TC Flashcards Preview

Y1 > TC > Flashcards

Flashcards in TC Deck (408):

What is the role of the GMC in ensuring students and doctors fitness to practice?

Tomorrow's Doctors - tells medical schools what to teach..


What is the regulatory role of the GMC?

Protect, promote, maintain health and safety of the public by ensuring proper standards in the practice of medicine.


What is the Family Law Reform Act 1969.

Governs consent to treatment of 16/17 year olds. However 16/17 year olds cannot refuse medical treatment.


What role does an OT (occupational therapist) have?

- quality of life assessment
- goal setting
- functional assessment
- activities of daily living assessment
- occupational issues
- advise and arrangements for employment


What is a chronic condition?

LT illness expected to last 12 months or more.


What is biological disruption?

Sees chronic illness as disruptive event. Onset of chronic illness can affect upon a person's sense of identity.


What uncertainty comes w/ chronic illness?

Social - employment, finance
Clinical - prognosis
Psychosocial - sense of self and identity.


What are the positive consequences of being diagnosed?

Access to sick role
Employment rights, welfare benefits
Acceptance as being ill
Access to information and support groups


What are the negative consequences of being diagnosed?

Limitations on paid work
Worry about complications
Worry about ability to fulfil obligations (e.g. childcare)


What is the Bradford-Hill criteria?

Factors to consider when assessing whether an observed association is causal.

- Analogy - the effect of similar factors may be considered.
- Dose-response relationship - greater the exposure, greater the incidence of effect.
- Experimental evidence
- Strength of association – larger the association, the more likely the causality.
- Specificity - does A always only cause B?
- Temporal association – Does the result always follow exposure?
- Theoretical plausibility – Can we see the biological pathway e.g. tar and carcinogens.
- Consistency – relationship seen in different cases and different places.
- Coherence - between lab findings and epidemiological findings.


What is clinical significance?

Practical importance of treatment effect, whether it has a noticeable effect on everyday life.


What are medically unexplained symptoms?

Physical symptoms not explained by organic disease


What is disease?

Discrete pathological processes within the body w/ clinical signs


What is illness?

Sufferer's subjective experience


What are the consequences of living w/ MUS?

Uncertainty - no diagnosis / prognosis.
Lack of social support - isolation.
Lack of legitimacy - can't enter the sick role.
Stained social relations.


What are the doctor's assumptions about MUS?

Explanation for MUS lies within the patient.
Patient's deny psychological cause.
Patients what a cure and diagnosis.
Patients get physical interventions because they demand it.


What is discreditable stigma?

Keeping stigma hidden.


What is discrediting stigma?

Stigma that can't be hidden.


What is felt stigma?

Shame you feel because of stigma.


What is enacted stigma?

Discrimination by others.


What is courtesy stigma?

Felt by someone who is with the stigmatised person (e.g. parent of autistic child).


What is stress?

An imbalance between the demands made on us and our personal resources to deal with these demands.


What are the 4 components of the stress response?

Emotional - feeling sad
Cognitive - cannot concentration
Behavioural - eating, smoking
Physiological - HR, RR, perspiration


What is illness cognition?

A patient's own implicit common sense beliefs about their illness.


What are Leventhal's 5 dimensions to illness cognition?



What is positive coping strategies to stress and illness?

Emotion focused


What is negative coping strategies to stress and illness?

Problem focused


What are the measures for assessment of disability?

Barthel index
Functional assessment measure (FAD)


What is the medical/ individual model of disability?

Sees disability as a problems doctors need to fix.


What is the social model of disability?

Disability is a social construction.
Society is build for able bodies people.


What is the medical model of disability?

Emphasis on what is wrong with the person.
Exclusion from society.
Views disability as a tragedy.
Puts disability between the patient and the doctor.


Define disability.

Any restriction of ability to perform an activity in a manner considered normal.


What is a handicap?

Disadvantage from impairment that limits/prevent the fulfilment of a role that is normal for the individual.


What are activities of daily living?

Everyday tasks and functional activities that are an essential part of life.


What role do physiotherapists have?

Impairment assessment
Management of condition


What role do occupational therapists have?

Functional assessment
Occupational assessment


What randomised trials?

Eliminate systematic bias in allocation of interventions.
Basis for statistical tests


What types of bias are there in RCTs?

Selection bias.
Performance bias.
Ascertainment bias - systematic distortion of the results of a RCT as result of knowledge of the group assignment.


What is a qualitative study?

Seeks to understand people's perspectives and motivations.


What is a RCT?

An experiment where participants are randomly allocated into groups. Results between control and experimental group outcomes compared.


What is an impairment?

A physical loss. Functional deficit.


What is the criticism of the social model of disability?

Looks at disability as through impairment can never cause an individual problem, but society can.
Doesn't fully appreciate the complexity of different disabled people's lives.


What is a 95% confidence interval

There is a 95% chance that the true value lies somewhere within the confidence interval.


How is 95% reference range interpreted?

95% probability that the true value lies within the interval.


Define confidence interval.

The range of values that the true value in the population is expected to fall within based on the study results.


Define validity.

How well the test or study answer the question it was supposed to answer.


What is used to measure validity?

Sensitivity and specificity.


What is internal validity?

Measures how well the results represent the sample being studied.


What is external validity?

Measures how well your results can be applied to overall population.


What are confounding variables?

Factors that are not directly associated by are linked by a 3rd factor.


What is bias?

A non-random (directional) deviation of the truth; systematic error in the collection/analysis of info.


How does high bias affect validity?

High bias --> Low validity.


Can you correct bias by having a larger sample size?



Describe an ideal research study.

• The study population is similar to overall population of interest.
• The groups are close to identical at start of study except for the variable being tested.
• All patients are compliant with any treatments or lifestyle changes assigned to them.


Define probability.

Ranges between 0-1. Basically same as percentage.


Define odds.

A ration of the likelihood of an event happening compared to the likelihood of an event not happening.


What is relative risk calculated with?

Probability / Probability


What is odds ratio calculated with?

Odds / Odds 


What type of studies and trials measure relative risk?

Cohort studies


What type of studies measure odds ratio?

Case-controlled studies.


