2. Screening
• Definition: “the identification of unrecognised disease or
defect by the application of tests, examinations or other
procedures which can be applied rapidly.”
• Number of types
• Mass screening
• Selective screening
• Opportunistic screening
• Multiphasic screening
10. Ethical Practice
• What is ethics?
• Duty
• Utility
• Rights
• Virtue
• Ethical principles
• Moral perception
• Moral reasoning
• Moral action
11. Consent
• Definition: “a volountary, and uncoerced decision made by a
sufficiently competent or autonomous person, on the basis of
adequate information and deliberation to accept rather than
reject a proposed course of action”
• Which situations do not require consent?
12. The competency criteria
• A patient must:
• Understand the relevant information
• Retain that information
• Weigh up the information to make a decision
• Communicate that decision
Can a 15 year old consent to treatment in the absence of parental
consent?
13. Negligence
• Must be a harm
• Must be a duty of care
• Must be a breach of duty of care
• Breach must have led to the harm
14. The information criteria
• To avoid the charge of battery
• Health care professionals only need to inform the patient in
“broad terms” about the nature of the procedure
• To avoid the charge of negligence
• A doctor is not negligent if he has acted in accordance with a
practice accepted as proper by a responsible body of medical
men skilled in that particular art [Bolam]
• If there is significant risk which would affect the judgement of a
reasonable patient, then in the normal course it is the
responsibility of the doctor to inform the patient of that
significant risk [Bolitho]
15. Bolam test
• Mr. Bolam was a patient undergoing electro-convulsive
therapy.
• He was not given any muscle relaxant, and his body was not
restrained during the procedure
• He flailed about violently before the procedure was stopped
and suffered serious injuries.
• He sued the hospital on the basis of negligence.
• Was there any negligence in this case?
16. Bolitho test
• Mr. Bolitho’s son was admitted to hospital for respiratory
difficulties under the care of Doctor H.
• Doctor H did not see the patient when the nurse called her,
and on the second occasion, the doctor delegated the care to
her junior, Doctor R.
• This doctor also did not see Mr. Bolitho’s son.
• This led to further complications in the patient resulting in
severe brain damage from which he died.
• However, this doctor found an expert who testified that
intubating of this child would not have made a difference.
17. Confidentiality
• Remember the wise words of Hippocrates:
• “that what I may see or hear in the course of
treatment or even outside the treatment in regard to
the lives of persons which is not fitting to be spoken, I
will keep inviolably secret”
• However confidentiality is relative:
• There are situations where a doctor is obliged not to breach
confidentiality
• There are situations where a doctor is allowed to breach
confidentiality at her discretion
• There are situations where a doctor is obliged to breach
confidentiality
18. No breach allowed
• Doctors are not allowed to breach confidentiality (unless the
patient consents) for
• Insurance companies
• Casual breaches (doctor’ family, friends or partner)
• To prevent / detect a minor crime
19. Breach allowed but not required in
law
• Sharing of information with other healthcare professionals
• Patient is a threat to themselves
• Patient who continues to drive when not medically fit
• Detection / prevention of serious crime
20. Breach required
• Situations where a doctor is obliged to breach confidentiality
• Misuse of Drugs Act (1971)
• Known or suspected drug addicts must be noted to the Home Office
• Public Health Regulations (1988)
• Certain infectious disease must be notified to health authorities
• Prevention of Terrorism Act (2000)
• Any person with information that might prevent an act of terrorism
must report it to the police
Medical students have same standard of confidentiality as
qualified doctors
22. Components of
Professionalism
• Composed of a doctor’s
• Relationship with knowledge
• Relationship with colleagues
• Relationship with patients
• Relationship with society
• Relationship with self.
23. 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?
24. General Medical Council
• The primary statutory purpose of the GMC is:
• “to protect, promote and maintain the health and safety of the
public by ensuring proper standards in the practice of medicine”
The Medical Act (1983) gives the GMC its five main functions of:
25. The GMC and US
• The GMC sets the knowledge, skills and behaviors that
medical students should learn at UK medical schools.
• The GMC also sets standards for teaching, learning and
assessment.
27. Decision making
• “selecting health services that increase the chance of valued
outcomes and that minimise the chances of undesired
consequences according to the best scientific evidence”
• Principles to consider when making a decision about patient
care
• Timing of situation
• Seriousness
• Complexity
• Consequence of intervention
• Availability of evidence
28. Doctors must work in
partnership with patients
• All decisions that are made should involve:
• The doctor listening to the patient and respecting their views
about health
• Discussion of the patients diagnosis, prognosis, treatment and
care
• Share information that patient needs to make decisions
• Respect the patient’s decision.
29. Exchange of information
• Patient’s needs and priorities
• Patient’s level of knowledge and understanding (of current
condition)
• The nature of the patients condition
• The complexity of treatment
31. Communicating numerical
data
• A woman is told her risk of developing breast cancer is 0.8%.
• How would you explain this to a patient?
• Mammogram screening reduces mortality from breast cancer
by 25%.
32. Information therapy
• “The right information for the right patient at the right time as
part of the process of care”
36. Errors and mistakes
• Rarely due to poor performance
• Generally due to systemic problem
• Therefore avoid blame culture and focus on systemic
improvement.
38. Notes and Records
• Notes
• Legal sub-heading in proceedings
• Good notes are ones: “that enable you to recall a consultation
without referring to any other source”.
