Professionalism

Question 1

What abilities does someone need in order to have capacity?

Answer 1

1) Understand the information given to them.
2) Retain the information.
3) Weigh up/ use the information.
4) Communicate their decision.

Question 2

What are the three aspects of valid consent?

Answer 2

1) Informed.
2) Capacity.
3) Voluntary.

Question 3

What information does a patient need in order to give informed consent to treatment?

Answer 3

Any potential benefits.
Any potential risks.
Any alternative treatments.

Question 4

Name a measure of income inequality that can be used to compare a local population with others.

Answer 4

Gini coefficient.

Question 5

What did the Black Report hypothesise were the possible determinants of health inequalities?

Answer 5

Artefact-healthy people move up the classes.
Natural selection (poor health pushes people into poverty).
Poverty causes ill health.
Life style differences.

Question 6

Name some government initiatives that aim to reduce child poverty?

Answer 6

Increased child benefit.
Increased minimum wage.
Strategy to reduce teenage pregnancy.
Childcare tax credits, and free childcare for working parents.
National fruit scheme.

Question 7

Why did child poverty indicators increase in the 1980s?

Answer 7

Increased unemployment, and more families without a member in unemployment.
Lower pay.
More single parent families.
Cuts in expenditure in some services.
More indirect taxation.

Question 8

What 4 factors are used when making an evidence-based decision?

Answer 8

1) Evidence from research (and NICE guidelines).
2) Clinical expertise.
3) Available resources.
4) Patient preference.

Question 9

What is opportunity cost?

Answer 9

The services/treatment that could be provided to a different patient using the money you are spending on your patient. Need to distribute resources fairly to reduce health inequality.

Question 10

Where would you find evidence-based information to help make a decision?

Answer 10

NICE guidelines.
Evidence-based journals.
Cochrane library.
Search on Medline or Embase.
GP Update.
Clinical guidelines.
Individual journal articles.

Question 11

What phrase is given to the cost of prescribing the drug in terms of the benefit lost from money that could be spent on other drugs or health services?

Answer 11

Opportunity cost.

Question 12

Name three measures of the benefits of a drug.

Answer 12

Mortality rate.
Morbidity.
Quality of life measures.

Question 13

What are the benefits of the NICE guidelines?

Answer 13

They are evidence-based.
They take into account the cost-effectiveness of a drug/treatment, as well as the clinical effectiveness (take into account the additional benefits of treatment compared to the additional costs).
There is a formal process of public consultation in the guideline development.
They reduce health inequality, so similar patients are treated equally across the UK.

Question 14

What are the 4 ethical principles?

Answer 14

Autonomy.
Justice.
Beneficence.
Non-maleficence.

Question 15

What is the decision making model used by more junior health professionals?

Answer 15

Hypothetico-deductive model.

Question 16

What are the three theories of ethical decision making?

Answer 16

1) Deontological (actions are either right or wrong).
2) Consequential (is the consequences that justify actions).
3) Virtue (what decision would a virtuous person make).

Question 17

What factors need to be considered when GPs implement opportunistic prevention in consultations?

Answer 17

Patient’s receptiveness.
Planning how much time can be allocated within the consultation.
Avoidance of preaching/victim blaming.
Respect for patient’s views.
Check that the health visitors are giving the same (evidence-based) information.
Planning how to involve practice nurse if no time left in GP consultation.
Planning how to reinforce message with posters/leaflets in waiting room.
Planning how to deal with complaints/distress.

Question 18

List the three kinds of exception to the duty to always keep medical information confidential.

Answer 18

1) There is a public interest in you breaching confidentiality, other people will be at risk of harm if you don’t.
2) There is a court order (statute) saying you have to break confidentiality.
3) The patient had capacity and has given you consent to share the information.

Question 19

How does confidentiality differ from privacy?

Answer 19

Confidentiality is a pledge or agreement which is implicit in the professional relationship, privacy is a qualified human right.

Question 20

Name some statutes obliging physicians not to disclose confidential information about the patient.

Answer 20

Public Health (control of diseases) Act 1984.
Abortion Act 1967.
Births and Deaths Registration Act 1953.
Road Traffic Act 1988.
Human Fertilisation and Embryology Act 1990.
NHS Venereal Diseases Regulations 1974.
Prevention of Terrorism Act 1989.

Question 21

If you have decided to breach confidentiality, name one thing the GMC says you must do first.

Answer 21

Inform the patient.

Question 22

Describe the 4 requirements for a patient to enter the Sick Role.

