Total HS Flashcards
What is the importance of causation?
Explains why things happen
Prevents disease by removing cause
Improve treatments through greater understanding of natural history of disease
Name the Bradford-Hill criteria?
Strength of association
Specificity - Does A always only cause B?
Temporal association - effect has to come after cause
Theoretical plausibility
Consistency - Do you always find the same relationship?
Coherence - Does the data fit in with what we know now?
Dose-response relationship - Does greater exposure lead to greater effect?
Experimental evidence - Can we test this experimentally?
Analogy - If A causes B, does something similar to A cause something similar to B?
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What is clinical significance?
Practical importance of treatment effect, whether it has a noticeable effect on everyday life
What is flasifiability?
We can rarely prove things are true, but can easily prove things are false
What is statistical significance?
Strength of association gained by hypothesis testing
How do you prove causation?
Find association
Consider cause of association
Use bradford hill criteria to inform decision
What is confounding?
Both factors not directly associated, but linked by a third factor
What is bias?
Error in the collection and analysis of data
What is chance?
The effect of random chance in finding a significant result
Describe the professional attitude expected of medical staff and students?
Make care of your patient your first concern. Protect and promote the health of your patients and the public. Provide a good standard of practice and care and keep up to date.Treat patients as individuals and respect their dignity. Work in partnership with patients. Be honest and open and act with integrity. Maintain confidentiality.
What is the definition of medical professionalism?
set of values, behaviours and relationships that underpins the trust that the public has in doctors
Describe the regulatory role of the GMC
o protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.
Outline the role of medical schools and the GMC in ensuring students and doctors fitness to practice?
GMC sets its guidance for what medical graduates need to accomplish in Tomorrow’s Doctors. This is taught by the medical schools. This is examined formally in various exams taken throughout the course, reflective essays, learning to give feedback and self-reflection, attendance and punctuality, plagiarism.
benefits of good communication?
More accurate diagnosis More accurate data gathering Increased adherence with treatment regime More effective patient-doctor relationship Increased patient-doctor satisfaction
Consequences of poor communication?
inaccurate diagnosisLess recognition of ICENon-adherence to treatmentDecreased satisfaction with doctorMore complaints
an communication skills be taught?
skilled training leads to improvement in communication Self reflection Feedback should be specific, descriptive, and non-judgemental
why is Calgary-Cambridge important
eery patient has their own problem and explains it within their own framework Understanding the CC model can help you treat them better and you can communicate with them from within their own framework
what models explain difference in people?
Biomedical explanations of difference rely on biologySocial models explain difference by social interactionsFaith system Epigenetics (combines biological and social)
what makes science social?
- Decisions about research funding
- Pharmaceutical industry - profits
- Ethical issues
- Nature of scientific work - communication
Name the theories of predicting and changing health behaviours?
- Transtheororetical model
- Health belief model
- Theory of planned behavour
What is sensitive analysis?
• Tests if results are sensitive to restrictions on data
What is heterogeneity?
• Similarity of studies
What is publication bias?
•
Not all clinical studies get published
Methods of quality assessment?
•
Randomisation
• Allocation concealment
• Blinding
• Withdrawals and intention to treat analysis
What is a clinical protocol?
•
Plan to be followed in patient care (more prescriptive that guideline)
How do you identify all relevant studies in systematic reviewing?
•
Search relevant databases
• Develop complex search strategy
• Include unpublished data
What factors affect self-management of a long term illness?
- Relationship with doctor
- Good experience with doctor in the past
- Drugs best avoided
- Experience of symptoms when they don’t take them
- Gender roles
What are guidelines?
• Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare specific clinical circumstances
How do you determine the quality of a guideline?
•
Application
• Clarity of representation
• Rigor of development
How should a guideline be developed?
•
Systematically
• Using a formal and explicit process
• Address relevant clinical question
• Use the best evidence to address each question
Why do we have guidelines?
- To allow practice to be more evidence-based
* Enable care to be more consistent across the country
Define health behaviour?
• Activity people perform to maintain or improve health
Why study health behaviour?
•
Treatment protocols are behaviours
• Rising medical costs
• Aging population
What is social cognition theory?
•
Attitudes are developed and modified based on assessments about beliefs and values
What are the typical grief reactions?
•
Affective - Depression, distress, guilt
• Cognitive - Denial, lowered self-esteem
• Behavioural - Fatigue, aggitation, social withdrawal
• Psychological - Loss of appetite, weight loss
• Immunological - Disease, illness
What is complicated grief?