What can cross-sectional studies be used to estimate?

Prevalence of disease but not incidence of disease.


What does cross-sectional studies examine?

Relationship between diseases and other variables in a population at one time.


What are case-control studies?

Subjects are recruited based on the presence or absence of disease and exposure is measured retrospectivity.


What is a cohort study?

Defined subset of the population can be identified and classified according to exposure status.

It can determine the incidence rate of disease amongst exposed and unexposed individuals.


Describe randomised controlled trials.

- A study in which individuals are randomly allocated to two or more groups.

- Often, one of these groups will be the treatment group while the other will be a placebo group that receives no treatment other than standard care.


In normally distributed data what is 1 SD?

1 SD either side of the mean = 68%


What is a double blind design?

Where neither participants or study personnel knows what treatment has been received until the end of the trial.


What is allocation concealment?

Making sure that those responsible for recruiting and allocating participants to the trial have no prior knowledge about which intervention they will receive.


What does randomisation ensure?

That no systematic difference arise during allocation between groups.
Ensures that treatment effects are not biased by confounding factors.


What does systematic mean?

Defined methodology that could be repeated by someone else and retrieve same publications and results.


What is a systematic review?

Systematically reviews the research evidence on a particular topic.


What is a market?

A network of buyers and seller who exchanged goods and services.
They are regulated by explicit and implicit (ethics) rules.


What is a meta-analysis?

Combining mathematical results of a student in the systematic review to get a more precise estimate of what's happening.


What is a focus group?

An evaluation activity comprising of a semi-structured discussion with a group of people.


Define bias.

A systematic error in measurement.
It's not a random error.


What is the market for used parts?

Organs from cadavers and living donors. E.g. kidney/liver.


How to ration resources?

- The use of evidence of clinical effectiveness
- The use of evidence of cost effectiveness
- The individual Hippocratic ethic and social ethics of economists and public health physicians


What is statistical power?

Probability of correctly rejecting a H0.

In general, the statistical power increases with sample size.

Also, called "Power".


Name organisations and professional groups (both within and outside NHS) involved in providing care to chronically diabetic patients.

MDT, diabetic clinic, specialist diabetic nurse, GP, practice nurse, receptionist, friends, family, neighbours, Diabetes UK or other support groups.


What is the bio-psycho-social model?

“An approach in which health and/or illness are viewed as a product with several interacting factors relating to the individual.” These include biological, psychological and social factors.


What is sensitivity?

The percentage chance that the test will correctly identify a person who actually has the disease.


Which study is good for rare disease and tracing source of an outbreak?

Case control studies


What is specificity?

The percentage of patients without the disease that receive a negative result


What is standard deviation?

How much the values in the data set differ from the mean.
Variability or dispersion of values in the data set.


What is a normal distribution?

(on histogram peak is in the middle)

Mean = median = mode


What is a negative skewed distribution? (left)

Mean < median < mode


What is a positive skewed distribution? (right)

Mean > median > mode


What does sample size and standard deviation share?

Larger the sample size, less role chance plays, SD is lower.


Define range.

Difference between the highest number and lowest number.


Define interquartile range.

▫ The ‘middle 50%’ – the range from the 25th centile to the 75th centile
▫ Describes the spread of data around the median.
▫ It is the distance between the lower quartile value and upper quartile value of a distribution.


What is a correlation?

Measures the relationship between any 2 variables.


What are discrete variables?

A variable with a numerical value, which cannot take on any intermediate values e.g number of children, number of deaths.


What is a categorical variable?

A variable, which refers to categories. It is given a ‘value label’, which is usually a number.


What is a continuous variable?

A variable with a numerical value, which has a potentially infinite number of possible values along a continuum, within a specified range.


What is reliability?

If you get the same results in same conditions.


What is incidence?

New cases of disease within a period / number initially free of disease.


What is incidence rate?

number of new cases of disease in a period number initially free of disease

new cases/people at risk of getting the disease


What is prevalence?

No. of people with disease at particular point in time / the total population

Changes are people die, recover or emigrate.


How is prevalence calculated?

Number of people with the disease and any point in time / total population


What is SD?

A measure of how spread the data is from the mean.


Why does rationing occur?

Because demand in higher than available resources.


In normally distributed data what is 2 SDs?

2 SD either side of the mean = 95%


In normally distributed data what is 3 SDs?

3 SD either side of the mean = 99.7%


What are p values?

Probability of results being found if there is no difference in treatments (accept null hypothesis)
High burden of proof – p <0.05
<1 in 20 chance that the difference is due to chance


What is risk ratio?

Ratio of the risk of an event between 2 groups.
1 indicates risk is the same.
Use cohort studies


What is odds ratio?

Chance that something will happen compared to change that it will not.
Used in case control studies.


What is absolute risk?

One population's risk in its own right. E.g. women have a 11% risk of getting breast cancer.


What is relative risk?

One population's risk compared to another population. E.g. women are 100 times more likely to get breast cancer than men.


In the hierarchy of scientific evidence, what is stronger, cohort studies or case-control studies?

Cohort studies.


What is a case-control study?

A case-control study is a type of observational study in which two existing groups differing in outcome are compared on the basis of some supposed causal attribute.


In the hierarchy of scientific evidence, what is stronger, cross sectional studies or animal trials?

Cross sectional studies


In the hierarchy of scientific evidence, what is stronger, meta analyses and systematic reviews or randomised controlled trials?

Meta-analyses and Systematic reviews


In the hierarchy of scientific evidence, what is stronger, case reports or case-control studies?

Case control studies.


In the hierarchy of scientific evidence, what is stronger, animal trials and in vitro studies or case reports?

Animal trials and in vitro studies.


What does RCTs tend to look at?

New treatment, often a drug.
Compares to current gold standard or placebo.


Which study looks at a population, assess their risk factors and evaluates who gets disease over time?

Cohort study


Which study is good for rare risk factors and can assess multiple risk factors at once?

Cohort studies


Do case control or cohort studies have recall bias?

Case control.


Are cohort studies expensive?



What do case-control studies look at?

Group of individuals with a disease and mathes the to those with similar demographic.


What does correlation coefficients measure?

Strength of an association.


