Foundations of Primary Care Flashcards
(156 cards)
1
Q
List 5 principles of person centred care
A
CRAPI 1) Choice and Empowerment 2) Respect 3) Access and Support 4) Patient involvement in health policy 5) Information
2
Q
What are the leading causes of death in men and women? overall?
A
men = cardiovascular disease women = dementia both = cardiovascular disease, lung cancer, stroke, dementia
3
Q
Define disability
A
one with physical, mental or sensory impairment which has a substantial adverse and long term (> 12 months) effect on ‘normal’ day to day activities.
4
Q
What are the three ways to define illness:
A
AEI 3)Actions - What actions they take in response to them. 1)Experience -what people experience when they are unwell 2)Interpret - How they interpret or define those symptoms
5
Q
What are the individual factors that can affect the impact of disability?
A
(the) SEA SPARES (you) Sex Education level Age Support network Personality Attitudes of family/community/society Resources available Early experience and attitudes Socioeconomic background
6
Q
Define ‘burden of treatment’
A
the impact of the “work of being a patient”on functioning and well-being. This work includes 1) medication management 2)self-monitoring 3) visits to the doctor 4) laboratory tests 5) lifestyle changes Coping with all these healthcare tasks requires a significant amount of time, effort, and cognitive work from patients and caregivers.
7
Q
Define biographical disruption
A
A long term condition leads to a loss of confidence in the body. There is then a loss of confidence in social interaction or self‐identity
8
Q
Define incidence
A
the number of new cases of a disease in a population in a specified period of time (water dripping IN the bath)
9
Q
Define Prevalence
A
the number of people in a population with a specific disease at a single point in time or in a defined period of time (existing cases/water already in bath)
10
Q
Define relative risk
A
the likelihood of an event (or developing a disease) relative to exposure (e.g. smokers have a higher risk of lung cancer vs non smokers)
11
Q
to explain the World Health Organisation (WHO) framework of body structure and function impairment, activity limitation and participation restrictions
A
BAP • Body structure and function impairment - is defined as abnormalities of structure, organ or system function (organ level) • Activity limitation - is defined as changed functional performance and activity by the individual (personal level) • Participation restrictions - is defined as the disadvantage experienced by the individual as a result of the impairments and disabilities (interaction at social and environmental level)
12
Q
Effects on other members of family/community of diability
A
Parents • Mother and/or father may not be able to combine work with the demands of caring for disabled child - financial implications for family • Guilt at having passed on the causative gene if genetic disorder • Psychological strain • Caring for disabled child may be detrimental to parent’s physical health • Some parents may have difficulty bonding with disabled child • Some parents may form a particularly strong bond with disabled child • Marital problems • Increased risk of child abuse • Over-protection of disabled child • May become a strong advocate for their child Siblings • Resentment at time parents spend caring for disabled child • Resentment at restrictions to normal family life • May have to develop carer role • Grow up with greater understanding of disability Peers • May “look out” for disabled child • Friend may be stigmatised along with disabled child • May grow up with greater understanding of disability • May need to adapt activities to include disabled friend • Teasing by other peers Teachers • May have lack of understanding of disability/lack of training • May have tendency to over-protect disabled child • May be lack of willingness to integrate in mainstream activities • May be additional challenges in personalising education for disabled child • Stress of managing both mainstream and additional support needs pupils in the same class
13
Q
Expert Patient definition
A
Patient/carer has an in-depth knowledge of their condition (or in this case the condition of the person they care for), sometimes exceeding that of health professionals
14
Q
Where do patients get information from?
A
• peers / family / friends • Internet - general information e.g. google, social media • TV • Health pages of newspaper or women’s magazine • “What should I do?” / “When should I worry?” booklet • SHOW (Scotland’s health on the web) website, NHS inform website • GP practice leaflet • GP practice website • Adverts in public places e.g. bus stops, railway stations • Health awareness events e.g. health fairs • Pharmacies e.g. posters, leaflets
15
Q
list several medical and non-medical factors which may influence an individual’s desire to seek medical attention and/or “trigger” the uptake of medical care
A
Factors affecting uptake of care- Medical Factors • new symptoms • visible symptoms • increasing severity • duration Non medical factors affecting uptake of care • crisis • peer pressure “wife sent me” • patient beliefs • Expectations • social class • Economic • Psychological • Environmental • Cultural • Ethnic • Age • Gender • Media
16
Q
Define health literacy
A
SCUnK Health literacy is about people having the knowledge, skills, understanding and confidence to use health information, to be active partners in their care, and to navigate health and social care systems.
17
Q
What are the three aims of SIGN
A
• Help health and social care professionals and patients understand medical evidence and use it to make decisions about healthcare • Reduce unwarranted variations in practice and make sure patients get the best care available, no matter where they live • Improve healthcare across Scotland by focusing on patient-important outcomes
18
Q
Give examples of sources/types of epidemiological data.
A
michael gove HIDES CHARM Health and household surveys ISD Scotland statistics Drug misuse databases Expenditure data from NHS Social security statistics Cancer statistics Hospital activity statistics Accident statistics Reproductive health statistics Mortality data
19
Q
Define a confounding factor
A
A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease.
