2. Professionalism
• ‘Medical professionalism signifies a set of values, behaviours
and relationship that underpins the trust the public has in
doctors’
• The report further describes:
• That medicine is a vocation in which doctors knowledge, clinical
skills and judgement are put in the service of protecting and
restoring human well-being.
3. Professionalism
• Composed of a doctor’s
• Relationship with knowledge
• Relationship with colleagues
• Relationship with patients
• Relationship with society
• Relationship with self.
4. Regulation of Professionalism
• The GMC has two main functions:
• It holds a list of all registered UK doctors
• It acts as a professional regulator.
• Why are medical students always threatened when we act like
normal students?
• Alcohol
5. Good Medical Practice
• Good clinical care
• Maintaining Practice
• Teaching and Training
• Relationship with Patients
• Working with colleagues
• Probity
• Health
Great Minds Think Revising Will Probably Help
6. Duties of a Health Care
Professional
• Moral duty – Respect patient autonomy
• Professional duty - GMC
• Legal duty - Law
7. Ethical Practice
• What is ethics?
• Duty
• Utility
• Rights
• Virtue
• Ethical Principles
• Moral Perception
• Moral reasoning
• Moral action
8. Ethical Practice
• Consent
• This is the “volountary, un-coerced decision made by a
sufficiently competent or autonomous person based on adequate
information and deliberation, to accept rather than reject a
proposed form of action”.
• Validity judged on the Mental Capacity Act.
• Mental Capacity Act (2005)
• Primary purpose is to provide a legal framework for acting and
making decisions on behalf of adults who lack capacity to make
decisions for themselves.
• Which situations do not require consent?
9. Importance of Consent
• Legal duty
• Respect for patient autonomy (Ethical principle)
• Respect Patient (Professionalism)
• Establish relationship of trust with patient
• Benefits patient
• Co-operate
• Jehova’s witness
10. Ethics in children
• Gillick competence
• Brief History
• “whether or not a child is capable of giving the necessary consent
will depend on the child’s maturity and understanding and nature
of consent required.”
• Fraser Guidelines
• They refer to the guidelines set out by Lord Fraser in his
judgement of the Gillick case which apply specifically to
contraceptive advice on the basis of a number of key principles.
11. Competence
• Four principles
• Patient must understand information
• Patient must retain information
• Patient must weigh-up options
• Patients must communicate decision.
12. Memory and Conditioning
• Memory process
• Encoding
• Storage
• Retrieval
• Atkinson-Shiffrin memory model
• Sensory information
• Short term memory
• Long term memory
14. Short Term Memory
• This is basically what you are thinking about at any given
moment.
• Holds limited amount of information for short period of time –
20 to 30 seconds.
• Capacity
• 7 +/- 2
• Increased by chunking
• Break large amount of information into meaningful information
15. Long Term Memory
• Unlimited capacity
• Requires consolidation of information in short term memory
• Involves long term potentiation
• Can improve working memory…how?
• Retrieval of information
• Cues
• Context
• Level of processing
• Organisation of information when learnt
16. Types of Memory
• Procedural memory
• Form of memory that involves a sequence of movements or
actions and enables us to perform various acts or skills.
• Declarative memory
• Episodic – form of memory that represents our knowledge of
personally experienced events and the order they occurred.
• Semantic – form of memory that represents our knowledge of
words, symbols and concepts including meaning and rules for
using them.
17. Question
• A patient comes in requiring bilateral removal of parts of the
hippocampus. After the surgery, the patient can remember
everything that occurred before the surgery and has a
functioning working memory. However, he cannot learn
anything new that has happened post-surgery but can still
learn procedural skills without realising he has learnt them.
• Which type of memory is affected?
• Does this patient have amnesia? If so what type?
18. Classical Conditioning
• The combination of a neutral stimulus with a stimulus which
does elicit a behavioural response.
• The conditioned stimulus produces no response at first but
after conditioning it elicits the conditioned response.
• Pavlov’s experiment is a good example to use.
19. Practical example
• If you take an Arab and put a shawarma platter
(unconditioned stimulus) in front of them, they will salivate
(unconditioned response).
• If you couple the shawarma (unconditioned stimulus) with a
picture of LITTLE RAT (conditioned stimulus), over
time, repeated exposure will cause the picture of the little rat
ALONE to cause salivation.
20.