What is a correlation coefficient of 0?

No correlation.


What is a correlation coefficient of 0.4?

Weak positive correlation


What do correlation coefficients range form?

-1 to +1


Is Pearson's correlation normally or not normally distributed?



Is Spearman's correlation normally or not normally distributed?

Not normally


What is a type 1 error?

Incorrectly rejecting the null hypothesis


What is a type 2 error?

Incorrectly accepting the null hypothesis.
Incorrectly saying there is no difference when there is.
Relies on statistical power.


What are guidelines?

Statements that include recommendations to optimise patient care that are informed on a systematic review of evidence alongside expert opinion.


What are protocols?

A set of rules to be followed by healthcare providers for a specific situation


What does high incidence to prevalence ratio mean?

High death or cure rate.


What percentage of adults smoke?



What percentages of men smoke?



What percentages of women smoke?



What is the average consumption of cigarettes per day?



Who smokes more?

Unemployed people


What percentage of those who have ever smoked have now quit?



What are risk factors for anxiety?

Aged 35-54
Being divorced or separated
Living alone or lone parent


What is the lifetime prevalence of anxiety?



Are women or men more likely to have anxiety?



What is the lifetime risk of depression in women and men?

Women - 25%
Men - 10%


What factors increase risk of depression?

Chronic illness
Other mental illness
Afro-Caribbean, Asian or refugee community


What is hypochondrial disorder?

Persistent belief of disease, refusal to accept negative test results.


What is malingering?

Fraudulent simulation or exaggeration of symptoms for financial or other gain.


What is conversion disorder?

Loss of motor/sensory function, no consciously undertaken.


What is somatisation?

Multiple physical symptoms with refusal to accept negative test results.


What is factitious disorder?

Intentional production of physical or psychological symptoms.


What is impairment?

Loss or abnormality of psychological physiological or anatomical structure or function.


What is labelling?

The recognising and naming of a difference of an individual.


What is stigma?

A mark of disgrace associated w/ a particular circumstance, quality or person.


What is sex?

Biological categorisation of humans by their reproductive organs.


What is gender?

The state of being male or female (may not be congruent w/ sex)


What is health promotion?

The process of enabling people to increase control over and improve their health.


What is the black report?

Reasons for inequalities in health.


What are the benefits of good communication?

Increases accuracy of diagnosis and data gathering.

Increased compliance with treatment.

Patient-doctor satisfaction


What are consequences of poor communication?

Inaccurate diagnosis
Less recognition of ICE
Poor compliance w/ treatment.


What is eugenics?

Improving a population by controlled breeding. Encourages good genetics and discourages bad genetics.


What are the tissues with eugenics?

• Thinking about the future based on genetics
• Designer babies
• Genetic screening – health insurance, employment, civil liberties
• Many conditions are polygenic


What is patient centred care?

Care that is responsive to the wants, needs and preferences of the patient.


Name 6 criterias of patient centred care.

• Explores patient’s main reasons for visit
• Seek integrated understanding of patient’s world – their whole person, emo needs, life issues.
• Finds common ground on problem and mutually agrees on management
• Enhances prevention and health promotion
• Enhances the continuing relationship between the patient and the doctor
• Is realistic


What is the sick role?

States the rights and responsibilities for patient and doctors when they have a consultation.


What is the patient expected to do in the sick role?

• Want to get well as quickly as possible
•Seek professional medical advice and cooperate w/ doctor
• Exempt from normal activities and responsibilities e.g. work
• Regarded as needing care and unable to get better by his or her own


What must the doctor do to uphold the sick role?

•Apply a high degree of skill and knowledge
•Act for welfare of patient, not self interest
•Be objective and emotionally detached
•Be guided by rules of professional practice


What does symptom iceberg mean?

Very small MINORITY of illnesses and symptoms are SEEN BY HEALTH PROFESSIONAL


What 4 sources are used when making a clinical decision?

• Patient preferences
• Available resources
• Research evidence
• Clinical expertise


Why is evidence based decision making important?

Variation - between practices reduced


Give 4 ways in which EBDM may be implemented?

• EB Clinical guidelines
• Summaries of evidence provided to practitioners
• Access to reviews of research evidence
• Practitioners evaluating research for themselves


What is economics about?

How people allocate scarce resources amongst competing activities.


Define opportunity cost.

The loss of other alternatives when one alternative is chosen.


Give 3 aspects of opportunity cost decisions.

Time - spending time on 1 person denies another.
Overspending budget cuts another elsewhere.
Good medical practice means you must be aware of the cost of the care you deliver to patients.


What are the sources of NHS funding?

Tax finance
Some user charges (prescriptions)


How is the NHS organised?

210 CCGs - Buyers
Public hospitals and GPs - Sellers


What is the best choice of treatment?

Have clinical effectiveness and cost effectiveness.


What are meta-ethics?

Study of moral concepts e.g. right and wrong.


What is normative ethics (moral theory)?

Study of the means of deciding what is right and wrong


What is applied ethics?

Application of moral theory


What are the 4 ethical principles?

Autonomy, Non-maleficence, Beneficence, Justice


What are the 2 agendas?

Disease and Illness


What is the difference between disease and illness?

• Disease - What is wrong with the body
• Illness - Look at the way that the patient experiences the disease


Why is it important to address both agendas?

• Disease - Means you treat the correct condition, improves biomedical health
• Illness - Can discover how illness is impacting patient’s life, patient more satisfied, enhances doctor-patient relationship


What is autonomy?

• Informing patients with capacity to make their own decisions
• Respecting wishes regarding patient’s treatment


What ethical principles should you think about when assessing patient’s best interests?

• Beneficence - Act to positively benefit patient
• Non-maleficence - Act in a way as not to harm the patient


What is paternalism?

Interference with a person's freedom of action/information.

The intentional overriding of a persons known preferences or actions by another person (this can be by coercion or misinformation).


Define coercion.

Persuading patient to do something by force of threats (e.g. forcing to eat)


What is misinformation?

Lying to save from distress


What is the Bolam test?

Test of negligence, determines standard of care.

A doctor isn’t guilty of negligence if he has acted in accordance with a practice accepted by a responsible body of doctors.