20
Q
List three common confounding factors
A
• Age • Sex • Social class
21
Q
List Reasons not to do with healthcare why numbers of elderly population increasing
A
• Decrease in birth/fertility rates • Improvements in housing • Improvements in water supplies • Improvements in sanitation/sewerage systems • Improvements in nutrition • Improved safety and reduction of injury • Migration (some areas only) • War/genocide (some areas only)
22
Q
social implications associated with Scotland’s increasing elderly population
A
• Increasing dependence on families and/or carers who are also ageing and perhaps still working themselves • Demand for home carers likely to increase • Demand for Care home/nursing home places likely to increase • Increasing emphasis on social activities for the elderly within communities • Role of elderly as grandparents and carers of grandchildren likely to change e.g. may have fewer/no grandchildren, may still be in employment themselves • Housing demands are likely to change as more elderly people live alone e.g. increased demand for one-bedroom flats, sheltered housing • Elderly people remaining in employment for longer may lead to an increase in unemployment rates in the young (this point could equally well be made as an economic implication)
23
Q
What are the different options for care when an elderly person becomes more ill?
A
• Living in own home with support from family • Living in own home with support from social services • Sheltered Housing • Residential Home • Nursing Home Care
24
Q
What is an anticipatory care plan
A
Advance and anticipatory care planning promotes discussion in which individuals, their care providers and often those close to them, make decisions with respect to their future health or personal and practical aspects of care.
25
examples of legal issues which may be included in an Anticipatory Care Plan for any patient
• Welfare power of attorney • Financial power of attorney • Guardianship (POA = arranged with patient when has capacity, guardian is arranged through court when no POA made and person no longer has capacity).
26
examples of medical issues which may be included in an Anticipatory Care Plan for any patient
• Potential problems • Home care package • Wishes re DNA CPR • Scottish Palliative Care Guidelines • Communication which has occurred with other professionals • Details of “just-in-case” medicines • Electronic care summary • Assessment of capacity/competence • Current aids and appliances (helps assess current functional level)
27
examples of personal issues which may be included in an Anticipatory Care Plan for any patient
• Statement of wishes regarding treatment/advance directive • Next of kin • Consent to pass on information to relevant others • Preferences and priorities regarding treatment • Who else to consult/inform • Preferred place of death • Religious and cultural beliefs re death • Current level of support e.g. family/carers
28
List all members of the MDT in community
• GP - day to day medical support, monitoring of Parkinson's disease and other conditions, co-ordination of care • District nurse - dressings and management of pressure sore • Nurse practitioner or paramedic practitioner or physician's associate-acute home visits with GP phone support or follow up visit • Home carer - practical tasks e.g. bathing, dressing • Pharmacist - advice on medication, dosette box • Social worker/care manager - advice on benefits e.g. attendance allowance, contact with agencies • Occupational therapist - adaptation of living environment to maximise independence • CPN - assessment and management of low mood • Physiotherapist - continue to improve mobility and stability • Dietician - advice on improving appetite, assessment nutrition • Receptionist - first point of contact for any issues/concerns/house calls • GMED/NHS 24 - out-of-hours care for unexpected deterioration/new condition • Parkinson's Nurse specialist - specialist advice to Sandra and her family relating to Parkinson's disease, assist contact with local Parkinson's support group • Community geriatric nurses - discharge assessment, support with development of a care plan • Community geriatrician - specialist overview of care/advice on care
29
Define the sick role
– the privileges and obligations which accompany illness.
30
What does the sick role do to patients?
• The sick role exempts ill people from their daily responsibilities • The patient is not responsible for being ill, regarded as unable to get better without the help of a professional. • The patient must seek help from a healthcare professional. • The patient is under a social obligation to get better as soon as possible to be able to take up social responsibilities again.
31
Why is disability increasing?
Increased age of population Rise in injuries from car accidents, falls and violence, chronic diseases
32
The sick role – Health professional role
Must be objective and not judge the patients morally Must not act out of self interest or greed but put the patients interests first He/she must obey a professional code of practice Professional must have the necessary knowledge and skills to treat patients Professional has right to examine patient intimately, prescribe treatment and has wide autonomy in medical practice.
33
What are descriptive studies and what are they used for?
Descriptive studies attempt to describe the amount and distribution of a disease in a given population This kind of study does not provide definitive conclusions about disease causation, but may give clues to possible risk factors and candidate aetiologies. Such studies are usually cheap, quick and give a valuable initial overview of a problem
34
What are cross sectional studies?
(disease frequency, survey, prevalence study) In cross-sectional studies, observations are made at a single point in time
35
What are case control studies?
two groups of people are compared: a group of individuals who have the disease of interest are identified (cases), a group of individuals who do not have the disease (controls).
36
What are cohort studies?
In cohort studies, baseline data on exposure are collected from a group of people who do not have the disease under study. The group is then followed through time until a sufficient number have developed the disease to allow analysis.
37
What is meant by a trial? A randomised controlled trial?
Trials are experiments used to test ideas about aetiology or to evaluate interventions. The “randomised controlled trial” is the definitive method of assessing any new treatment in medicine.
38
What is standardisation?
A set of techniques used to remove (or adjust for) the effects of differences in age or other confounding variables, when comparing two or more populations. An age-sex standardised rate represents what the unstandardised (crude) rate would have been in the study population if that population had the same proportion of males and females, and of people in different age groups, as the standard population. Rates can be standardised for any other relevant confounding factor (eg, social class). Comparisons of incidence or mortality rates in a population over time, or between two different populations, or between population subgroups, should always be based on standardised rates, never on crude rates.
39
What is the Standardised Mortality Ratio (SMR)?