Answer 22

1) They must want to get better as soon as possible.
2) They should seek advice from a medical professional and cooperate with the doctor.
3) They may be expected to shed some normal activities and responsibilities (e.g employment and household tasks).
4) They are regarded as being in need of care, and unable to get better by his or her own decisions and will.

Question 23

Describe the 4 requirements of a doctor, laid out in the Sick Role.

Answer 23

1) They must apply a high degree of skill and knowledge to the problems of illness.
2) They must act for the welfare of the patient and community, rather than for their own self-interest or desire or money or advancement.
3) They must be objective and emotionally detached (don’t judge the patient’s behaviour in terms of personal values system, or become emotionally involved with them).
4) They must be guided by the rules of professional practice.

Question 24

Describe the 3 rights afforded to doctors by fulfilling the Sick Role.

Answer 24

1) Granted the right to physically examine patients, and to enquire into intimate areas of their physical and personal life.
2) Granted considerable autonomy in professional practice.
3) Occupy a position of authority in relation to patients.

Question 25

What is the Prospect theory of decision making?

Answer 25

There are two phases in decision making. Phase 1 = framing and editing (preliminary analysis of problem, influenced by context and wording) Phase 2 = framed prospects evaluated, prospect with highest value selected (influenced by people's different values)

Question 26

What types of evidence can be used in clinical situations?

Answer 26

``` Available resources. NICE guidelines. Evidence from research. Patient preference. Clinical expertise. ```

Question 27

What is the difference between expressed and implied consent?

Answer 27

Expressed consent can be verbal or written. Implied consent can be something like raising an arm to have blood taken, and is trickier as it is easier to misinterpret.

Question 28

When do you need consent from a patient?

Answer 28

Before examining, treating, or caring for a patient. Before taking part in research or teaching. Before screening. Before disclosing confidential information.

Question 29

Why is consent important?

Answer 29

To maintain the patient's trust in doctors and uphold the doctor-patient relationship. To respect patient autonomy. To avoid causing psychological/physical harm by treating without consent. To acknowledge that patient's know what is in their best interests. To fulfil the professional requirement by the GMC, as part of the duty of a doctor. To fulfil the legal requirement and avoid claims of battery and negligence.

Question 30

What is battery?

Answer 30

Touching a person without his/her consent, even if no harm results.

Question 31

What are the three criteria of negligence?

Answer 31

There is a duty of care owed to the patient The duty of care has been breached Breach has led to harm of the patient

Question 32

What is the difference between Statute Law, Common/Case Law, Public Law, Private Law?

Answer 32

Statute Law = acts of Parliament Common/Case Law = judgements/precedents from courts e.g GMC guidance Public Law = criminal law (the state is the prosecutor) Private Law = between private relationships (e.g hospital and patient)

Question 33

What is the term for how much information is required to be given to a patient?

Answer 33

Reasonable Patient Standard (how much would a reasonable patient want, relevant to decision making).

Question 34

What is the age above which capacity is presumed?

Answer 34

16.

Question 35

What is Gillick competence?

Answer 35

Children under 16 who have consent can consent to treatment without their parents giving consent, but can't refuse treatment.

Question 36

Name some situations where you wouldn't have to obtain consent.

Answer 36

In an emergency, when giving life-saving treatment to people sectioned under the mental health act, when patient's lack capacity and it is in their best interests, under the Public Health act when patient has infectious disease (can be detained, not treated), disclosure of confidential information if non-disclosure puts others at risk.

Question 37

What types of uncertainty are there in medical decisions?

Answer 37

People are different and so react to the same situation in different ways Technical uncertainty - inadequate information for accurate diagnosis or estimation of treatment effects Personal uncertainty - don't know what the patient wants Conceptual uncertainty - difficulty applying your knowledge (e.g guidelines) to specific patient

Question 38

What are the benefits of evidence-based decision making?

Answer 38

Clinical care is improved by ensuring patients receive the most appropriate treatment, proven by research. There is increased efficiency of health care services. There is reduced variation in practice among health care professionals.

Question 39

How is evidence based medicine implemented?

Answer 39

Evidence based clinical guidelines provided by NICE. Summaries of evidence provided for practitioners. Access provided to reviews of research. Practitioners evaluate research for themselves.

Question 40

In what way does patient-centred care enhance prevention and health promotion?

Answer 40

It contributes to: Health enhancement Risk avoidance and reduction (primary prevention) Early identification (secondary prevention) Complication reduction (tertiary prevention)

Question 41

In what way is patient-centred care realistic?

Answer 41

It is conscious of time and timing It is about team building and teamwork It has an awareness of resource constraints

Question 42

In what way does patient-centred car enhance the doctor-patient relationship?

Answer 42

``` It contributes to: Caring Feeling Trust Power Sense of purpose ```

Question 43

What is justice?