What is the Bolitho amendment?

Doctors should behave in a logical way. If they don't they are being negligent.

BOLITHO - you cannot defend a case on the basis of a current practice that is not reasonable or logical

ie doctor's behaviour should have been logical


List 5 potential difficulties that might occur when assessing best interest.

•Difficulties in predicting future outcome
•Conflict between benefits of treatment and patients own views
•Conflict between patient and doctor view of best interest
•Emotional attachment may distort doctor’s views
•Patient may be unable to communicate relevant information


Why do we need to study populations?

• To find out about risk (diseases, drugs, etc.)
• Need to use evidence of what has previously happened to a population to work out how drugs act


What is the study of incidence, distribution and control of diseases in populations called?



What are 3 types of epidemiology?

• Descriptive - Tell us how things are distributed
• Analytical - How we can exploit those distributions to ask questions
• Experimental - Change the distributions ourselves to see what happens


Give examples of lay people.

relatives, pharmacists


Who is most health care done by?

Lay people - lay referral system


What is illness behaviour?

The way in which symptoms may be differently perceived, evaluated and acted upon by different kinds of persons


What is the symptoms iceberg?

• Only a small minority of symptoms are seen by health professionals
• Patients only report 5-15% of symptoms


What is the llay referral system?

People talk to other people (lay people) before seeking help


What demographic/social factors influence help seeking and illness behaviour?

• Gender
• Age
• Social class
• Race
• Culture


What are Zola’s triggers to help-seeking behaviour?

• Sanctioning – relative/friends tell them to seek help
• Prevention/interference with work or physical activity, social relations
• Interpersonal crisis e.g. death in family
• Time limit on symptoms



What influences health seeking behaviour?

• Perception and evaluation of symptoms
• Perceived risk
• Previous experience
• Psychological factors – Fear of what it might be
• Denial
• Concern about using NHS resources


What barriers are there to help seeking?

• Provision and availability of services
• Car ownership, transport cost, availability
• Disruption to work
• Attitudes of staff – Previous bad experience
• Inverse care law – Better off areas get better health provision that poorer areas
• Geographical distance
• Time, effort
• Long waiting times


What are WHOs 5 aspects of health promotion?


H - Healthy public policy
A - Action in the community
R - Re-orientating health services
P - Personal skills
S - Supportive environment


What are 4 different approaches to health promotion?

•Medical - Focuses on disease and prevention
•Behavioural - Focuses on attitudes and lifestyles
•Client-centred - Focuses on empowering individuals
•Societal - Focuses on political and social action


What is primary health prevention?

• Aims to prevent onset of disease
• Screening risk factors
• Health protection
• Health education


What is secondary health prevention?

• Detect and cure disease at early stage
• E.g. cancer screening


What is tertiary health prevention?

Minimise the effects or reduce the progression of irreversible disease


What is health persuasion?

•Includes mass media campaigns, such as sexual health and healthy eating
•For example, 5-a-day TV campaign


What is legislative action?

Passing a law to promote health. E.g. law that subsidise the price of healthy food.


What is personal counselling?

Opportunistic prevention in consultations. E.g. working with dietician on food.


What is community development?

Locally based initiatives.


What is health education?

Learning experiences designed to facilitate voluntary actions conducive to health.


What is prevention paradox?

A preventative measure which bungs musch benefits to the population but offers little to each participating individual.


What is advocacy for health?

A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme.


What is enabling in health promotion?

Acting in partnership with individuals or groups to empower them to promote andprotect their health.


What is health literacy?

Represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, use information in ways which promote and maintain good health.


What are social inequalities in health?

Differences in people's health linked to social inequalities in their lives.


Are new diseases inversely related to social class?

No, but as disease progresses the social gradient tends to re-emerge


What is the gini coefficient?

Measure of inequality.


Give some examples of social inequalities in health.

Routine manual workers have higher chance of infant mortality

Mortality from injury and poisoning in children is higher is lower social groups

Teenage pregnancy more common in lower social groups


When was the black report published?



What did the black report show?

• Confirmed social health inequalities are involved in mortality
• Shows health inequalities were widening


What are the 4 explanations of socioeconomic inequalities in the black report?

• A statistical artefact
• Natural selection - People's health drives their social class, healthy people are more likely to get promoted, while unhealthy people are more likely to lose their jobs
• Result of differences in health behaviour
• Poverty causes poor health


How do childhood circumstances influence inequalities?

• Childhood is a period of rapid development and heightened sensitivity to environmental influences
• Father's occupation at birth is a strong indicator of life expectancy


Name some government initiatives to help reduce child poverty?

• National minimum wage
• Increase child benefit
• Increase income support
• Teenage pregnancy strategy


Why has child poverty increased?

• Unemployment/part-time work
• Lower pay
• More single parent families
• Freezing or abolition of some benefits
• More indirect taxation


What is the marmot report 2010?

Proposes evidence based strategy to address health care inequalities


What are the 6 policies of the marmot report?

Develop healthy and sustainable places and communities.

Ensure healthy living standards

Fair employment and good work for all

Give child best start to life

Strengthen the role and impact of ill-health prevention

Enable everyone to maximise capabilities and have control over lives


What is culture?

System of knowledge, experience, belief, attitudes, meanings, signs, and symbols shared by a group of people


What is enculturation?

Process of learning your own groups culture


What is acculturation?

Process of taking on another groups culture.


Why are complementary and alternative medicine used?

Easily accessible, control over treatment, dissatisfaction with healthcare, poor doctor-patient relationship, desperation, perceived effectiveness and safety.


What is diagnosis?

Determining the nature of a disorder by considering the patient's signs and symptoms, medical background, and test results


What is prognosis?

Assessment of future course of patient’s disease and management


Where can good evidence be found?

• Cochrane database
• Evidence based journals
• Medline


Why is the symptoms iceberg an iceberg?

Because health professionals only see the symptoms above . water on an iceberg.

Most of the symptoms aren't seen by doctors (under water)


What is medicalisation?

Process of viewing a concept from a medical perspective and trying to deal with it in this way. E.g. pregnancy, menopause, palliative care.


What 4 factors are needed for consent?