This is a special kind of standardisation which you may encounter in your reading. It is a standardised death rate converted into a ratio for easy comparison. The figure for a standard reference population (eg, Scotland) is taken to be 100 and the standardised death rates for the comparison (study) populations (eg, Grampian) are expressed as a proportion of 100. A figure below one hundred means fewer than expected deaths, and above 100 means more. For example, an SMR of 120 means that 20% more deaths occurred than expected in the study population, allowing for differences in the age and sex structure of the standard and study populations and an SMR of 83 means 17% fewer deaths occurred.
40
What is meant by case definition?
The purpose of case definition is to decide whether an individual has the condition of interest or not. It is important in because not all doctors or investigators mean the same thing when they use medical terms. Differences in incidence of disease over time or in different populations may be artefact, due to differences in case definition, rather than differences in true incidence.
41
What is meant by Coding and classification?
This is related to the issue of case definition. When data are being collected routinely (eg, death certificates), it is normal to convert disease information to a set of codes, to assist in data storage and analysis. Rules are drawn up to dictate how clinical information is converted to a code. If these rules change, it sometimes appears that a disease has become more common, or less common, when in fact it has just been coded under a new heading
42
Define bias?
Bias is any trend in the collection, analysis, interpretation, publication or review of data that can lead to conclusions that are systematically different from the truth. There are very many types of bias which can creep into epidemiological studies. Four important types are described below.
43
Define Selection bias?
Occurs when the study sample is not truly representative of the whole study population about which conclusions are to be drawn. For example, in a randomised controlled trial of a new drug, subjects should be allocated to the intervention (study) group and control group using a random method. If certain types of people (eg, older, more ill) were deliberately allocated to one of these groups then the results of the trial would reflect these differences, not just the effect of the drug.
44
Define Information bias?
arises from systematic errors in measuring exposure or disease. For example, in a case control study, a researcher who was aware of whether the patient being interviewed was a 'case' or a 'control' might encourage cases more than controls to think hard about past exposures to the factors of interest. Any differences in exposure would then reflect the enthusiasm of the researcher as well as any true difference in exposure between the two groups.
45
Define follow up bias?
arises when one group of subjects is followed up more assiduously than another to measure disease incidence or other relevant outcome. For example, in cohort studies, subjects sometimes move address or fail to reply to questionnaires sent out by the researchers. If greater attempts are made to trace these missing subjects from the group with greater initial exposure to a factor of interest than from the group with less exposure, the resulting relative risk would be based on a (relative) underestimate of the incidence in the less exposed group compared with the more exposed group.
46
Define Systematic error?
A form of measurement bias where there is a tendency for measurements to always fall on one side of the true value. It may be because the instrument (eg, a blood pressure machine) is calibrated wrongly, or because of the way a person uses an instrument. This problem may occur with interviews, questionnaires etc, as well as with medical instruments.
47
Define Cofounding factor?
A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease. In some cases the confounding factor may be the true causal factor, and not the exposure that is under consideration.
48
List two common cofounding factors
Age Sex
49
List how cofounding factors are dealt with in trials
depending on the particular study design: • In trials, the process of randomisation (in effect the play of chance leads to similar proportions of subjects with particular confounding in the intervention and control groups). • Restriction of eligibility criteria to only certain kinds of study subjects . • Subjects in different groups can be matched for likely confounding factors. • Results can be stratified according to confounding factors. • Results can be adjusted (using multivariate analysis techniques) to take account of suspected confounding factors.
50
Define multimorbidity
the co-existence of two or more long-term conditions in an individual (multi-morbidity often results in polypharmacy)
51
What are the pros of screening?
1. Early detection of cancer: As discovering the cancer when it is small increases the chances of successful treatment. 2. Mortality reduction: breast cancer screening saves about 1400 lives per year in UK. 3. Possibility of breast conserving surgery: Screening will help to find the cancer when it is small and this will help in having lumpectomy instead of mastectomy.
52
What are the cons of screening?
• Personal costs include problems with false positive results, which can lead to distress and possible unnecessary treatment. • Individuals who choose not to participate in screening may be disadvantaged - for example, being labelled as from a 'positive family' with regard to genetic susceptibility, when other family members have chosen to be screened and have been found to be positive. • False negative tests. No test is 100% sensitive, which can then lead to false reassurance by both patients and doctors. This may even dissuade patients from returning for future screening tests. • False positive tests. One study found that 15% to 25% of cases of breast cancer detected by screening are overdiagnosed, translating to 6 to 10 women over-diagnosed for every 2,500 women invited. • Misinterpretation of results can lead to a false sense of security - eg, patients with normal cholesterol or normal blood pressure may continue to smoke. • Costs to society: actual costs of equipment, services, treatment, etc; also, the time taken off work for people to attend the screening test and for the treatment.
53
give examples of measures to prevent activity limitation in children and adults
Disease prevention: e.g. folic acid given to pregnant mothers to prevent spina bifida Disease prevention interventions e.g. vaccination programmes Screening heath education and promotion e.g. stop smoking Disease modifying drugs e.g. analgesia in rheumatoid arthritis Physiotherapists and OTs input (safe working conditions so no further injury, maximise persons optimal functioning after injury)
54
What is the process of clinical audit?