Answer 43

Treating people in a way that is fair and equitable.

Question 44

What is distributive justice?

Answer 44

Distributing limited resources in a way that is just and fair.

Question 45

What is the difference between equality and equity?

Answer 45

Equality is ensuring everyone receives the exact same amount. Equity is fairness - ensuring most resources are directed to the most needy.

Question 46

What is the Veil of Ignorance?

Answer 46

When trying to imagine an equitable society, not knowing what your place in the society would be so not being able to pick the society that most benefits you. Leads to people designing societies where the worst off receive maximal resources. This is called the Principle of Need.

Question 47

What is the Bottomless Pit objection?

Answer 47

If you prioritise improving the lives of the poorest in society, all your resources will be poured into a bottomless pit of suffering and the rest of society will be neglected.

Question 48

Describe some criteria for deciding which patients receive resources.

Answer 48

QALY (Quality Adjusted Life Years) - looking at morbidity and mortality How long has the patient been on the waiting list? What is the likelihood of the patient complying to the treatment, what is the likelihood they will benefit from it? What lifestyle does the patient have? What is the patient's ability to pay? (US) (Last 3 are controversial)

Question 49

Describe some arguments for prioritising patients based on their lifestyle choices.

Answer 49

They are less deserving of treatment because they have knowingly damages their health. They have forfeited their right to healthcare by not looking after themselves. By not prioritising them you deter them from further harmful behaviour. The treatment is likely to have poorer outcomes, with the benefits being less substantial and shorter lived.

Question 50

Describe some arguments against prioritising patients based on their lifestyle choices.

Answer 50

People may not always be responsible for their lifestyle choices. It could be a result of peer pressure, or of lack of awareness of health consequences. The threat of non-treatment may not actually be effective as a deterrent, particularly in the case of addiction. It is not the role of healthcare professionals to use treatment decisions to deter lifestyle choices (coercion?), and it may affect the patient's trust in doctors.

Question 51

When was the Declaration of Human Rights?

Answer 51

After WW2 in 1948.

Question 52

When was the European Convention onHuman Rights enforced in the UK?

Answer 52

In October 2000 as the Human Rights Act

Question 53

What are rights?

Answer 53

A justified claim on other people, where the other person has a duty to fulfil that right. Or something a person is entitled to.

Question 54

Why are rights important?

Answer 54

They provide security of expectations - people know where they stand and the social environment is predictable/secure. They provide protective boundaries, can limit the actions of others in respect to the vulnerable. They are conductive to dignity, respect and equality. They provide minimum standards, represent the least a person can expect. They pose ideal directives - showing what should be the case. The 4 medical principles are only achievable if rights are respected.

Question 55

Name the three types of rights.

Answer 55

Legal rights - observed by the legal system Moral rights - universal, no matter which legal system you live in Human rights - moral/natural rights that are implemented legally

Question 56

Name the two theories that justify why people have rights.

Answer 56

Status theory - people have particular properties/characteristics which enable them to have rights Instrumental theory - people have rights because in a society where rights are respected, people are happier/more peaceful (similar to utilitarianism)

Question 57

Name the four different types of rights.

Answer 57

Positive - a right to something, so someone is obliged to provide that Negative - obligation on other people to leave you alone Passive - obligation on other people to do/not do something Active - your right to do something

Question 58

What are the two main aims of the Human Rights Act?

Answer 58

To bring most of the rights in the European Convention of Human Rights into UK law. To bring about a new culture of respect for human rights in the UK.

Question 59

How does the Human Rights Act achieve its aims?