Individual must
not be COERCED
must AGREE


What is confidentiality?

Information shared between health professionals and patients. There are exceptions for when they can be shared.


When can confidentiality be broken?

Sharing directly related to individual care
Disclosures for the protection of patients
Disclosures for the protection of others
Legislative - laws that oblige doctors disclose:

1. Public health act 1984
2. Road traffic act 1988
3. Prevention of terrorism act 1989


What is the role of the GMC?

Determine which doctors are qualified to work.

Oversee medical education and training.

Set standards for doctors to follow.

Take action to prevent the doctor from putting the safety of patients at risk.


Name the 4 ethical principles.

Autonomy - Patient’s right to self-rule of their body.
Non-maleficence - Not doing harm.
Beneficence - Doing good.
Justice - Fair and equal access to healthcare.


Name 4 ethical theories?

Deontology - based on adherence to rules

Utilitarianism - actions are right if they benefit the majority

Consequentialism - based on consequence of action

Intentionalist - based on persons intention


Define deontology.

People should adhere to their duties and obligation.

Consistent and does not vary.
Follows rules rigidly.


Define utilitarianism.

Greatest good for the greatest number.


Define consequentialism.

Consequences of actions are the determinant of the validity of an action.


Define intentionalist.

Intentions and activations are determinant of their validity.


What does a systematic review look at?

Looks at all available evidence and combines the results to determine what the evidence says overall (meta-analysis)


What is a highly sensitive test?

It picks up most causes of disease.
Low false negatives.
May have higher false positives.


What is a highly specific test?

A positive test will strongly suggest that the individual has the disease.

Picks up less people with disease. (Higher false negatives).
Few false positives.


What approaches have been suggested to reduce social inequalities in health?

Reduce poverty and inequality.

Improve targeting of health expenditure towards children and public health.


What is Beattie's typology?

Contrasts authoritative and negotiated health promotion

Contrasts individual and collective focus

- Health persuasion
- Legislative action
- Community development
- Counselling


What are individual and collective approaches to health promotion?

Individual – personal counselling, health persuasion

Collective – legislative action, community development


In which age group is smoking most prevalent?

25-34 years, followed by those aged 15-24 and 35-54


What do correlational studies measure?

Outcomes in relation to some factor of interest such as age, time, utilisation of services or exposure.

They use measures that represent characteristics of entire populations to describe outcomes in relation to factors of interest.


What is the prospect theory?

Decisions are divided into 2 parts:

1. Framing and Editing – The preliminary analysis of the decision problem.

2. Phase of Evaluation – Framed prospects evaluated and the prospect with the highest value selected.


What is evidence?

Broad Definition – Any factor than can and should influence clinical decision making.

Narrow Definition – Results of rigorous clinical trials and studies i.e. information research studies. In EBDM the narrow definition predominates.


How are sources of research organised into a hierarchy?

Based on resistance to bias.


What is a stratified sample?

A sample selected from a population that has been stratified, with a sample selected independently in each stratum.

The strata are defined for reducing sampling error.


Why are results drawn from samples are presented with confidence intervals?

To allow you to decide what is statistically significant.


Define confidence interval.

An interval with given probability (e.g. 95%) that the true value of a parameter such as a mean, difference between proportions or risk ratio is contained within the interval.


What a hypothesis?

An idea expressed in such a way that it can be tested and refused.


What are false negatives also known as?

Type 2 error.

Chance of accepting the null hypothesis when the research hypothesis is actually true.


Rejecting the hull hypothesis when it's true is known as what?

False positive.
Type 1 error.


How is clinical obesity defined?

BMI greater than 30


How is overweight defined?

BMI greater than 25 and below 30


What are health consequences of being overweight?

Increased risk of CV disease, stroke, type 2 diabetes, breast, uterine and colonic cancer, osteoarthritis and gout.


What is cost-effectiveness?

The usefulness derived from expenditure per unit spent.


What are current trends in obesity?

Increasing particularly in children.
Due to lack of physical exercise, changes in eating habits and reliance of television and video games for childminding.


What is a quality adjusted life year (QALY)?

Calculated by multiplying the change in utility value (overall measure of a patient's perception of well-being) conferred by an interventional therapy by the expected duration of the treatment, benefit or harm.


How can QALYs be used in making rationing decisions?

The greater the number of QALYs can be used in comparison with opportunity cost.


What is the calculation for the risk ratio?

RR = risk in exposed ÷ risk in non-exposed

(d1/n1) ÷ (d0/n0)


What is the risk difference?

The difference in risk between exposed subjects and non-exposed subjects.

(d1/n1) - (d0/n0)


What factors influence perception of risk?

More willing to accept risks that are voluntary, controllable, familiar, non-catastrophic, fair in the way benefit and risk are distributed i.e. more risk = more general benefit.

General anesthetic and surgery.


What is a correlation coefficient of 1?

Very strong positive correlation


What is the case against a market for blood?

(Titmuss, 1970)
- Represses altruism
- Erodes the “sense of community”
- Sanctions profits in hospitals and clinics, subjects medicine to marketplace rules


What is the case for a market for blood?

(Cooper and Culyer)
- Blood is no different from any other tradable product
- Supply can be increased by removing obstacles to donors
- This needs to be linked with either offering direct payment of exemption from payment in the future based on blood donated
- It is not clear from the evidence which method is cheapest and offers the highest supply quality


Explain rationing.

- Rationing is a feature of all healthcare systems.
- Rationing involves depriving patients of care from which they would benefit and which they would like to consume.
- The issues is not whether to ration care, but how to do so.


What are methods of rationing?

- Ability to pay: this method favours the rich and is accepted in most markets though not usually in healthcare.
- Ability to benefit as measured against cost – this method favours those who can benefit the most per unit cost.


What are the differences between the spectrum of mental ill health seen in primary and secondary care?

Primary care is mostly minor health problems, mild stress and less severe mental illness e.g. some forms of anxiety and depression.

Secondary care is more concerned with relapses of serious mental problems, which require admission to a facility with 24 hours medical and nursing care.


Which gender are more likely to be diagnosed as suffering from psychosis, alcohol or drug abuse?



What are the major causes of learning disability?