1) Selecting a topic. 2) Agree/review standards 3) Collect data on current practice 4) Compare data with standards 5) Implement change if needed 6) (cycle starts again) review standards
55
how epidemiological data may be used in daily practice in community and hospital settings
Epidemiology: the study of changing patterns of disease with the aim to improve the health of populations Assist in making a diagnosis (e.g. in COPD, the patient having all the risk factors making it more likely) Assess which services are required for prevention, diagnosis, primary care, secondary care, rehabilitation Ensure a high quality of these services (clinical audit, implementation of guidelines) Care out health need assessments to provide a rational framework for decisions on prioritisation of COPD healthcare resources.
56
Define criteria for causality?
Criteria establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect
57
List some criteria for causality? What are the famous causality criteria?
Bradford Hill criteria 1. Strength (effect size): A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal. 2. Consistency (reproducibility): Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect. 3. Specificity: Causation is likely if there is a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship.[1] 4. Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay). 5. Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence. 6. Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge). 7. Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that "... lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations". 8. Experiment: "Occasionally it is possible to appeal to experimental evidence". 9. Analogy: The effect of similar factors may be considered.
58
List causes of disability around the world
Congenital Injury Communicable Disease Non-Communicable Disease Alcohol Drugs-iatrogenic effect and/or illicit use Mental Illness Malnutrition Obesity
59
Describe the variety of individuals’ responses to long term conditions and the reasons for these – personal reactions to disability
PARENTS Personality/ mood of person All those around them (reactions) Resources /role of person (e.g. job) Education Nature of the disability Time since disability Support network
60
• Medical and Social Models for Disability; to be able to explain theoretical models of activity limitation; medical model and social model
Medical ▪ Individual/personal cause e.g. accident whilst drunk ▪ Underlying pathology e.g. morbid obesity ▪ Individual level intervention e.g. health professionals advise individually ▪ Individual change/adjustment e.g. change in behaviour Social ▪ Societal cause e.g. low wages ▪ Conditions relating to housing ▪ Social/Political action needed e.g. facilities for disabled ▪ Societal attitude change e.g. use of politically correct language.
61
What are the tasks of consultation from a doctors point of view according to neighbour?
1) Connect with the patient 2) summarise and verbally check the reasons for attendance are clear 3) handover and bring the consultation to a close 4) ensure a safety net exists and no serious possibilities exist 5) deal with housekeeping of recovery and reflection Connect, Summarise, Handover, Safety net, Housekeeping.
62
What 5 factors increase the chance of someone changing their behaviour?
1) Think advantages of change outweigh disadvantages 2) Anticipate a positive response from others to your behaviour change 3) There is social pressure for you to change 4) You perceive the new behaviour to be consistent with your self image 5) You believe you are able to carry out the new behaviour in a range of circumstances 1) adv vs dis, positive response, social pressure, self image consistent, able
63
What are the two models of ethical principles?
Deontology - duties 'right' and 'wrong' actions and absolute values (deon) Utlitarianism - look at benefits and harms to individual and society, look at consequences
64
What is trnasference? Countertransference? List 7 barriers to good treatment outcomes
Transference When the patient transfers past emotions, beliefs or experience to the present situation countertransference When the physician transfers past emotions, beliefs or experience to the present situation 1) Lack of knowledge 2) Fear and distrust 3) bias and ethnocentrism (evaluation of others cultures according to preconceptions originating in the standards and customes of ones own culture) 4) stereotyping 5) Language barriers 6) Differences in perceptions and expectations 7) Situation
65
What is the WHO definition of health?
'Health is a state of complete physical, mental and social well being, not merely the absence of disease or infirmity'
66
What factors need to be considered when putting together a case holistically?
1) organic/biological 2) social 3) psychological Can each be predisposers, precipitants (cause of event) or perpetuators (keep it going)
67
What are the three main reasons for culturally competent healthcare?
1) eliminating misunderstandings in diagnosis or treatment planning 2) improve patient adherence with treatment 3) eliminate healthcare disparities
68
What are the components of the mental state exam? MSE - structured way of observing and describing a patients current state of mind
ASEPTIC - R Appearance - Age, sex, dress, unkempt? signs of self harm? and B- behaviour - alert? fidgeting? eye contact? inappropriate conduct? Speech Emotion (mood and affect - blunted, flat, labile) low, elated, anxious Perception - hallucinations Thought/ Thinking - Content (abnormal beliefs/delusions, obsessions) and Process - speed and fluency Insight and judgement - Do they think they have a problem? What do they think caused it? Do they want help? Cognition - orientation, attention and concentration
69
What is psychopathology? What is descriptive pathology? Define phenomenology? (phenomenon)
Psychopathology is concerned with abnormal experience, cognition and behaviour Descriptive pathology - describes and categorise the abnormal experience as described by the patient Phenomenology - in psychiatry refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patients experience feels like
70
What is the hypothetico- deductive process?
1) Make 4 or 5 diagnostic hypotheses 2) rare but not immediately concerning diagnosis excluded at this stage 3) strengthen case for diagnosis through brief history and examination 4) extend the search thereafter if no diagnosis identified 5) not about common diagnosis, rather about likely diagnosis
71
List two coping mechanisms used to cope with stress and describe
1) Problem focused e.g. enlist friends and family help 2) emotion focused e.g. seek counselling/stress management (positive) alcohol or drug misuse (negative)
72
What are the individual variables in risk perception?
Previous experience attitudes towards risk values beliefs socioeconomic factors personality demographic factors
73
What are the three principles that govern the perception of risk?