21. Operant Conditioning
• Form of learning in which an individual’s behaviour is modified
by its consequences.
• What is the difference between Operant and Classical
conditioning?
• Reinforcement and punishment are the core tools of operant
conditioning, are either positive or negative.
• Extinction
22. Example
• The bird in the box gets a seed when it speaks but when it
moves and does not speak, the chute closes.
• Therefore, the bird realises that in order to gain a seed it must
speak.
• This is positive reinforcement.
• Extinction would be no longer giving the seed after the bird
speaks
23. Clinical Use
• Cognitive Behavioural Therapy uses Operant conditioning
• Targets emotional response to event and thus modifies
behaviour.
• Common exam question.
24. Stress, Illness and Coping
• Understanding the terms stressor, stress response and strain
• Three theories
• General Adaptation Syndrome
• Life Events Model
• Transactional model
25. General Adaptation Syndrome
• Alarm stage
• Fight/flight reaction
• Resistance stage
• Defence / adaptation to stressor
• Exhaustion
• Failure to adapt to stressor
The problems with this model?
26. Life Events Model
• This theory states that an accumulation of life events and
continuous adjustments is detrimental to health.
• This model measures stress by totalling number of life events
within a period of time e.g. …
• Problems?
27. Transactional model
• This model is based cognitive appraisal of the stressor.
• The effect of the stressor is influenced by coping strategies
• Stress results from an imbalance in demands versus resources
• The perceived resources include factors such as personality
traits, family support, experience.
Problem – situations that occur without prior cognitive appraisal
28. Models of Health and Disability
• Biological model of disability
• Social model of disability
• Bio-psycho-social model of disability
Impairment – loss of normal age-related structure and function
of the body
Disability – result of any social system which does not allow for
inclusion of people with an impairment.
29. Biological model of disability
• Disease centred approach
• Management of illness revolves around identifying the illness
from a clinical perspective.
• Then controlling it by medical intervention to cure the disease.
• The biological model advocates an investment of health
resources to cure disabilities with medical intervention.
Problem with a purely biological approach?
30. Social model of disability
• Reaction to the dominant medical model of disability.
• This model identifies systemic barriers, negative attitudes and
exclusion by society that means society is the main
contributory factor in disabling people.
• Not everyone with an impairment has to be classed as
disabled.
• Difference between biological and social model?
• Problems?
31. Bio-Psycho-Social model
• Health is best understood in terms of a combination of
biological, psychological and social factors.
• This looks at the biological, psychological and social effects.
• Complex interaction between all three.
32. Health Behaviour
• Any behaviour which has an effect on health is known as a
health behaviour.
• This can be positive (exercise) or negative (smoking).
• Three main theories that influence health behaviour
• Health Belief Model
• Theory of planned behaviour
• Cognitive dissonance
33. Health Belief Model
• The model predicts that individuals will act to promote their
health if they believe:
• There is a perceived threat
• The consequence and susceptibility to the threat is severe
• Recommended actions to deal with the problem are beneficial
• The benefits of taking action outweigh the barriers.
Problem?
34. Example
• Application of the Health Belief Model to prevent the spread
of HIV/AIDS, individuals would be more likely to practice safe
sex if they believed:
• They are at risk of HIV infection
• The consequences of HIV infection are severe
• Safe sex practices are effective in reducing the risk of infection
• The benefits of safe sex practice outweighs the potential barriers
35. Theory of Planned Behaviour
• Health behaviour depends on:
• Attitudes
• Individual evaluation of a behaviour
• Subjective norms
• How society or environment contributes to behaviour
• Perceived behavioural control
• The extent to which the individual believes he or she can control
behaviour
Problem?
38. Reducing dissonance
• In order to reduce dissonance:
• Change one or more beliefs
• Eliminate a cognition
• Introduce another cognition
39. Loss, Bereavement and Grief
• Loss – the physical loss of something.
• Bereavement – the process we go through after we lose
something to which we were emotionally attached.
• Grief – the emotions associated with bereavement.
• Mourning – psychological process resulting from loss and
process of recovery.
40. Emotions associated with grief
• Acute Grief – agitation, crying and hallucinations
• Long term – sleep disturbance, sleep withdrawal and
depression
42. Pathological grief
• Absent – failure to display symptoms of grief but may show
severe signs on occasions
• Prolonged – initially is normal grieving, but loss is still central
after 6 months
44. Common Mental Disorders
• Mental illness – abnormal behaviour associated with reports
of distressing experienecs.