• Prescriptions
• Person who signed is legally responsible if they sign the
prescription, even on the advice of another.
39. Important Acts
• Health Act (1998)
• Working in the NHS must provide a statutory level of quality and
the Clinical governance is responsible for monitoring clinical
performance and ensuring competence
• Public Interest disclosure Act (1998)
• Protection of whistleblowers from dismissal / victimisation
41. The ethics of distribution
• Decisions
• Macroeconomy
• Midieconomy
• Minieconomy
• Resources
• The economical problem: “how do we satisfy unlimited wants
with limited resources”?
• Distribution must be fair
42. Veil of ignorance
• What does it actually mean?
• Concept put forward by John Rawls
44. Example of QALY
• Intervention A would lead to two more years of perfect health
at a cost of £5000 over the two years
• Intervention B would increase quality of health from 0.7 –
0.99 for 10 years at a cost of £10000
• Therefore in A it costs £2500 per QALY
• In B it costs £3448 per QALY
45. Approach to rationing
• Personal responsibility
• Social worth
• Democracy
• Pluralism
Try to mention Article 2 of the Human Right Act (1998): “the
right to live”
47. Pain
• “It is an unpleasant sensory and emotional experience
resulting from actual or potential tissue damage”.
• Acute
• Chronic
• What is the difference between Pain threshold and pain
tolerance?
48. Theories of pain
• Specificity theory
• Extent of pain is proportional to extent of tissue damage
• Specific stimulus specific receptors brain pain perception
• Pattern theory
• Opponent to specificity theory
• Pain results from patterns in neural transmission rather than a
single unique pathway to the brain
• Gate control
• Emphasises the dynamic role of the brain in which there is
psychological interaction in pain processing.
• Example of things which will open and close the gate?
Problems with theories 1 and 2?
49. Multidimensional Model of
Pain
• Combination of all theories
• Has four components
• Detection
• Perception
• Emotions
• Behaviour
50. Problem with chronic pain
• Risk factors for Acute pain Chronic pain?
• How do we go from acute pain to chronic pain?
• Stage 1 – initial fear and anxiety
• Stage 2 – depression and low self esteem
• Stage 3 – acceptance of sick role
• All of this results in lower quality of life
53. Definitions
• Active euthanasia
• Physician Assisted Suicide
• Passive euthanasia
• Suicide
• Assisted suicide
• Which ones are legal?
54. Acts and Omissions
• Suppose I wish you dead, if I act to bring about your death I
am a murderer, but if I happily discover you in danger of
death, and fail to act to save you, I am not acting, and
therefore, according to the doctrine, not a murderer.
• But if an omission and act lead to the same consequence is
there a moral distinction?
• Does the morality lie in the behaviour or the consequence?
55. Doctrine of Double Effect
• Intentional killing is classed as murder
• Criminal law classes intention as the performing of an act
which is virtually certain to cause death
• Medical law distinguishes between intention and foresight
• Benefits of treatment are intended, side-effects are foreseen
but not intended
56. Debby Purdy
• Patient with progressive MS who went to court to seek
reassurance that her husband would not be prosecuted if he
accompanied her to a dignitas clinic.
• The conclusion of that case was that it highlighted the
ambiguity of the prosecution guidance and variable response
of the Crown Prosecution Service (CPS) in the past.
57. DPP Guidance
• In favour of prosecution
• Under 18
• Question of capacity
• Unsettled on decision to die
• Grounds for death has possibility of gain
• Evidence of coercion
• Against prosecution
• Clear, settled and informed decision to die
• Consistent about dying
• No evidence of coercion
• Evidence that suspect motivated purely by compassion
58. A view from across the north
sea
• Which country decriminalised volountary euthanasia in April
2001?
• Legal framework
• Doctor convinced that the request is volountary
• Patient is in unbearable suffering
• Doctor must discuss with patient all the options
• Doctor and Patient should conclude there is no reasonable
alternative
59. Safeguards
• Doctor must consult with at least one independent physician
who will examine the patient
• All cases must be reported to the public committee comprised
of a doctor, lawyer and ethics expert
• Those who do not follow the safeguards are punishable by law
60. Psychology of perception and
misperception
• What is the difference between sensation and perception?
61. Theories of perception
• Bottom up
• Perception is a building process that starts with the information
presented to the sensory organ
• No use of prior knowledge
• Top down
• Sensory information is insufficient to interpret a stimulus.
• Interpretation is based on our knowledge and expectation of the
world.