Feeling in control Size of the possible harm Familiarity with the risk
74
List four ethical principles and their meanings
Respect for autonomy; promote right to self determination, confidentiality, informed consent, promote capacity. Can we promote autonomy? Justice ; fairness/equity, individual vs population (non discrimination, equal treatment for equal need, rationing) Beneficence; To do good, what are the benefits of giving treatment? Non maleficence; avoidance of harm (to do no harm) what are the \*harms\* of giving treatment?
75
Define stress
An imbalance between demands and resources occurring when pressure exceeds ones perceived ability to cope
76
What are the 4 options of decision making? When are they used?
1) degree of certainty 2) speed of change Pattern recognition (both 1+2 high) if speed of clinical change is high and complexity or ambiguity is high (ie A and E/ ITU) Algorithms Speed of clinical change is high, complexity or ambiguity is low = childbirth Pathways Speed of clinical change is low and complexity is low. e.g. elective hernia surgery Scenario/option planning Speed of clinical change is low but complexity is high e.g. GP caring for patient at home with co-morbidity
77
Blaxter (1995) identified factors which influence lay beliefs around health (list 4)
Age - if older - see health as functioning, young people see health as fitness social class /difficult economic and social circumstances - more likely to think in terms of being able to work/care for others ie. functional Gender - women of higher social class or educational equlifications have a more multidimentional view of health. women include social aspects of health, find concept of health more interesting. Culture- e.g. Afro-Caribbean patients hypertension regarded as normal and less likely to take medication
78
List actions a government might take to promote health in the population as a whole (5 actions)
legislation/policies on smoking/alcohol (minimum age to buy products, licencing laws, taxation) improvements in housing provision of health education health and safety laws traffic/transport legislation/policies
79
List 5 reasons why people may feel they are in good health
1) no diagnosed long term conditions 2) not on medication 3) able to work/socialise 4) able to have children (fertile) 5) on a 'healthy diet' 6) 'exercise regularly'
80
Define: Hazard and Risk Risk factor Protective factor Susceptibility
Hazard: something with potential to cause harm Risk: the likelihood of harm occurring Risk factor: something that increases the risk of harm Protective factor: something that decreases the risk of harm Susceptibility: influences the likelihood that something will cause harm
81
What makes a culturally competent doctor re 'Practical skills' ? What makes a culturally competent doctor generally?
- Has an awareness and acceptance of difference whereby diversity is valued - understands how your own culture influences how you think, act and deliver services - understand the dynamics of difference and be conscious of dynamics when cultures interact - knows competency involves a deep commitment to the people for whom we provide services - recognises and learns to work within context of different languages, customs, world views, religions, spiritual beliefs, health beliefs, gender roles, sexuality, family relationships when interacting with clients/patients
82
Define a 'health policy' What is cultural competence?
All policies which have a direct bearing on health includes income security, employment, education, housing, business, agriculture, transportation, justice and technology Cultural competence: The ongoing capacity of healthcare systems, organisations and professionals to provide for diverse patient populations high quality care that is safe, patient and family centred, evidence based and equitable.
83
List some examples in disparities in disease outcomes between people who are different races (3) Disease prevalence? (3)
- Lung cancer death rates are higher in black men than white men - Ethnic minority women with breast cancer have a poorer survival rate than white women (even with similar access to care) - Racial disparities in uptake of joint replacement for knee osteoarthritis not explained by prevalence -Diabetes 5 x higher amoung pakistani and bangladeshi women than in general population - all male minority groups (except chinese) have higher rates of heart attacks - black Caribbean men have higher rates of stroke
84
Name a model used for consultation Name its 6 steps
Calgary Cambridge Model 1) initiating the session 2) gathering information 3) providing structure 4) building the relationship 5) explanation and planning 6) closing the session
85
What 3 dimensions are needed in cultural competence continuum? How does a GP find out a patients 'explanatory model of illness'?
Knowledge - learn the meaning of culture and its meaning in healthcare Attitudes - Having respect for variations in cultural norms Skills - Eliciting patients explanatory models of illness 1) Asking questions to find out the patients understanding of their illness 2) Having strategies for identifying and bridging the different communication styles 3) Having skills for assessing decision making preferences and the role of the family
86
What are the three domains in the model for cultural competence training? List elements and skills emphasised for all three
Structural domain Elements: structural, cultural, historical, political, economic skills: advocacy, activism Internal domain Elements: blind spots, biases, sympathies, vulnerabilities, sources of strength, concepts of the world, personal experience, motives skills: selfcare, reflection, self awareness, ongoing learning Interpersonal domain Elements: Language, transference, rapport, communication Skills: relational communication skills (body language, paraphrasing, active listening) Empathetic imagination, humility
87
What do you do when a patient has limited English proficiency? What are the problems of using family members to translate?
Determine language at first point of contact Language line services if using phone - confidential room (confidentiality) setting stage - summarise the situation time constraints - plan questions ahead of time If on site interpreters position interpreter beside you ask them to speak in first person to patient address the patient (not the interpreter) directly Family members are not desirable; error, lack of knowledge, bias, selective communication
88
List 5 types of hazard List 4 routes of exposure
Hazards: chemical (e.g. pesticides) physical (noise, pollution, radiation) mechanical (machinery use) biological (infectious agents psycho-social (stress, violence) Route of exposure skin blood/sexual inhalation ingestion
89
List 5 duties of a doctor registered with the GMC
make the care of your patient your first concern treat every patient politely and considerately respect a patients privacy and dignity give patients information in a way they can understand recognise the limits of your professional competence be honest and trustworthy avoid abusing your position as a doctor.