• Psychosis – an inability to distinguish fantasy from reality and
is associated with delusions and hallucinations
• Neurosis – is not a psychotic illness and is associated with
anxiety and low mood.
45. Biological Model
• Dominated psychiatric profession in the last century.
• Huge amounts of research has gone into this area of
psychiatry.
• Mental dysfunction is the result of a physical / chemical
change in the brain.
• This abnormal functioning in the brain should be treated as
any other physiological illness.
46. Psychodynamic model
• Behaviour and feelings as adults are rooted in our childhood
experiences
• Relationships (particularly parenting) are of primary
importance in determining how we feel and behave
• Our behaviour and feelings are powerfully affected by the
meaning of events to the unconscious mind
• The symptoms shown are expression of unconscious thought
and can indicate underlying problem
47. Behavioural Model
• Mental illness is associated with abnormal behaviour.
• Behaviour is a result of the environment rather than genetics
and so reject the view that abnormal behaviour has a
biological basis.
• Abnormal behaviour result from unhelpful learned responses.
48. Example
• A patient’s fear (phobia) of heights would be explained
through the process of classical conditioning. Some time in the
past, she would have learned to associate the emotion of fear
with the stimulus of being in a high place through a chance
association between the two stimuli. As a result, she would
avoid heights, and therefore not have the opportunity to
relearn the association in a more adaptive way. Treatment
would involve desensitising the fear through conditioning
techniques.
49. Cognitive model
• Mental illness is an error in thinking
• View of the world is determined by our thinking.
• Dysfunctional thinking dysfunctional view of the world.
• Therefore treatment targets necessary changes in thinking.
50. Example
• A patient suffering from a depressed mood after failing a
driving test may be having negative thoughts not only about
that specific failure but may be generalising those to other
areas of her life. She may believe she is a failure in all aspects
of her life and will never be successful again. These thoughts
are irrational and polarised, and the therapist would strive to
teach the patient ways of changing her thoughts. The
therapist might also emphasise the importance of increasing
positive reinforcements, and suggest ways in which this might
be achieved.
51. Advantages and Disadvantages of
Classificaiton of Mental Illness
• Advantages
• It gives a diagnosis to the individual
• It frames the problem and allows goal-directed activity from the
individual to get better.
• Disadvantages
• People often want to blame something for their illness, who do
you blame?
• Labelling and stigma
• Felt
• Enacted
53. Standard Deviation
• Measure of spread of data
• Used in normal distributions
• Calculate variance
• Standard Deviation is the square root of variance
• Don’t need to know how to calculate but need to know what
it means in simple terms…
57. What is a 95% Reference range
• It is calculated
• Mean + (2 x SD)
• Mean – (2 x SD)
• 95% of the data will lie within these limits if the data is normally
distributed.
58. Example
Systolic BP in 1500 middle aged
men BP = 140mmHg
• Mean
• Standard Deviation = 20mmHg
• 95% Reference Range
• Mean + (2 x 20) = 180mmHg
• Mean – (2 x 20) = 100mmH
• Based on this sample, we expect 95% of men to have BP
values between 100 and 180mmHg. This can be extended to
say that we expect 95% of middle aged men in the population
to have BP values between 100 – 180mmHg
59. Standard Error
• Imagine that samples of the same size ‘n’ are repeatedly taken
from a defined population…and the mean BP of each sample
is calculated.
• There will still be a spread of the means, even in the absence
of bias because of sampling error or random variation.
• Standard error is simply a spread of sample means.
• Key features
60.
61. Standard Error
• But instead of doing lots and lots of samples, we can
determine the standard error using one sample.
• Standard Error = Standard Deviation / √n
• What do you think a small standard error means?
62. Confidence Intervals for a
mean
• From: Mean – 2 x SE
• To : Mean + 2 x SE
Take the following figures
Mean – 140mmHg
SE - 0.5
140 – (2 x 0.5) = 139
140 + (2 x 0.5) = 141
95% CI = 139-141
63. Interpreting a Confidence
Interval
• In the population from which this sample came we estimate
the mean BP to be 140mmHg and we are 95% sure that the
true mean BP in the population is within the interval
139mmHg – 141mmHg.
64. Key Points
• If looking at 95% Confidence Intervals from relative risks –
check to see whether the range includes 1.
