk factor
Something that increases the risk of harm
Protective factor
decreases the risk of harm
Susceptibility
influences the likelihood that something will cause harm
Types of hazard
Physical, Chemical, Mechanical, Biological, Psychosocial
Routes of exposure for hazards
Skin
Blood/ sexual
Inhalation
Ingestion
Principles governing the perception of risk
Feeling in control,
Size of the possible harm,
Familiarity with the risk
Individual variables in risk perception
Previous experience, Attitudes towards risk, Values, Belief, Socio economic factors, Personality, Demographic factors
Direct pathological effects of the environment
Physical - e.g. radiation
Chemical - e.g. pesticides
Biological - e.g. infectious agents
Indirect pathological effects of the environment
Housing,
Transport (encourage walking?),
Town planning (access),
Income/ wealth distribution
Ethics definition
The body of moral principles or values governing a particular culture or group
Ethics comprise of…
Principles
Values
Honesty
Standards
Morality definition
Our attitudes, behaviours and relations to one another
4 principles of ethics
Respect for autonomy
Non-malfeasance
Beneficence
Justice
Culture definition
The learned and shared values of a particular group that guides:
- thinking
- actions
- behaviours
- emotional reactions to daily living
The sum of beliefs, practices, habits, likes and dislikes
Norms and customs that are learned
Cultural sensitivity
The ability to be open to learning about and accepting of different cultural groups
Multiculturalism
The recognition and acknowledgement that society is pluralistic; there exists many other cultures
Influences of culture on health care
Misunderstandings arising from differences in language or culture
Poor patient adherence and poor outcomes
Health care disparities (differences in health care between different groups)
Barriers to health care
Lack of knowledge, Fear and distrust, Bias and ethnocentrism, Stereotyping, Language barriers, Differences in perceptions and expectations, Situation
Aspects of acquiring cultural competence
Knowledge,
Attitudes,
Skills (eliciting patient’s explanatory model of illness)
Cultural competence
The understanding of diverse attitudes, beliefs, behaviours, practices, and communication patterns attributable to a variety of factors
proportion of doctor patient consultations that occur within primary care
90%
For 1000 people, how many report symptoms each month
750
For 1000 people, how many see their GP per month
250
For 1000 people, how many are admitted to hospital each month
9
3.5% of those seen in primary care
For 1000 people, how many are referred to another doctor each month
6
Factors that increase the chance of someone changing their behaviour
You think the advantages of change outweigh the disadvantages
You anticipate a positive response from others to your behaviour change
There is social pressure for you to change
You perceive the new behaviour to be consistent with your self-image
You believe you are able to carry out the new behaviour in a range of circumstances
Governmental actions to promote health in the population
Legislation/policies on smoking/alcohol Improvements in housing Provision of health education Health and safety laws Traffic/transport legislation/policies
Environmental factors which influence behaviour
Culture Social support Location Income Time
Factors which influence lay beliefs about health and how
Age - older people focus on functional ability
Social class - lower class regard health as functional
Gender - women include a social aspect
Culture - different perceptions of disease
Advantages of GPs as gatekeepers
GPs identify patients in need of secondary care
Patients may not know which speciality to go to
Limits exposure to certain investigations
GP acts as a coordinator of care
Puts GP in a position to provide patient education
Advantages of GPs as gatekeepers
GPs identify patients in need of secondary care
Patients may not know which speciality to go to
Limits exposure to certain investigations
GP acts as a coordinator of care
Puts GP in a position to provide patient education
Systems of behaviour
Reflective system
Automatic system