- Metabolic – Lack of enzyme leads to build up of phenylalanine leading to microcephaly, epilepsy, autism.
- Toxic – Alcohol, lead
- Injection – Rubella, syphilis
- Neoplastic process – Epilepsy, autism
- Trauma – Hypoxia during birth
- Chromosomal and genetic – Downs Syndrome


What aspects of mental health services are provided: by organisations outside the NHS, by the community and acute sectors of the NHS?

- Community Support: Primary Care, crisis intervention, community based alternatives to acute care.
- 24-hour care: Housing w/ intensive support, sheltered accommodation, group home/shared housing, medium support hostels, residential homes, high support accommodation, 24 hours nursed accommodation, acute inpatient care, low secure units, medium secure units, special hospitals.
- Day-care and daytime activities: Ordinary employment, supported employment, adult education.
- Financial support: Welfare advice centre.


What are the possible consequences of stress on personal performance?

- Improvement, no change, sub-par performance.
- Impact on personal health.


What facilities are available to help both during training and for practicing doctors?

Treatment from doctors outside your local area to save embarrassment.


What is analogy?

Are there similar studies with similar results?


Interpret the coefficient (b) and intercept (a) of a simple regression equation: y=a+bx?

- Regression: Finds the best mathematical model to describe y, the outcome, with respect to x, the exposure. The most common form is linear regression.
- The regression co-efficient is an estimate of the change in outcome (y) for a unit change in exposure (x) according to the equation is y=a+bx, where a is the intercept and b is the slope.
- The regression line is a diagrammatic presentation of a regression equation.
- The steeper the gradient (coefficient) the more effect x has on y.


What is NICE?

National Institute for Clinical Effectiveness

Produces guidelines and provides advice to clinicians about best practice


What is the correlation coefficient, what does it tell you about the nature of the relationship between 2 variables?

- Correlation coefficient: A measure of association that indicates the degree to which variables change together.
- The stronger the relationship the closer it is to 1.


What does NICE do?

Technology appraisals of new and existing health technologies

Clinical guidelines for the management of specific conditions

Interventional procedures program.


What is the Cochrane collaboration?

An international, non-profit, independent organisation, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide.

It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions.


When was the Cochrane Collaboration founded?

1993 and named after British epidemiologist, Archie Cochrane.


What are major causes of death/illness among children and adults in MEDCs?

Adults - Circulatory disease, cancer, respiratory disease. Children – Infection, poisoning and cancer.


What are major causes of death/illness among children and adults in LEDCs?

LEDC – Cholera, malnutrition, malaria, diarrhoea, problems with pregnancy and neonatal death, infection, AIDS.


What is taking a population perspective?

A population perspective complements the focus on the individual.

Sometimes the interests of the individual and population conflict.


What factors led to changes in life expectancy in the developed world over the last century?

Creation of safe water and sewage disposal systems, the control of disease-bearing insects/rodents, immunisation programs, improved nutrition.


What does the population pyramid of a developing country look like?

Triangular (pyramid or exponential) population distribution
♣ Wide base = high birth rate
♣ Narrow top = high death rate (short life expectancy)
♣ Typical pattern for LEDC w/ little birth control, poor hygiene, poor health service access.


What does the population pyramid of a developed (UK) country look like?

Rectangular population distribution
♣ Narrow base – low birth rates
♣ Lack of change in size between consecutive age groups – few die until they reach old age.
♣ Wide top – long life expectancy
♣ MEDC w/ contraception, good public hygiene and health care.


How is the NHS organised?

- Taxpayers
- Department of Health – Sets policy, strategy and standards
- Strategic Health Authorities – Manage performance
- Primary Care Trusts – Fund and commission services
- Hospital NHS Trusts – Give secondary and tertiary care
- Patients and Public


What is the role of primary care trust?

- Improve health of community, secure provision of high quality services in primary, secondary and tertiary care.
- Integrate health and social care locally (work with local authorities).
- Contract services from “independent contractors” such as GPs, dentists and community pharmacists.
- Responsible for examination of premises, investigation of complaints, screening, communicable disease control and emergency planning services are provided.


What is the role of primary care trusts?

Improve health of community.

Integrate health and social care locally (work with local authorities).

Contract services from “independent contractors” such as GPs, dentists and community pharmacists.

Responsible for examination of premises, investigation of complaints, screening, communicable disease control and emergency planning services are provided.


How do you identify all relevant studies in systematic reviewing?

• Search relevant databases
• Develop complex search strategy
• Include unpublished data


How should guidelines be developed?

Using a formal, explicit process.
Use the best evidence to address each relevant clinical question.


What are the typical grief reactions?

Affective - Depression, distress, guilt

Cognitive - Denial, lowered self-esteem

Behavioural - Fatigue, agitation, social withdrawal

Psychological - Loss of appetite, weight loss

Immunological - Disease, illness


Which part of the brain is involved in grief?

Nucleus accumbens - Associated with reward and motivation


Describe the nature of grief.

Universal - e.g. crying

Culturally determined - Time of grief varies



Name Bowlby's stages of grief.

Yearning/ Searching
Despair / Disorganisation


What is complicated grief?

Impaired by prolonged guilt.
Symptoms - depressive thoughts, anxious, painful memories


When is, consent required?

• Before examination
• Before treatment or care
• Disclosure of confidential information
• Screening
• Teaching
• Research


What information does the patient require as part of the consent process?

Potential benefits
Alternative treatment options


What are the 4 forms of consent?

Oral, written, implied, expressed.


What are 3 requirements for valid consent?

Informed, voluntary, with capacity.


What is the Bolam principle?

Practitioners are not negligent if they act in accordance with the practice accepted by a responsible body of medical opinion


What is battery?

If a person touches another person without consent


What is negligence?

The concept of failure to exercise care


Which act focuses on who has capacity?

Mental capacity act 2005


Who does the mental capacity act apply for?

16 and older


Which act says a 16-year old has full capacity?

The family law reform act 1969


What is. Gillick competency?

Child (under 16) can consent to medical treatment if deemed competent by medical professional without need for parental permission or knowledge.


Why are P drugs used?

Pharmacists can ask customers questions about who it is for, symptoms, etc.