• If looking at 95% Confidence Intervals from differences in
means – check to see whether the range includes 0.
65.
66. 95% Reference range and 95%
Confidence Interval
• 95% reference range tell us about the spread of data.
• Therefore it is the spread of data which contains 95% of the
observations
• 95% confidence intervals use standard error and tells us about
the distribution of estimates (such as means)
• Therefore it is a measure of the accuracy of sample estimate
67.
68. Interpreting 95% CI Intervals
• Narrow CI Precise estimate
• Wide CI Imprecise estimate
• When looking at differences between means does 0 lie in the
CI?
• When looking at relative risks does 1 lie in the CI?
69. P values
• Defined as “the probability that the result could have arisen by
chance if there is no genuine association at all (null
hypothesis)”
70. Example
• A randomized double blind clinical trial of propranolol vs
placebo after a myocardial infarction reported the following
results after 1 year of follow-up:-
• Relative risk of cardiac death in propranolol vs. placebo = 0.64
• 95%CI from 0.38 to 1.06
• P value = 0.12
71. We get more information from
confidence intervals.
• The value of the null hypotheses for relative risk is 1
• Does the 95% CI contain the null hypotheses value
• Yes – it includes the value of 1
• Therefore this study cannot conclude that propranalol reduces
the risk of cardiac death compared to placebo
• More data is needed.
72. Things you should go through
• Intelligence
• Always comes up but you just need to learn the facts
• Lay Health Beliefs
• Boring descriptive rubbish, so just read it and try and remember
bits and pieces
Attitude – so its an evaluation of the positive and negative of behaviours weighted by likeliness of conseequences coming aboutSubjective norms – belief about others opnions and motivations – if you think everyone will look badly on you, you may be more inclined to change your behaviourPerceived control – indivdiual belief on amount of contrl they have on their own behaviourThe main advantage of this theory is it allows us to distinguish health behaviours in different populations. For example, take smoking…Group A say that they don’t want to quit smoking because they believe the benefits of it as a stress relief is > the risk. Conversely, Group B, say they don’t want to quit smoking because they don’t believe they can i.e. they have low control.However, people do not always do what they intend, particularly with regards to habits or addiction. Also, the actual control is different to perceived control which results in failure to have behavioural change e.g. quit smoking and thus failure to seek help.
This occurs when one holds two cognitive beliefs that are not psychologically compataible feeling of dissonance. For example as you can see above…
Acute Grief – 6 weeksLong term – 3 – 12 months
Neurotic patients candistinguish reality from fantasy.
The underlying assumption of this model is that mental illnesses resemble physical illnesses and can therefore be diagnosed and treated in a similar way. Just as physical illnesses are caused by disease producing germs, genetic factors, biochemical imbalances or changes to the nervous system, it is assumed that this is also true of mental illnesses. Because it assumes that mental disorders arise from such physical causes, the medical model is therefore a biological model.
This model is interested in how childhood relationships and experiences affect future mental health. The core assumption of this approach is that the roots of mental disorders are psychological. They lie in the unconscious mind and are the result of failure of defence mechanisms to protect the self.
Behaviourists have a similar view to Psychodynamic model in that they believe that our actions are largely determined by our experiences in life. However, unlike the Psychodynamic model, they see abnormal behaviour as a learned respnse (through conditioning) and not as a result of an unconscious process. They argue that maladaptive learning can be treated by changing the environment so that un-learning can take place.
From this theory we have gained uses of a number of behavioural therapies which have a high success rate. However, opponents to this theory argue that the model provides a limited view of the causes of mental illness and does not explain the evidence relating to genetic predispositions to mental illness.
This is an outgrowth and a reaciton to the behaviourist approach. The basic assumption of the cognitive approach is that it understands mental disorder as a being the reuslt of an error in thinking. Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder. This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT). CBT aims to identify and correct ‘errors’ in thinking. In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past.
If data is normally distrbuted it means that 65% of all measurements fall within 1 Standard Deviation of the mean and 95% of all measurements fall within 2 standard deviations of the mean. This is called the 95% central reference range.
Small SE narrow spread all sample means close to the true meanLarge SE wide spread some sample means are far from the true mean.Therefore standard error is a measure of precision for the sample mean.
Therefore if it is a measure of the accuracy of sample estimate is a narrow or wide CI more precise?
If 0 lies in it – not statistical signifncaIf 1 lies in it – not statsitical significant