90
Name and describe the three doctor/patient relationships by Szasz and Hollender 1956
Authority Autonomy Pleasing/obedience Mutual participation; patient and doctor have equal power, mutual independence, the patient has autonomy over their illness and actions, the doctor can give advice, increased degree of empathy Authoritarian/paternalistic; the physician uses all of the authority inherent in his/her status and the patient has no autonomy. The patient tries hard to please the doctor and does not actively participate in their own treatment. Guidance/cooperation; The physician still exercises much authority and the patient is obedient, but has a greater feeling of autonomy and participates more actively in relationship.
91
List ethical factors faced by patients Psychological issues face by patients Social issues faced by patients
Ethical patient beliefs surrounding issue/procedure religious beliefs ethical consequences of issue/procedure, impact on others Psychological anxiety about procedure/issue (doing it vs not doing it) anxiety/stress about consequences anxiety/stress about level of support from family/friends Social support network - does patient feel friends/family will support them? impact on social life ability to find/maintain job/work
92
List three types of skills needed for successful interviewing and describe
1) content skills what doctors communicate - the substance of their questions and responses, the information they gather and give, the treatments 2) Perceptual skills - what the doctor is thinking/feeling, their internal decision making, clinical reasoning, their awareness of their own biases, attitudes and distractions 3) process skills - how they do it - the way doctors communicate with patients how they go about discovering the history or providing the information. the verbal and non verbal skills they use, the way they structure and organise communication
93
What is culture? What does culture influence?
The learned and shared values of a particular group that: 1) guides thinking 2) actions 3) behaviours 4) emotional reactions to daily living It is norms and customs that are learned It is the sum of beliefs, practices, habits, likes and dislikes 1) patient healthcare beliefs 2) patients attitudes towards care 3) trust in the system
94
What factors make GPs appropriate HCPs to sort out a problem for a patient? List types of questions
Awareness of current and past medical history Awareness of social circumstances A GP has a knowledge of a broad range of illnesses and health conditions Trusted HCP ho is likely to be known by the patient/family for some time/lifelong GP local to patients home 1) direct (specific) 2) closed (yes/no) 3) leading 4) reflected (doctor asks patient to think of the answer)
95
List five questions for practising Realistic medicine
Is this test, treatment or procedure really needed? What are the potential benefits and risks? What are the possible side effects? Are there simpler, safer or alternative treatment options? What would happen if I did nothing?
96
Define terminal care
The last phase of care When the patient is deteriorating And is near death
97
List 6 points to consider when breaking bad news
Setting - Listen to patient and the carers Set the scene Check whether patient wants to speak alone or with a relative Perception - Find out what the patient already understands Invitation - Find out how much the patient wants to know Knowledge - Share the information with a common language/avoid jargon review and summarise the information Empathising -allow opportunities for questions Strategy and summary - agree follow up and support
98
List 5 actions that are taken because of anticipatory care plans
Preferred place of death noted and organised patient put on palliative care register and discussed at MDT meeting Information on social and financial support given to patients and families - appropriate referrals completed Assessment of symptoms and partnerships with specialist palliative care team to customise care to patient needs Dies in preferred place, family bereavement and support GP and district nurse phone calls and visits
99
Define sustainability
The ability to be able to continue over a period of time
100
List 4 positive factors that might contribute to a sustainable career in medicine
Autonomy work life balance manageable work load flexibility of role good job security good financial security
101
Give 2 reasons why there are differences between two population pyramids one from 1800s and one from 2031
increased life expectancy decrease in birth rates migration greater availability in contraception improved housing conditions
102
Give three ways the change in population pyramids will affect healthcare services give three social issues that could arise due to these population changes
Heath increased number of Geriatricians Increased numbers of people with long term conditions such as diabetes Promotion campaigns aimed at the elderly Social increasing dependence on families/carers demand for home carers/nursing home places likely to increase housing demands change as more elderly people living on their own increasing emphasis on social activities for elderly within communities
103
Give a description of a case controlled study
two groups of people are compared a group of people who have the disease of interest are identified (cases) and a group that do not (controls) Data is then gathered to see if each individual has been exposed to the suspected aetiological factors Then whether a conclusion can be drawn as to whether that factor caused the disease
104
Give a description of a cohort study
a group of people are selected who do not have the disease yet They are then followed through time until a sufficient number of the cohort have developed the disease to allow analysis
105
List 6 possible sources of epidemiological data which provide information on IHD
Mortality data hospital activity statistics General practice disease registers NHS expenditure data Household surveys social security statistics
106
List five psychological issues that may be affecting a patient who works offshore and is from russia
drug/alcohol abuse being away from home (if not from scotland) and anxiety towards travelling anxiety from job insecurity pressure to maintain standard of living shift work stress
107
List ten potential difficulties during a consultation as a result of cultural differences
lack of knowledge about health issues fear and distrust racism bias and ethnocentrism stereotyping language barriers presence of third party translator in room differences in perceptions and expectations examination taboos religious beliefs
108
List 5 ways a role as a carer may affect a patient
poor mental health due to stress/anxiety may have to give up work/ work part time financial implications lack of privacy for patient and family (if live with person caring for) less time for hobbies adaptations to patients home e.g. stair lift
109
suggest 5 ways that issues with being a carer can be alleviated
sitter services (crossroads) home carers to assist with personal care day care centre respite care benefits - carers allowance psychological support - counselling
110
List 5 aspects in a patients history that could indicate that they are a suitable patient to receive palliative care if a respiratory patient
not expected to be alive in 6-12 months breathless on rest/minimal exertion spends more than 50% of day in chair long term oxygen therapy three acute exacerbation hospital admissions in past year symptomatic right heart failure BMI below 21 FEV less than 30%
111
List two emotional reactions to receiving bad news
shock - news completely unexpected, patient may be tearful anger - anger with themselves for previously unhealthy habits or behaviour denial - patient does not believe it can be true bargaining- perhaps if I change something in my life things will be better sadness/depression fear/anxiety - distressed about end of life/death/ issues surrounding dying shock anger denial = SAD
112
List ten factors that should be taken into consideration before starting a screening programme
will the test detect changes at an early preclinical stage? Is the disease an important public health problem? is the natural history of the disease understood? is a test available for this condition? Is the test sensitive? (low false negatives) is the test specific? (low false positives) Is the test safe? Is the cost of the test reasonable? Is the method of the test acceptable to the public and GPs carrying it out? Are facilities for diagnosis and treatment available?