• Integration of prior knowledge
68. Benefits of Psychological
Intervention
• Benefits
• Equally or more effective than drug therapies
• Pre surgical psychological interventions can reduce intervention
• Psychological intervention can help with things like addiction
• Make patients cope better with treatment
• Can help control high blood pressure (emotional state)
69. Behavioural Mechanisms
• Relaxation
• Progressive muscle relaxation
• Operant conditioning
• Modification of volountary behaviour by consequence
• Systemic desensitisation
• Eliminate fears by substituting a response that is incompatible
with anxiety
• Biofeedback
• Target physiological measures of stress
70. Stress Inoculation Training
• Conceptualisation
• Understanding nature of stress and stress response
• Skills rehearsal
• Relaxation techniques, social support
• Application
• Practice the coping skill with imagined stress situation
71. Cognitive Therapy
• Alteration of maladaptive cognitions
• Introduction of adaptive cognitions
• There are two types
• Rational emotive therapy (RET)
• Cognitive behavioural therapy (CBT)
73. Rational emotive therapy
(RET)
• A – ctivating event
• B – eliefs in response to A
• C – onsequence of B (emotions and behaviours)
• D – ispute the irrational belief
• E – ffect of therapy
75. Stress Management
• Aims to:
• Understand the cause of the stress
• Develop behavioural skills to cope
• Develop appropriate attitudes
76. Critical Incident Stress
Debriefing
• Steps
• Introduction – Hi I am…
• Facts – This happened to me…
• Thoughts – In the moment, I did not know what was going on
• Emotions – I feel terrible…
• Normalisation – It was a life or death situation
• Future planning / coping – Don’t blame yourself
• Disengagement – Carry on your life
77. Brief Interventions
• F – eedback about risk of personal harm
• R – esponsibility to make change
• A – dvice
• M – enu of alternative strategies
• E – mpathetic interview style
• S – elf efficacy
78. Race and Ethnicity in Health and
Illness
• All definitions and not going to lie, it’s just boring if I sit and
read out.
79. Social Inequalities in Health
• Social stratification – be aware.
• Effect of social stratification on different social grous
80. Socioeconomic health model
• Social inequalities are based on differences in risk factors
across the whole life.
• Not just in adulthood, childhood or just before catching an
illness.
• The exposure is simply an accumulation of the risks
throughout life.
81. Measuring social class
• Registrar-General’s Occupational Classification
• National Statistics Socio-Economical Classification
82. Trends in health inequality
• 1931 – 1991 the gap between no of deaths / 10,000 in Class 1
and 5 increased greatly
• From 1972-2005 life expectancy rose for everyone, but again,
the gap between Class 1 and 5 increased
83. In light of this…
• Black Report
• Always Say Brup Mate
• Artefact
• Social selection
• Behavioural factors
• Material circumstances
• Acheson Report
• Medicine Is Incredibly Pants
• Medical care
• In workplace
• In social structure
• Preventative approach
84. Public Health Target
• White Paper (1999)
• Government set out to reduce health inequality
• NHS Plan
• Narrow health gap
• Department of Health
• Target reduction in health inequality
85. Recent Changes
• There was an improvement in absolute mortality across all
socio-economic classes between 2001-2008
• However, looking at relative changes highlighted an increase in
mortality rate for the least advantaged.
86. Example
• 2001
• Professional has 100 deaths per 100,000 years
• Manual worker has 500 deaths per 100,000 years
• 2008
• Professional has 75 deaths per 100,000 years
• Manual worker has 450 deaths per 100,000 years
Work out the relative risk of dying if you were a manual worker in
2001 and 2008.
88. Definitions
• Loss
• State of being deprived of, or being without someone which one
has had.
• Grief
• Pain and suffering experienced after a loss.
• Mourning
• Period in which signs of grief are visible and these are culturally
specific
• Bereavement
• Process of losing a close relationship
89. Children’s grief
• Do not underestimate how much children know and
understand
• Adults are biggest barrier to children healing
90. Acute and Long term Grief
• Acute
• Disbelief, Anger, Agitation
• Crying, Hallucinations and Images of lost person
• Long term
• Social withdrawal and sleeplessness
• Anxiety, mood changes and appetite changes
91. Theories of Grief
• D – isbelief
• A - nger
• B - argaining
• D - epression
• A – cceptance
Pathological grief is either abnormally severe or abnormally
prolonged (> 6 months)
92. Task of mourning
• Accept reality of loss
• Adapt to environment in which deceased is missing
• Work through pain of grief
• Emotionally relocate deceased and move on
93. Risk factors for pathological
grief
• Circumstances
• Individual circumstances
• Initial reaction
• Quality of lost relationship
• Disenfranchised grief
94. Physical activity
• Physical activity: “this is any bodily movement produced by
skeletal muscle that leads to expenditure of energy”.
• Structural - sport
• Lifestyle - gardening
95. Recommendation
• Adults
• They are recommended to perform 30 minutes of at least
moderate intensity exercise five times a week
• Children
• They are recommended to perform 60 minutes of at least
moderate intensity exercise seven times a week.
Statistically men are more likely to reach the national guidelines
on exercise than women, and boys are more likely to reach it than
girls.
96. Benefits of exercise
• Cardiovascular
• Reduced risk of CV disease and low BP
• Psychological
• Reduced risk of depression and increased self esteem
• Other
• Increased immunity and bone mineralisation
97. Psychological benefits of
exercise
• Distraction
• Opiates
• Stress-management
Which factors determine amount of physical activity?
How do we stay motivated?