Ensures no 'red flags' about how long the patient can use it for

Duration of a symptom may mean it is not safe to self-treat


Name 3 community pharmacy teams?

• Minor ailment schemes
• Emergency contraception
• Smoking cessation
• Health education


What are descriptive statistics?

Data is collected and summarised and described in terms of means, SDs etc.


Self-medication scale of analgesics say that the belief of patients can fit into 3 categories?

• People reluctant to take mild analgesics
• People who 'don't think twice' about taking mild analgesics
• People who prefer to let pain 'run its course'


What is ecological fallacy?

Inferences about nature of individuals are deduced from inference for the group to which they belong


What is ordinal data?

Categories ordered in value e.g. degree of pain


What are measures of. dispersion?

• Standard deviation
• Interquartile range
• Range


What are measures of location?

Mean - Average of all observations
Median - Midpoint of the data set
Mode - Most frequent observation


What are confidence limits?

The actual upper and lower boundaries that state the boundaries of the confidence interval.


What is standard error?

• Describes how good a given estimate is
• Tells you how good your sample statistic is
• Looks at how accurate your estimation of the mean is


At what point is statistical significance generally accepted?

• P=0.05
• Strong evidence against the null hypothesis, can reject the null hypothesis
• Statistically significant


What is nominal data?

Categorical e.g. sex


What is a confidence interval?

Range of values that we think contain the mean


What are the primary, secondary, and tertiary management principles associated with sickle cell?

• Primary - Carrier screening
• Secondary - Postnatal screening
• Tertiary - Treatment, preventatives, therapeutics


Which anaemias are genetic/

SCA and thalassaemia


How is ethnicity important in medicine?

Disease prevalence varies with ethnicity

Approaches to best treatment may vary with ethnicity

Affects behaviour towards others

Can look at the patient per their own values


What is risk?

Probability that an event will occur during a specified time

Only works if a time period is fixed


What is absolute risk?

Risk of developing the disease over a time period


What is relative risk?

The ratio of the probability of developing an outcome in those exposed compared to those not exposed (risk ratio)


When can confidentiality be breached?

Statute (law)
Consent by patient
Public best interest


Name some statutes (laws) that oblige doctors to disclose information?

• Public Health Act 1984
• Road Traffic Act 1988
• Prevention of terrorism act 1989


What is a cross-sectional survey?

Descriptive study, observational

Analyses data from a population at one specific point in time


What is an ecological study?

Disease rates and exposures are measured in a series of populations and examined


What is a cohort study?

Can be prospective (looking to future) or retrospective (looking into past)

Subjects with certain exposure followed over time for outcome occurrence
What is a case control study?

Looks back to understand risk factors that lead to a particular disease


What is a case report?

Detailed report of symptoms, signs, diagnosis, treatment, and follow-up of individual patient


What is a randomised control trait?

An experiment where participants are randomly allocated into groups

Compare experimental group and control group for outcomes


What is. statistical power?

The probability of rejecting a null hypothesis when it is false.


What is regression towards the mean?

If a variable is extreme on its first measurement, it will tend to be closer to average on its second


What is the biopsychosocial model?

• Individuals must be an active participant in their own rehab and recovery
• Management must relieve pain and prevent disability


What is a carer?

A person who, without payment, provides help and support to a partner, child, relative, friend, or neighbour who could not manage without their help.


RCT are not appropriate to provide evidence for prognosis outcomes. What study designs are better?

Cohort studies
Case-control studies

(Because they are observational)


Why is prognosis important? Give 4 reasons

Knowledge of prognosis can help diagnostic / treatment decisions

Important for patients to know the likely course of their disease

Different patients will value outcomes differently, and hence this must be taken into account during decision making

Doctors are not always accurate in their prognosis judgement


Define prognosis.

An assessment of the future course and outcome of a patient's disease


What is a "risk factor"?

Patient characteristics associated with development of the condition in the first place


Define "prognostic factor"?

Characteristics used to predict outcomes more accurately.


Give examples of 3 prognostic factors

Demographic (age, gender)
Disease-specific (tumour grade)
Co-morbidities (existing conditions)


What population of individuals are studied in a Cohort Study?

A group of individuals with a disease or who have been exposed to a risk factor.

Compared to a comparison group.


What population of individuals are studied in a Case Controlled Study?

People with diseases are compared with controls without diseases, against risk factors exposed to them in the past.


What is the sick role?

Sick Role defines the obligations and privileges of the doctor-patient relationship.


What must the doctor do to uphold the sick role?

• Apply a high degree of skill and knowledge
• Act for welfare of patient (patients best interest), not self interest
• Be non-judgemental and emotionally detached
• Be guided by rules of professional practice


Describe the professional attitude expected of medical staff and students?

First concern - patient
Protect and promote health
Good standard of practice and care
Dignity - respect patients dignity
Honest, open, integrity


What right does the doctor have? (as part of the sick role)

• Right to examine patients
• Granted autonomy in professional practice
• Occupies position of authority in regard to the patient


Criticisms of the sick role?

• Symptom iceberg - Patients do not necessarily act on symptoms and go see the doctor
• Chronic illness and MUS - If cause unknown, patients can't enter sick role due to uncertainty
• People try to label themselves as sick
• Conflict between best interests for the patient and cost to society in allocation of resources

• Tension/strain on doctor to be non-judgemental and ignore their own beliefs


What is evidence?

Body of facts/information indicating whether a belief or proposition is true or valid


What 4 sources are used when making a clinical decision?

• Patient preferences
• Available resources
• Research evidence
• Clinical expertise


Why is evidence-based decision making important?

• Deals with uncertainty
• Medical knowledge is incomplete/shifting
• Patients will receive most appropriate treatment
• Constant need for innovation and improvement
• Improving efficiency of healthcare services
• Reduces practice variation


Give 4 ways in which EBDM may be implemented?

• Evidence based clinical guidelines
• Summaries of evidence provided to practitioners
• Access to reviews of research evidence
• Practitioners evaluating research for themselves


What is flat of the curve medicine?

The phenomenon where health care consumption (costs) continues to rise while health outcomes (usually defined by life expectancy), remain the same


Criteria for choosing the best treatment

Must be cost effective and clinically effective


What must the doctor do to uphold the sick role?