Answer 59

``` Regulating the relationships between individuals and public authorities. Giving people (even non-citizens) the opportunity to enforce rights in UK courts. UK legislation must be read in a way that is compatible with the Human Rights Act, otherwise it has t go back to parliament to be changed. Doctors need to question whether their decision making contravenes human rights, and whether it is right in this case to interfere with the rights. ```

Question 60

Name some rights relevant to healthcare.

Answer 60

The right to life Prohibition of torture Right to liberty and security Right to respect for private and family life Freedom of thought, conscience and religion Right to marry and found a family Prohibition of discrimination

Question 61

What are the three types that the rights in the Human Rights Act are divided into?

Answer 61

Absolute - can never be withheld or taken away by the state (e.g prohibition of torture) Limited - limited only under explicit and finite circumstances (e.g right to liberty, right to life) Qualified - require a balance between the rights of the individual and the interests of the wider community or state (e.g right to respect for a private and family life, right to manifest religious beliefs, freedom of expression)

Question 62

What is professionalism?

Answer 62

A set of values, behaviours, relationships, which underpins the trust the public has in doctors.

Question 63

Describe 5 aspects of a profession.

Answer 63

Commitment to serve the public good Presupposes generalised and systematic knowledge Standards are set, and there is an element of self-regulation Certification or licensing procedure Regulatory/professional body e.g GMC

Question 64

Describe some of the values and standards expected of doctors and medical students by the GMC.

Answer 64

Resilience in coping with stress and challenges Deal with doubt and uncertainty Apply moral and ethical reasoning Work effectively within a team Manage own learning and development Prioritise time well and ensure a balance Ensure patient safety, raise concerns where appropriate Work collaboratively Deal with a mitigate against personal bias

Question 65

What is the purpose of the GMC?

Answer 65

To protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine. The GMC decides who can practice medicine in the UK.

Question 66

What are the main reasons medical students are refused provisional registration with the GMC?

Answer 66

Probity (honesty and integrity) Absence of remediation (showing remorse and learning from mistakes) Lack of insight/awareness of actions Health of student

Question 67

Whilst mental health problems in themselves aren't a fitness to practice issue, non-disclosure is, why is that?

Answer 67

Concealment of the mental health issue goes against probity.

Question 68

What are the 6 stages of fitness to practice issues at HYMS?

Answer 68

Stage 1 = MBBS Academic Phase Lead receives concerns about student and decides if case needs to be referred to Case Management Group Stage 2 = Case Management Group reviews student case and makes appropriate referral. Appoints an Investigating Officer to report on the factual accuracy of the concern, then makes a collective decision on whether to make a direct referral to the Student Fitness to Practice Committee. Stage 3 = Student Fitness to Practice Committee considers Investigating Officer's report and recommends what action should be taken Stage 4 = formal panel hearing by Fitness to Practice Panel Stage 5 = notification of hearing outcome and opportunity to appeal Stage 6 = the matter is recorded at the next full meeting of the Student Fitness to Practice Committee

Question 69

Describe some instances where withholding the requested treatment is appropriate.

Answer 69

There is provision in the law for conscientious objection e.g abortion The treatment is not clinically appropriate so is contrary to the physician's duty of care The requested treatment is illegal e.g active euthanasia

Question 70

Describe the three ethical theories.

Answer 70

Consequentialism - an action is right is it promotes the best consequences (the best consequences are those in which happiness is maximised) Deontology - an action is right if it is in accordance with a moral rule or principle (requires absolute adherence to rules, obligations, duties) Virtue ethics - an action is right if it is what a virtuous person (someone who acts virtuously) would do in the circumstances

Question 71

What is a guideline?

Answer 71

Systematically developed statement to assist practitioner and patient decision making about appropriate healthcare in a specific clinical circumstance.

Question 72

What four things are guidelines important for?

Answer 72

Enabling care to be more consistent Enabling care to be more evidence-based Closing the gap between what clinicians do and what is supported by the evidence (which can occur when it's hard to keep up with fast moving research) Assist, but NOT dictate

Question 73

Who develops evidence based guidelines for the NHS in Scotland?

Answer 73

Scottish Intercollegiate Guidelines Network (SIGN)

Question 74

For what 4 reasons would practitioners not follow guidelines?

Answer 74

Lack of knowledge of the guideline Conflicting guidelines for patients with multiple morbidities Rapidly developing area of therapy, so guideline not up to date The guideline is complex, so there is a failure to understand or agree responsibility for using the guideline

Question 75

What is the difference between traditional reviews and systematic reviews?

Answer 75

A traditional review is not systematic, and is a review of the subject by an expert in the field. It may be biased to reflect the views of the author, and it is unclear to the reader whether or not the review is objective. However with a systematic review you can tell it is objective and can see how it has been put together.

Question 76

What is a systematic review?

Answer 76

A review which evaluates and interprets all the available research evidence relevant to a particular question.

Question 77

What are the 7 steps in the process of a systematic review?

Answer 77

1) Well formulated question (PICOS) 2) Comprehensive data search 3) Unbiased selection and abstraction process 4) Critical appraisal of data 5) Synthesis of data 6) Objective interpretation of findings 7) Structured report with clearly reported methods and results

Question 78

What are the 5 inclusion criteria of the specific review question of a systematic review?

Answer 78

``` PICOS Population Intervention Comparators Outcomes Study designs ```

Question 79

What are the 4 things you need to do when literature searching for the comprehensive data search of a systematic review?