Screening tests aim to sort out people who appear well and have a disease compared to those who probably do not. However, a screening test is not intended to be diagnostic. This is very important…all persons with abnormalities on the screening test will be referred for diagnostic examination.Mass screening – application of screening tests to unselected populations (cervical smear and mammography…I know your going to say that strictly speaking they are technically a selected population because only women of certain age are invited for such screening but other potential risk factors are not used to decide who is / is not invited for screening so still classed as mass.Selective screening – involves only high risk groups (those with family history of a disease or screening for consequences of diseae e.g. screening diabetic patients for diabetic retinopathy)Opportunistic screening – case finding screening involves screening patients who are attending health services with an unrelated compliant e.g. measurement of blood pressure in a patient presenting with a sprained ankle. It can be applied to the whole population.Multiphasic screening – general health check is the simultaneous application of several screening tests (heel prick blood samples from nenates are used to screen for phenylketonuria and hypothyroidism)
The performance of a screening test (or indeed a new diagnostic test) can be compared with a reference test or gold standard test to define the new test’s characteristics. The ffollowing 2x2 is table is helpful.False positive error – represent false alarms in screening and may be due to confusion between the disease of interest and other diseases with a similar presentation.False negative errors represent missed cases and relate to the problems of detection of mild or early cases of disease.The folloiwng measures of screening performance can be derived from the 2x2 table. They are usually expressed as percentages.
Sensitivity / detection rarte measures the proportion of subjects with disease who test positive on the screening test [a / (a+c)]False positive rate: the proportion of subjects without disease who test positive on the screening test [b / (b+d) ] which is the same as 1 – specificitySpecificity: the proportion of subjects without the disease who test negative on screening test [d / b+d ]. This is the same as 100% - false positive rate.Odds of being affected given a positive result (OAPR) is the ratio of the number of subjects with disease to those without disease among those with poissitive test results [a / (a+b) Positive predictive value: the proportion of subjects with postiive test results who actually have the disease [ a / a+b) ] Negative predicted value: the proportion of subjects with negative test results who do not have the disease [d / c+d]
Diabetes is common but there are not enough opthalmologists to routinely screen all diabetis for eye diseases that may be sight threatening. A proposed approach is to screen for retinopathy in the community (at local opticians) using a single view photograph of the retina taken by a technician. The photograph can then be assessed for specific retinal changes associated with diabetic retinoathy. Those showing signs of retinopathy would be classified as screen positive and referred to an opthalmologist. A small study evalutaed this screening protocol in 340 patients with diabetes. All underwent retinal photograhy by a technician. The photographs were then graded by an optometrist. All 340 patients were also examined by an opthalmologist for the presence of retinopathy.Retinal examination is our gold standard (reference standard). However, we wish to compare how well the screening test results (grading of photograph) agree with the gold standard. The optometrist classified 58 patients as screen positive based on grading of the retinal photographs i.e. requiring referral to the opthalmologist. On review by the ophthalmologist, 57 of these patients actually had retinopathy and another 16 patients had retinopathy that the optometrist had classified as screen negativeTrue Positive – 57 – these patients have retinopathy and are positive on screening test.False Positive – 11 – these patients do not have retinopathy and are positive on screening testFalse negative – 16 – these patients have retinopathy and are negative on screening testTrue negative – 266 – these patients do not have retinopathy and are negative on screening test.
So this is what you all said…Now you want to convert these numbers into percentages soDetection rate = 57/73 = 78False negative rate = 16/73 = 22%False positive rate = 1/267 = 0.37%Specificity = 266/267 = 99.6%Therefore this means that there is a 78% chance that diabetics with retinopathy will test positive on screening test.It also means that there is a 0.37% chance that diabetics without retinopathy will test positive on screening test.There is a 22% chance that diabetics with retinopathy will test negative on screening test.There is a 99.6% chance that diabetics without retinopathy will test negative on screen test.
The duties of a healthcare professional fits in to three categories which all overla:Legal duty – by law we are expected to follow guidelines of say the Mental Capacity ActMoral duty – doing what is right…e.g. respecting patient autonomyProfesional duty – doing what is right as governed in the GMC guidelines.
What is ethics? To be fair, it is just doing the right thing but for exams you have to be all fancy and right key words they want to hear. These include; duties (what is expected), utility (having the right attributes and skills), rights (no forcing), virtue (wanting the best outcome).There are three main ethical principles in medicineMoral perception – this involves looking at ethical dimensions not apparent at first sight i.e. look at each individual patient as an individual as opposed to a patient so make sure you always ask the right questions.Moral reasoning – this includes four main points: Autonomy – respect the decision making ability of the patiet. This is important as it promotoes happiness and well being as patients generally know what will make them happy.Beneficience – always act in a way to benefit the patient – this is as simple as good bedside manner, competence and appropriate knowledge.Non-malifieince – harm from treatment should never be greater then benefit…im not going to say the obvious things which is you should never go out to harm a patient, because that’s just retarded.The final aspect is moral action which is what you should do is what you must set out to do.
No consent is required if treatment is necesiry i.e. treatment si best interest of partient and patient is not competent to make their own consent or in an emergency e.g. unconscious and requires blood tranfusion.
Yes… if they are Gilick competent:“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.”For example take the xeample of a 15 year old girl wanting contraception.."...a doctor could proceed to give advice and treatment provided he is satisfied in the following criteria:1) that the girl (although under the age of 16 years of age) will understand his advice;2) that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;3) that she is very likely to continue having sexual intercourse with or without contraceptive treatment;4) that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;5) that her best interests require him to give her contraceptive advice, treatment or both without the parental consent."
The judgement ruled that Doctor P, because much medical opinion was opposed to the use of relaxant drugs, and manual restraint can increase the risk of fracture, and that it was not common practice to warn of risk of treatment (when it is small) unless asked. Therefore what is common practice in a particular profession is relevant to the standard of care expected.Therefore a person is only falling below standard of care, if he fails to do what a resonable person in the same profession would do in the circumstance.