113
List 5 factors that may contribute to tiredness in a child that aren't physical illness
poor diet inadequate sleep excess screen time lack of exercise/too much exercise academic issues home/relationship difficulties bullying loneliness
114
List 5 aspects in a patients history that could indicate that they are a suitable patient to receive palliative care if a dementia patient
unable to dress, walk or eat without assistance, unable to communicate meaningfully worsening eating problems (dysphagia) or needing pureed diet recurrent febrile episodes/aspiration pneumonia urinary and faecal incontinence
115
List 5 aspects in a patients history that could indicate that they are a suitable patient to receive palliative care if a liver patient
advanced cirrhosis with: intractable ascites hepatic encephalopathy recurrent variceal bleeds bacterial peritonitis low serum albumin prolongued INR over 2 not fit for liver transplant hepatocellular carcinoma
116
List 5 aspects in a patients history that could indicate that they are a suitable patient to receive palliative care if a kidney disease patient
stage 4/5 chronic kidney disease (eGFR under 30ml/min) deteriorating on renal replacement therapy/dialysis or with persistent symptoms
117
List 5 aspects in a patients history that could indicate that they are a suitable patient to receive palliative care if a cardiac patient
NYHA class III or IV heart failure, extensive valve disease, or coronary heart disease breathless or chest pain at rest or on exertion cardiac cachexia renal impairement (eGFR under 30 ml/min) two or more acute episodes needing hospital care in last 6 months
118
What scale can be used in palliative care to assess patients function
Palliative performance scale
119
What are the WHO aims for palliative care
provide relief from pain and other distressing symptoms affirms life and regards death as a natural process intends neither to hasten or postpone death integrates the psychosocial and spiritual aspects of patient care offers a support system to allow patients to live as fully as possible until they die offers a support system for the patient and family during the patients illness and for bereavement uses a team approach to address the needs of the patients and family
120
What specialists can be involved in a palliative patients care?
marie curie nurse macmillan nurse CLAN religious groups
121
What are the main components of a 'good death'
pain free death open acknowledgement of iminent death death at preferred place surrounded by family and friends personal conflicts and practical matters settled death as personal growth person centred and tailored to the patients individual wishes and individuality
122
Where is most peoples preferred place of death? what percentage of people achieve this?
Home 25%
123
What framework offers tools to support palliative care patients at home?
The golden standards framework including - setting up a cancer register -reviewing these patients - reflective practice (e.g. significant event audits)
124
Define: voluntary euthanasia non voluntary euthanasia physician assisted suicide
voluntary euthanasia = patients request non voluntary euthanasia = no request physician assisted suicide = physician provides the means and advice for suicide
125
List three reasons people may request euthanasia
1) depression - 60% of patients that request are depressed 2) fear of unrelieved symptoms and dread of further suffering
126
Define sociology
the development, structure and functioning of human society
127
List the characteristics of a 'profession'
1) systematic theory (has a theoretical basis) 2) authority recognised by its clientele (patients and government come to it for help) 3) broader community sanction (no one is allowed to practice without a licence) 4) code of ethics 5) professional culture sustained by professional sanctions
128
What are the social/socio-economic influences on our health?
gender ethnicity housing education employment financial security health system environment
129
List five reasons why employment is a social factor
Provides income and financial security; this obviously varies and relates in part to the previous slide on social class. (Deprivation is a major determinant of health inequalities) Provides social contacts Provides status in society Provides a purpose in life Unemployment is associated with increased morbidity and premature mortality
130
Define health inequalities according to WHO definition
The WHO states that health inequalities can be defined as the differences in health status or in the distribution of health determinants between different population groups
131
List some main health inequalities in scottish children
Birthweight Dental health breastfeeding obesity/overweight teenage pregnancy
132
What health inequalities are present for the homeless population?
Average age of death of longer-term homeless is 47 years for men and 43 years for women Death by unnatural causes has been found to be four times more common than average amongst rough sleepers, and suicide 35 times more likely Rough sleepers are more likely to be assaulted than the average person Alcohol and drug problems are very high amongst rough sleepers, and people being resettled from the streets are more likely to face problems sustaining a tenancy if they have these problems The prevalence of infectious diseases, such as tuberculosis, HIV and hepatitis C, is significantly higher than in the general populations This population experiences poorer oral health than the general population. Access to health care for this population is different to that of the general population: one third of rough sleepers are not registered with a GP; attendance at accident and emergency is at least eight times higher than the housed population.