Answer 79

Search all relevant databases, not just Medline. Use an appropriate search strategy (e.g NICE use search specialists) Check reference lists Check all relevant sources for unpublished data

Question 80

What is the study protocol which systematic reviews are conducted according to, to ensure the validity of a review?

Answer 80

Clear inclusion criteria Good strategy for literature searching Selection of studies performed in duplicate by two reviewers to avoid unconscious bias Assess the quality of the included studies Data extraction performed according to a template

Question 81

Why is it important to assess the quality of included studies in a systematic review?

Answer 81

If the primary studies are of poor quality then you can't trust the results.

Question 82

Which are the most commonly assessed factors of primary studies included in a systematic review?

Answer 82

Randomisation Sufficient allocation concealment Blinding Withdrawals, and intention to treat analysis

Question 83

What is sensitivity analysis in a systematic review?

Answer 83

The results are presented with all the studies included, then you see what happens to the results if you remove the poor quality studies from the analysis.

Question 84

What are the key concepts in the data synthesis in a systematic review?

Answer 84

Descriptive data synthesis Quantitative data synthesis (meta-analysis most useful but not always possible) Heterogeneity Sensitivity analysis Publication bias (missing unpublished data?)

Question 85

What does the diamond in a forest plot represent?

Answer 85

The pooled result.

Question 86

What are the two types of heterogeneity in a systematic review?

Answer 86

1) Clinical diversity - differences between included studies in things like patient population, contact the treatment is given in 2) Statistical heterogeneity - differences in the results of the different studies

Question 87

What is publication bias?

Answer 87

When unpublished data (which may only be unpublished because it's not headline-grabbing enough, but is no less relevant) is omitted which skews the results.

Question 88

What two things affect how useful a systematic review is?

Answer 88

Whether the specific review question is relevant to you | The available primary literature

Question 89

Why might guidelines draw on other sources of evidence (e.g expert opinion) as well as systematic reviews?

Answer 89

There is not enough time or evidence available for a systematic review to address every question in a guideline.

Question 90

What two things combine together to form graded recommendations in a guideline?

Answer 90

Synthesis of evidence from a systematic review, layered with considered judgement from the people compiling the guideline.

Question 91

What numbers can be assigned to sources by the Levels of Evidence?

Answer 91

1++ (high quality meta analyses, RCTs, systematic reviews) 1+ 1- 2++ (cohort studies, case-control studies) 2+ 2- 3 4 (non analytical studies e.g case series, case reports, expert opinion)

Question 92

What are the grades of recommendation that can be assigned to sources of evidence?

Answer 92

A (systematic reviews of RCTs directly applicable to target population) B C D (evidence level 3 or 4, or extrapolated evidence from 2+ studies)

Question 93

For what two reasons might RCT evidence used in a guideline still be downgraded?

Answer 93

It has limited applicability to the relevant population. | It was based on surrogate outcomes.

Question 94

What are the requirements for good clinical guidelines?

Answer 94

Be based on systematic reviews. Be developed by a knowledgeable multidisciplinary panel made up of experts and representatives from the key affected groups. Consider important patient subgroups and patient preferences. Be constructed through an explicit transparent process that minimises bias and conflict of interest. Provide clear explanations of the logical relationship between alternative healthcare options and health outcomes. Provide evidence on both the quality of evidence and the strength of the recommendations. Be reconsidered and revised when important new evidence warrants modifications of recommendations.

Question 95

What six things should you assess a clinical guideline on?

Answer 95

``` Editorial independence Applicabilty (is it relevant to your practice and patient groups) Clarity of presentation Rigor of development Stakeholder involvement Scope and purpose ```

Question 96

What is a clinical protocol?

Answer 96

Basically a small guideline, which is very specific and forms a straight forward plan to be followed in patient care. May offer concise instructions on which diagnostic test to order, how to provide medical or surgical services, how long to hospitalise patients for... Protocols are simpler and more prescriptive than a guideline.

Question 97

What are the two reasons good communication is needed in consultations?

Answer 97

Avoid complaints | Make a diagnosis

Question 98

Why is it crucial to set an agenda during a consultation?

Answer 98

Patients often bring more than one problem to a consultation, and they don't raise their concerns in any order of importance so it is important to establish the MAIN reason for the visit.

Question 99

When finding common ground in a patient-centred consultation, what three things is it important for the patient and doctor to reach a mutual understanding about?

Answer 99

1) The nature of the problem 2) The goals of treatment 3) The priorities of treatment