Therefore according to the Bolam test, this doctor was not negligent. However,, this ruling meant that a doctor accused of medical negligence needed only to find an expert who would testify to having done the same thing. Over the year, the Bolam test sustained significant criticism for being overly reliant on medical testimony.The decision in Bolitho v City and Hackney Health Authority (1997) created a modification to the ruling in Bolam. A Lord Browne-Wilkinson gave the following two statements, which somewhat restrict the boundaries of the Bolam test:1. "The court should not accept a defence argument as being 'reasonable', 'respectable' or 'responsible' without first assessing whether such opinion is susceptible to logical analysis.2. "However, where there is a body of medical opinion which represents itself as 'reasonable', 'responsible' or 'respectable' it will be rare for the court to be able to hold such opinion to be other than represented.This Bolitho ruling means that testimony for the medical professional who is alleged to have carried out the medical negligence can be found to be unreasonable, although this will only happen in a very small number of cases.
This is a definition from the Royal College of Physciians Working Party.
number of components that emphasises the mutuality of professionalism i.e. that professional behaviour is about the quality of relationships that a medical practitioner has with others – including oneself. Therefore professionliam is composed of…This highlights the importance of normal behaviour outside of uni because part of our professionalism as a medical student is judged by our relationship with society
Therefore any doctor who is alleged to have demonstrated unproffesional behaviour can be referred to the GMC, to be assessed under the fitness to practice procedures. In light of this latter function, the GMC produces guidance on what constitutes Good Medical PracticeThis is because whilst medical students are restricted in the clinical work they are permitted to undertake, they must still act responsibly and professionally as patients regard them with the same responsibilites as a doctor and also with the same knowledge. In addition, medical students must be aware that their behaviiour outside their course will have an effect on their fitness to practice as behaviour should justify why society puts faith in doctors. If you get caught with alcohol poisoning twice in Georges A&E they will refer to Georges registry.
keeping up-to-date registers of qualified doctors licensing doctors fostering good medical practice promoting high standards of medical education dealing firmly and fairly with doctors whose fitness to practice is in doubt.
These are set out in issues of Tomorrow’s doctors. However, it is important to note that the GMC has no direct statuatory role in matters of student health and conduct, but it has a strong interest in it…
Timing of situation – acute illness versus chronicSeriousness of the sitautionComplexitiy of the situationConsequence of intervention – harm v benefitAvailability of evidence – to make the best decision
The exchange of information between a doctor and their patient is central to good decision making.Doctors should tailor their approach to discussions with patients according to:The nature of the patients condition – e.g. chest infection versus lung cancer…the doctor shuold set a different tone, use different words / empathy / reassurance etc.The complexity of treatemnt – affects how much information you need to give regardnig treatment e.g. chest infection – just know your giving antibiotics, don’t need to know about mechanism of action whereas in cancer treatemnt, patient concerned about ramifications of chemotherapy e.g. will I lose my hair etc?Doctors should not make assumptions about the information a patient might want/need, the factors a patient might deem significant or their level of knowledge/understanding about what is proposed. Consultations should be patient centred with adequate time for the patient to discuss their concerns and for the doctor to explain treatment, prognosis etc. Doctors should be honest and use language that the patient can understand and aim to build a trusting relationship. They should have a non-directive manner as the decision rests on the patient.
When giving patients information, we need to make sure that the purpose of the test or examination or whatever is clear. For example, a preganant women going for a scan may think there is somtehing more serious wrong with her child if she is not appropriately informed of the purpose of the test e.g. it could just be a routine test such as a nuchal translucency at 11 weeks…it can cause unnecessary worry or stress.Give information to patients when they need it. Overloading is not good and neither is a lack of information. Results of tests should be explained as information without explanation can cause unnecessary anxiety in patients.We should be aware that numeric data as well as screening results in the form of probabilities are hard for patients to understand, so this should be explained in an easily accessible way to them.
When communicating numerical data, we should explain it to the patient in terms of absolute risk, not relative risk. It means that for every 1000 women LIKE HER, 8 will develop breast cancer. If I said this to a patient shed b like wow that’s a very big reduction..right?However, in reality…. , actually translates to 3/1000 women dying from breast cancer instead of 4/1000. Screening saves 1 life out of every 1000.
This is common sense but might be worth learning that definition.e.g. when giving information remember:Patients need to be aware of the consequences of treatment and no treatmentWith complex information, it may need to be clarified and numeric risks/data may need explanation
The best example of this is how doctors are overworked because of lack of doctors and cut in NHS funding etc.It is imporatnt to be open and report the problem. From here, its important to analyse the problem and what went wrong. From doing so one can look at ways to improve. Therefore if we learn from our mistakes we can avoid the same ones happening in the future.
Unconscious incompetence – a person neither understands or knows how to do something, nor recognises the deficitConscious incompetence – a person does not understand or know how to do something, but is aware of his deficitConscious competence – a person understands or knows how to do something but to demonstrate his knowledge / skill requires a great deal of concentrationUnconscious competence – a person is so experienced at performing the task that it is second nature to him and requires no great deal of concentration.
All notes should be: legible, use appropriate abberviations, don’t diguise or alter notes, no humerous or personal comments and write as if each patient were to seek access.Prescriptions should have the correct name and drug, no absolute / relative contra-indications, correct dosage, and arrange appropriate follow-up.