• Apply a high degree of skill and knowledge
• Act for welfare of patient (patients best interest), not self interest
• Be non-judgemental and emotionally detached
• Be guided by rules of professional practice


What are meta-ethics?

Study of moral concepts, eg right and wrong


What is normative ethics (moral theory)?

Study of the means of deciding what is right and wrong

Seeks to tell us how we can find out what things have what moral properties, to provide a framework for ethics


What is applied ethics?

It seeks to apply normative ethical theories to specific issues, telling what it is right and wrong for us to do- APPLICATION OF MORAL THEORY


What are the 3 main types of moral theory?

• Consequentialism - Moral based on the consequence of the action (Whether an act is right or wrong depends only on the results of that act.
The more good consequences an act produces, the better or more right that act)

• Deontology (duty based) - Moral based on actions adherence to the rules (focuses on the rightness or wrongness of actions themselves)

• Virtue ethics - Right act is one a virtuous person would do (emphasizes an individual's character as the key element of morality)


What are the 2 agenda's and what's the difference between them?

• Disease - What is wrong with the body (physically)
• Illness - Look at the way that the patient experiences the disease


Why should you treat both the disease and the illness (2 agendas)?

• Disease - Means you treat the correct condition, improves biomedical health
• Illness - Can discover how illness is impacting patient's life, patient more satisfied, enhances doctor-patient relationship


What ethical principles should you think about when assessing patients best interests?

• Beneficence - Act to positively benefit patient
• Non-maleficence - Act in a way as not to harm the patient


What potential difficulties that might occur when assessing best interest?

• Difficulties in predicting future outcome.
• Conflict between benefits of treatment and patients own views.
• Conflict between patient and doctor view of best interest.
• Emotional attachment may distort doctors views.
• Patient may be unable to communicate relevant information.


What are CCGs?

- Clinical commissioning groups
- There are 210 CCGs (buyers) of the NHS).
- Responsible for planning commissioning health care services for local area.
- Created following health & social care act 2012.
- Clinically led statutory NHS bodies.


When might it be appropriate to withhold requested treatment?

- Treatment is contrary to physician's duty of care.
- When law make provision for a conscientious objection e.g. abortion.
- Requested treatment is illegal e.g. euthanasia.


Salmon et al. identified that patients tend to be given 3 explanations for their symptoms/illness:

1. Rejection
2. Collusion
3. Empowerment - most appropriate


How do you prove causation?

- Find association
- Consider cause of association
- Use Bradford hill criteria to inform decision


Define chance.

The effect of random chance in finding a significant result.


Define bias.

Error in the collection and analysis of data.


Define falsifiability?

We can rarely rove things are true, but can easily prove things are false.


What is a rejective response?

Doctor denies the reality of the disorder and implies it is a stigmatising psychological problem.


What is an empowering response?

- Legitimises patients suffering, exculpation.
- Removes blame.
- Opportunities for self-management.


What is publication bias?

Not all clinical studies get published.


List 6 barriers which prevent people from making an appointment,

Responsibilities - childcare
Work - loss of pay
Psychological factors - fear of what it might be
Previous negative exp
Expecting it to go away
Reassurance by family and friends


List the legislations the health care service works within.

Disability Discrimination Act
Human Rights Acts
The Health Act
NHS Community Care Act
Equality Act 2010


What is Hill's criteria for causation?

Group of guidelines useful for providing evidence of a causal relationship between a cause and an effect.


What is strength in the Bradford Hill criteria?

Effect size.

A small association does not mean that there is not a causal effect.

The larger the association the more likely that it is causal.


What is consistency in the Bradford Hill criteria?


Consistent findings observed by different persons in a different place with different samples strengthens the likelihood of an effect.


What is specificity in the Bradford Hill criteria?

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 better the probability of a causal relationship.


What is temporality in the Bradford Hill criteria?

The effect has to occur after the cause.


What are Zola's triggers to (help seeking behaviour) consultation?

1. Interpersonal crisis occurs
2. Interference with social or personal relations
3. Interference with work or physical activity
4. Temporising - setting a personal deadline
5. Sanctioning - pressure from other people to go to doctor


What is analogy in the Bradford Hill criteria?

The effect of similar factors may be considered.


What is Experimental Evidence in the Bradford Hill criteria?

A very strong proof of cause and effect comes from the results of experiments.

In experiments other variables are held stable to prevent them interfering with the results.


What is coherence in the Bradford Hill criteria?

If laboratory experiments in which variables are controlled and external everyday evidence are in alignment, then there is coherence.


What is dose response in the Bradford Hill criteria?

Biological gradient.

Greater exposure should generally lead to greater incidence of the effect.

In other cases, an inverse proportion is observed: greater exposure leads to lower incidence.


What do confounding variables damage?

Internal validity of an experiment.

They are 3rd variables researcher failed to control.


Name some measures that assess activities of daily living?

• Measures of disability - Barthel Index, SF36
• Observation
• History taking
• Clinical examination


What is performance bias in randomised controlled trials?

Systematic difference in the care provided to the participants in the comparison group (control group)


Which act gives rights to disabled people?

• Disability discrimination act 1995


What is standard error?

If the population was sampled many times, standard error is a measure of the variability of the mean in those samples.

Standard error shows how well the mean of the data (sample estimate) approximates the true value (population mean).

SD / square root number in sample


What are rights?

Justified claims on others or things to which a personal is entitled.

Rights provide minimum standards.
And pose ideal directives.


What is a type 1 error?

Incorrectly rejecting H0

False positive


What is incorrectly accepting the null hypothesis called?

False negative or type 2 error.


Describe type 1 and type 2 errors.

Type 1 - rejecting H0, false positive
Type 2 - accepting H0, false negative


What is the reference interval?

Same as reference range.

Range of values for a physiologic measurement in healthy persons.

E.g. Partial pressure of oxygen in arterial blood is 38-42mmHg


What is the Gini Coeffienct?

Measure of inequality

- greater the coefficient the more unequal income is being distributed in the population
- area between Lorenz curve and perfect distribution = Gini coefficient