133
List barriers that prevent people with a learning disability accessing healthcare
a lack of accessible transport links patients not being identified as having a learning disability staff having little understanding about learning disability failure to recognise that a person with a learning disability is unwell failure to make a correct diagnosis anxiety or a lack of confidence for people with a learning disability lack of joint working from different care providers not enough involvement allowed from carers inadequate aftercare or follow-up care
134
What challenges do refugees face in accessing healthcare?
Family integrity and social adjustments trump medical issues for most arriving refugees Competing demands of distinct services such as: social welfare, education, housing, transportation, public health, mental health, primary care, and specialty care encountered by refugees may overwhelm them and limited resources Language barriers impede the adjustment process Some refugees with urgent and complex medical conditions are unable to establish care and specialty referrals in a timely manner Underdeveloped or eroding health care systems in the countries of origin or first asylum leave many refugees with poorly controlled or undiagnosed chronic medical conditions Most refugees are unfamiliar with the biomedical practice of preventive medicine and primary health care Public health’s infectious disease screening results are not communicated to those providing ongoing medical care Exposure to violence, torture, warfare, and internment is common, even among children Loss upon loss is the nature of refugee life and so depression, PTSD, and anxiety are prevalent and often unrecognized Anti-immigrant sentiments further burden refugee life in the U.S.
135
What health inequalities do prisoners face?
more likely to smoke more likely to use illicit drugs more likely to have mental health conditions more likely to be involved in violence, accidents and higher suicide rate
136
What health inequalities do LBGTX people face?
higher suicide rate more likely to have mental health condition depression/anxiety
137
What factors can reduce health inequalities?
Effective partnership across a range of sectors and organisations e.g. to promote health, improve patient education about health Evaluate and refine integration of health and social care Government policies and legislation e.g. smoking ban, Keep Well campaign Time to invest in the more vulnerable patient groups Improve access to health and social care services and professionals Reduction in poverty Social inclusion policies Improved employment opportunities for all Ensuring equal access to education in all areas Improved housing in deprived areas
138
What is the difference between equality and equity?
139
What are the benefits of volunteering
gain confidence
learn a new skill
meet people
take on a challenge
140
Why is global sustainability important to healthcare?
Material Inequality
* Population and Consumption
* Resource Depletion
* Climate Change
* Loss of Biodiversity
* Crisis in Healthcare
141
List some actions that could be taken to slow global warming
Increase use of renewable energy resources ( that is any natural energy resource that can be replenished with the passage of time)
Modifying human behaviour, being more active
Move back to more plant based diet
Educate on carbon literacy and numeracy
Promote patient resilience
Teach healthcare students that as well as human anatomical systems we are also part of a wider ecological system
142
List some ways the NHS could improve sustainability
Prioritise Environmental Health Substitute harmful chemicals with safer alternatives.
Reduce and safely dispose of waste
Use energy efficiently and switch to renewable energy.
Reduce water consumption Improve travel strategies
Purchase and serve sustainably grown food
Safely manage and dispose of pharmaceuticals
Adopt greener building design and construction.
Purchase safer more sustainable products
143
What questions should you ask in an occupational history?
A description of the present and previous jobs from leaving school. Identifying any exposure to chemicals or other hazards ( may need to see confirmation from labels). Did the symptoms improve when not exposed e.g. at weekends, holidays? Determine the duration and intensity of exposure e.g. was it so noisy it was impossible to communicate Is personal protection used e.g. what kind of mask? What maintenance is in place for the protection measures? Do others suffer similar symptoms? Are there known environmental hazards in use? Any hobbies, pets, worked overseas, moonlighting?
144
Describe the components of the Fit Note
It’s purpose is to facilitate earlier discussion about returning to work and about rehabilitation.
It now includes items of consideration for employers when signing a patient’s return to work.
It can only be completed by a Doctor
It is advice to patients as employees, is not binding on the employer and does not affect Statutory Sick Pay
It is required if the patient has been off more than 7 consecutive days ( including non working days)
145
What are the aims of realistic medicine?
●Build a personalised approach to care
●Change our style to shared decision-making
●Reduce unnecessary variation in practice and outcomes
●Reduce harm and waste
●Manage risk better
●Become improvers and innovators
146
What areas of health are affected by health promotion?
access
environment
lifestyle
147
Define health promotion
an overarching principle which enhances health.
It includes health education, disease prevention and health protection
It may be opportunistic or planned
148
149
Define health education
An activity involving communication with individuals or groups aimed at changing knowledge, beliefs, attitudes and behaviour in a direction which is conducive to improvements in health.
150
Define health protection
involves collective activities directed at factors which are beyond the control of the individual.
Health protection activities tend to be regulations or policies, or voluntary codes of practice aimed at the prevention of ill health or the positive enhancement of well-being.
151
What are the benefits of empowerment?
An ability to resist social pressure.
An ability to utilise effective coping strategies when faced by an unhealthy environment.
A heightened consciousness of action.
152
Draw out the circle of change
153
Give some examples of health promotion in
1) primary care
2) governmental level
Primary Care : Planned or Opportunistic
Government : Legislation, Economic, Education
154
Define primary prevention and give an example
Measures taken to prevent onset of illness or injury
Reduces probability and/or severity of illness or injury
vaccinations
155
Define secondary prevention
Detection of a disease at an early (preclinical) stage in order to cure, prevent, or lessen symptomatology”
156
Define tertiary prevention
measures to limit distress or disability
caused by disease