Macroeconomy – percentage of total income spent on healthcare…anyone know how much that is atm? The NHS budget is 100 billion which is 15% of taxpayers money.Midieconomy – allocation of healthcare budgetMinieconomy – how clinicians are paid etc.In healthcare the allocation of resources involves ethical considerations such as fairness, respect of patient autonomy (I want to have this operation BUT), respond to individual needs versus balance of benefitting the population. However, if resourecs are limited who gets what?The younger patient who is likely to survive longer?The parent with a dependant child?Treating greater number rather than fewer with greater needTreatemnt based on quality of life, or extension of lifeTreatemnt using established treatemnt rather than experimental and more expensive treatment.Be aware that resources are not just financial, they include personnel, bed space, energy and time.
Anyone know what this means?John Rawls put forward the concept of the veil of ignorance as a theory of justice. In this sitatuoin, there are a range of societies to live in, but the indivdiual is unaware of his status, ability, wealth, ethnicity etc. in any of the socieities. Rawls believse that most rationale people would choose the society in which the disadvantaged would be as well of as possible, so that if they were disadvantaged they would get good treatment.
Free market economics based on demand and supply, the more demand, the more expensive the supply with no government intervention.But? People have insuficcient information to make decisions wisely and likely to exclude the poor from healthcareNeed – allocation of resourecs on the basis of need..but this is too simplistic, how do you define need? Healthwise? Family wise? Lottery – allocation of resourvecs on the basis of a lottery as everyone is treated equally, no discrimination but no emphasis of needConsequentalism and QALY – allocation of resources on the basis of maximisation of utility and this requires cost-effective calculation on value of health e.g. 1 year of perfect health = 1 QALY, 2 years of half perfect health = 1 QALY…
Cost / number of perfect yearsIntervention B = 0.29 a QALY x 10 = 2.910000 / 2.9 = 3448But only takes account of health…what about personal responbiility? Or who needs what operation more urgently?
Personal responsibility – allocate resourcse on maximisation of responsibility i.e. where people are responsible for their actions so why subsidise their mistakes? It should act as an inecntive for people to behave wisely. But – judgemental…harsh?...people make mistakes and become addicted..Social worth – allocate resourceso n the basis of past, current and present contribution to society…those who put something into society deserve the most back. But this is an example of prejudice and discrimination, and takes no account of need, or circumstances to why they may not have contributed to society etc.Democracy – allocation of resourecs on the basis of democratic decision making – peopple in government lack enough information on how to distribute resources…often results in arguments and they have proven to make bizzarre choices in the past.Pluralism – allocation of resources based on a mixture of the above choices…most reasonable approach, but how do you weigh up each value?The article 2 – right to live says this act is important when understanding that while the state cannot be expected to fund every treatment, it must act responsily in allocation of resourecs, also try to remember Article 14 which is the prohibition of discrimination in allocation of resources.
Therefore pain is described as personal and subjectiveAcute – brief and occurs after injury / infectionChronic – Persists long after injury has healed and cause is often a mysteryPain threshold is the minimum amount of stimulation that evokes a report of pain whereas a pain tolerance is the time it takes for continuous stimuus can be endured for or the maximum tolerated stimulus intensity
Specificity theory – Described by Descrates (1664) in which the extent of the pain is directly proportional to the extent of tissue damage. Specific stimulus activates specific receptors which travel to the brain where the pain is perceived. The extent of nociceptiveactiavtion will determine the extent of perceived pain.Pattern theory – this was a major opponent to the specificity theory as it believed that pain was as a result of patterns in neural transmission rather than a single pathway unique to pain. The brain has no role morethan being a passive receiver of informationGate control theory – this emphasises the dynamic role of the brain in which there is no psychological interaction in pain processing. Therefore explains why severe pain can be experienced without organic cause.The problems with theorieis one and two is that it does not account for pain without tissue damage, tissue damage without pain, or differences in pain perception. However, with the Gate Control Theory there is a gating mechanism in the dorsal horn which modulates the passage of pain information from the periphery to the central nervous system. This mechanism involves large diameter and small diameter fibres.Open gate – anxiety, depression, tension, focus on painClose gate – happiness, optimism, coping mechanisms, distraction, and relaxation.
Detection – neuronal detection of noxious stimuliPerception – throbbing / stabbing sensationEmotion – fear / tensionBehavioural – limping or grimacing
Risk factors are poor coping strategies, slow recovery (individual, or type of treatment e.g. hospitals tend to promote better recovery like by increasing mobility, low mood / depressionThe one thing I will say is that the depression that is associated with chronic pain is different to the clinical depresion drawn from mental health. The somatic symptoms are frequent e.g. sleep disturbance but the symptoms corresponding to negative self evaluation are less frequent.
Simple is a scale of 1 – 10, multidimensional is the McGill Pain Questionnaire, and computerised is like visual animation to measure different pain sensations which is used for language barriers. Problem is that they are subject to bias and inaccuracies.Verbal – moans, groans, crying, Physical – limping or rubbing of injury, postural – guarding. Problem is that the presence of the observor can change behaviour displayed and different observors may interpret observors in different ways e.g. do you interpret a deep breath as a deep breath or a sigh?EMG measures muscle tension which is a sign of anxiety which in turn can be related to pain. Therefore muscle tension is either due to pain or the anxiety which makes interpretation difficult.
Active euthanasia –occurs when the medical professionals, or another person, deliberately do something that causes the patient to die.Physciian assisted suicide – a sub set of active euthanasiaPassive euthanasia – an omission that leads to deathSuicide – the taking of ones own lifeAssisted suicide – contributing to anothers death by actionPAS, AE and AS are currently illegal in the UK while PE and suicide are legalIf your asked to make an argument about Active and Passive euthanasia always think:Some people think that it is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to kill a patient by a deliberate act.But some people think this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment.Take someone who is on a ventilator; he could either die with lethal injection or switchinig off the ventilator, both are an act which will lead to death so techniically there is no real difference between active and passive euthanasia since they both have the same result?
This is one of the classic ideas in ethics. It says that there is a moral difference between carrying out an action, and merely omitting to carry out an action.
For example, a patient with a cerebral tumour is sedated heavily with Midazolam whose primary effect is to act an analgesic and alleviate patient distress. The second effect is that it shortens the patients life. The 1st effect is intended, but the second effect is foreseen but not intended and therefore there is no crime.However, in the situation with Dr. Cox and Lilian Boyles, the administartion of Potassium Chloride has no beneficial effect. Therefore charged with attempted murder because the intention of administration was primarily to cause death.
The case went on to the House of Lords who allowed Purdy’s appeal but required the Director of Public Prosecutions to issue guidelines setting out circumstasnces under which prosecution is essential. Therefore there was no change in the law, or support of change, merely a statement that the UK is uncertain and clarity is required.
Netherlands but they did so together with a legal framework which would end uncertaintyPatient in unbearable suffering – nor purely a terminal illnessHowever whilst children aged 12-16 can appeal for euthanasia, request can only be granted with parental permission.Also – children aged 16-17 can appeal for euthanasia without parental consent but parnts should be involved in the discussion.
Sensation is the detection of the presence of stimuli by sensory organ whereas perception is the recognition and interpretation of a stimulus. It is trhough perception that we develop a knowledge and understanding of the world.
Bottom up – recognition and interpretation of a stimuli is determined by the information presented to the sensory organ. From the basic information, we build a meaningful representation of the scene e.g. a square is perceived as a square because it has four sides of equal length, at rigt angles to each other and by matching these factors with stored information, perception is used to objectively identify squares in the environment.Top down – this system argues that sensory information is insufficient to interpret or explain recognition of a stimuil in the environment. It belives that our recognition and interpretation is an active process by our knowledge and expectation of the world e.g. look at an optical illusion and spot the hidden image, in future you use your previous knowledge, expectation etc. to immediately recognise the image.
Phenomenological approach is descriptive i.e. see what you see.Psychophysical method – quantitative relationship between a stimulus and perception. Absolute threshold is the minimum intensity required for the sense to perceive the stimulus at least half of the time with regards to vision, taste, smell, hearing and touch.
Remember that perception is, to a large degree, our interpretation of the sensory stimuli, its unsurprising that we experience stimuli in different waysPersonality – people with different personalities behave differently in different sitautions e.g. introverts have better visual perception and better ability at performing perceptual task than extrovertsEmotion – Anxiety – enhanced perception of feared situation or Depression – increased perception of painMotivation – perceive information relate to their needs i.e. over-estimate benefits of treatmentPerceptual set – context, expectation and past history will influence the interpretation of perceptual information we receive e.g. we hear what we expect so say you heard there is burglers in the area, a noise late at night might make you think there is a burglar, whereas if you did not know about the burglaries you will say it’s a pipe.Physiology – fluent aphasia or agnosia (inability to recognise shapes etc.)AttentionDemography – e.g. old person walking down road and see person with hood up, Id get scared..whereas say I am Bruce Lee and I see little chav, I will think nothing of it, same with gender, and culture.
The goal of any therapeutic intervention is to bring about some sort of change in belief, behaviour or mood. They are important because of the mind body link and that 40% of disability is a result of mental illness.
These can be split into four main techniques.Operant conditioning – an example of this is selective reinforecment. Positive behaviours will be rewarded whereas others will be ignored. This is an important method of modifying behaviour in children e.g. ignoring tantrumsSystemic desensitisation - atreatmentofphobias in which the patient while relaxed is exposed, oftenonlyinimagination, to progressively more frightening aspects ofthephobia.Biofeedback – record the physioloigcal measures of stress e.g. BP, HR and muscle tension. Then, teach the patients methods to reduce their readings e.g. deep breathing, muscle relaxants. Positive aspect of this technique is that patients see results immediately.
There are three components
This is an intervention that aims to alter the maladptive cognitions (beliefs) or introduce adaptive cognitions. It is based on the assumption that is not the event itself, but the beliefs and thoughts that are attached to the events that evoke an emotional / behavioural response. Therefore if we can modify that beliefs and thoughts associarted with this event we can eliminate the emotional and behavioural response
Arbitrary inference – conclusion in the absence of evidenceSelectiveabstractation – detail taken out of context and ignoring other imoprtant information in the situation e.g. if your girlfriend kissed another man but she did it during CPRPersonalisation – relating an event to oneself without basis for this connection e.g. friends go to McDonalds and don’t invite you, you immediately think that it is because they hate you and did it on purpose when in reality they just forgot and were hungry. This is an example of FOMO.
An individual is scared of cats because they hold the belief that everytime they see a cat, it will attack them. The consequence of this they turn around and go home everytime they see a cat which is obviously an irrational response. The aim of RET is to dispute the irrational belief and make them aware that cats will not always attack them. Therfore the effect of therapy is to restructure the belief system to discard irrational belief.
The stages are education, skills acquisition and maintenance.
The main targets of this are to change external cause of stress, individual response to stress, provide short/long term solutions and act as a preventative measure,
This is designed for emergency service workers to cope with acute traumatic event e.g. by meeting someone else who experienced the same trauma as you to normalise it.
An example is women who smokes…Feedback about personal risk of smokingResponbiility is on the indivdiual to changeGive advice on how to cut down, and resources availableMenu of alternative strategies to alter maladptive behaviour e.g. if you smoke because you are stressed, try different mtehods e.g. hypnotherapyEmpathetic interview style – don’t blame the patientSelf-efficacy – make the patient feel able to make the change themselves, set them a target.
The bulk of inequalities in human history results not from biological differences but from social differences that exist between individuals and social groups, and results from structured social divisions of a particular society at that given time – social stratification.The idea of socio economic class has been used by social scientists to investigate the effect of this stratification on the different social groups e.g. unequal life chances and differences in health outcomes.
Overall, the relative risk for disease is primarily associatied with the persons socio economic class.
Most common measure until 2000 was the Registrar General’s Occupational Classification (RGOC) which was based on relative status of occupation of a person. The new classification measures, National Statistic Socio Economic Classifications (NS SEC), are still based on occupation, but not assessed on level of skill. They are assessed on employment conditions and relations in the work environment.
The post war assumption was that the introduction of the welfare state would eradicate poverty and inequity. The aim to reduce mortality in the population was stressful, but on closer examination, the gap in death rates bewteen social classes was increased.
------------The Black Report examined the association between social class and health and it was found that the morbidity and mortality in the population was not randomly distributed amongst social classes.Artefact – health results from individual behaviourSocial selection – those with poor health are downwardly mobile Behavioural factors – look at class differferences in health belief..people more well off never get illMaterial circumstances – social differences in income, diet, or housing is important in social inequality of health It was concluded that the material circumstances were primary determinants of social inequality in health.--------------------------------As a result of the Black Report, the Acheson report in 1998 used the socioeconomic model of health to outline different layers relating to a person’s socioeconomic class that affect their health outcome and how these layers interact. It targeted different areas and recommended the following: - Medical care be given at the level of morbidity to prevent early death. -- Improvement of psychological conditions[Symbol] these can be targeted in the workplace - Interventions in social structure in the community to reduce socioeconomic inequalities The use of preventative approaches to change an individual’s risk.
The national health inequality targets to narrow the health gap in children and throughout life between socioeconomic groups and between the most deprived areas and rest of country.Department of Health outlines targets for reduction in health inequality:To reduce the mortality group between manual groups and rest of population by 10% by 2010, starting with children who were below 1 year old in 2001.To reduce the inequality between quintile of area of lowest life expectancy and rest of population by 10%.
For example, the highly qualified professionals have a risk of 100 deaths per 100,000 years whereas the manual worker has a risk of 500 deaths per 100,000 years in 2001.In 2008, this changed to 75 deaths per 100,000 years in professionals and 450 deaths per 100,000 years in manuals. Therefore the absolute number has changed from a difference of 400 to 375. However, in 2001, the manual workers are five times more likely to die than professionals whereas in 2008 they are six times more likely to die. Therefore if we look at absolute figures they are better off, whereas they are relatively worse off.
For example, the highly qualified professionals have a risk of 100 deaths per 100,000 years whereas the manual worker has a risk of 500 deaths per 100,000 years in 2001.In 2008, this changed to 75 deaths per 100,000 years in professionals and 450 deaths per 100,000 years in manuals. Therefore the absolute number has changed from a difference of 400 to 375. However, in 2001, the manual workers are five times more likely to die than professionals whereas in 2008 they are six times more likely to die. Therefore if we look at absolute figures they are better off, whereas they are relatively worse off.
Children often know and understand much more than we give them credit for and because of this, the biggest barrier to children healing is adults. Basically..children should be allowed to make a meaning of the situation as opposed to ‘fixing them’ i.e. take emotions and learn from them and not run from them.
Disbelief – Oh my God, I cant believe he is dead.Anger – how could he die and leave me here? In an angry voiceBargaining – I would do anything to get him backDepression – I cant eat or sleep without him being hereAcceptance – He is dead
Circcumstances of death e.g. violent / suddenIndividual circumstances – previous failure to copeInitial reaction – severe denial is often a precursor for patholoigcal griefQuality of lost relationship – clearly, the more attached you are, the harder it will be.Disenfranchised grief – relationship not recognised
There are a number of different types of excericse that include individual, group, organmisational and societal.Individual – labour intensive and flexibleGroup – good for morale but less flexibleOrganisational – wide impact, limited resourvecsSocietal – widest impact e.g. walk to school initiative
These include non smokers, male, an increase motivation for exercise, being young and an active lifestyle as a child.Goal setting (frequency, intensity, time, type), monitoring (diaries), contracts (membership) but the main barrier to exerise is illness, lack of motivation, poor peer group or lack of leisure centres.