•
Impaired by prolonged guilt
• Symptoms - depressive thoughts, anxious, painful memories
Name Bowlby’s stages of grief?
•
Numbness
• Yearning/searching
• Despair
• Reorganisation
Describe the nature of grief?
•
Universal - e.g. crying
• Culturally determined - Time of grief varies
• Biological
Which part of the brain is involved in grief?
• Nucleus accumbens - Associated with reward and motivation
What is a chronic condition?
•
Long term illness expected to last 12 months or more
What is biographical continuity?
•
Biographical distribution based on adult-centred model
• It is a part of themselves since birth
• Older adults will usually maintain the same activities, behaviours, relationships as they did in their earlier years of life
What is biological disruption?
•
Sees chronic illness as disruptive event
• Disrupting structures of everyday life
• Onset of chronic illness can affect upon a person’s sense of self and their identity
What uncertainty comes with chronic illness?
•
Social - Employment, finance, etc
• Clinical - Prognosis
• Diagnosis
• Psychosocial - Sense of self and identity
What are the negative consequences of being diagnosed?
•
Face new set of uncertainties - prognosis etc
• Stigma
• Possible limitations on paid work
• Worry about being able to fulfil obligations e.g. look after children
• May have to claim benefits
• Worry about complications
• Worry about being able to deal with medications
What are the positive consequences of being diagnosed?
•
Relief
• Access to sick role
• May result in employment rights, welfare benefits
• Accepted as ill be friends and relatives
• Access to information
• Access to support groups
What are the characteristics of a long term condition?
•
Uncertainty - Diagnosis, prognosis, complications, etc
• Involves high levels of self management
• Can have consequences for employment
• Can be a source of embarrassment or stigma
• Can have impact on social life
• Can impact self identity and personal relationships
What is consent?
• Voluntary agreement given by a competent patient that has been fully informed
What is Gillick competency?
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Child (under 16) can consent to medical treatment if deemed competent by medical professional, without need for parental permission or knowledge
Which act says a 16 year old has full capacity?
•
The family law reform act 1969
Who does the mental capacity act apply to?
•
People who are 16 and over
Which act focuses on who has capacity?
•
Mental capacity act 2005
What is capacity?
• Determined by a physician, refers to an assessment of the individual’s ability to understand, appreciate, and manipulate information to form rational decisions.
What is negligence?
•
The concept of failure to exercise care
What is battery?
•
If a person touches another person without consent
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
Why is consent needed?
•
Improves trust between patient and doctor
• Legal requirement
• Respects autonomy
• Professional duty
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
- Potential risks
- Alternative treatment options
What are the 4 forms of consent?
- Oral
- Written
- Implied
- Expressed
What are the 3 requirements for valid consent?
- Informed
- Voluntary
- With capacity
What is addiction?
• Continued repetition of a behaviour despite adverse consequences
What are the symptoms of end stage addiction?
- Overwhelming desire to take drug
- Almost automatic habit
- Can be triggered by cues many years after abstinence
What maintains addiction?
- Personality factors
- Social factors
- Withdrawal symptoms
What factors make a drug addictive?
•
Pleasure producing potency
• Rapid onset of action
• Short duration of action
• Tolerance and withdrawal
What are the symptoms of dependence syndromes?
- Salience
- Compulsion
- Tolerance
- Withdrawal
- Relief after abstinence
- Narrowing of repertoire
- Reinstatement upon absence
Medically unexplained symptoms
What are medically unexplained symptoms?
• Physical symptoms not explained by organic disease
What is an empowering response?
• Legitimises patients suffering, exculpation
What is a collusion resopnse?
• Using explanations about blood pressure and serotonin to push antidepressants
What is a rejective response?
• Doctor denies the reality of the disorder and implied it is a stigmatising psychological problem
What is exculpation?
• Recognise reality of suffering and exculpate symptoms by confirming that they are not the patients responsibility
What does the patient want?
- Alliance with the doctor over problems
- Wants the doctor to recognise they are suffering and it’s not their fault
- A convincing explanation that is plausible and credible
What are the doctors assumptions about MUS?
- Explanation lies with the patient
- Patient’s deny a psychological cause
- They want a cure and diagnosis
- They get physical intervention because they demand it
- Doctors should help patients to appreciate psychological factors
What are the consequences of living with MUS?
- Uncertainty - no diagnosis or prognosis
- Lack of social support
- Can’t enter the sick role
- Strained social and family relations
What are the main problems with medically unexplained symptoms?
• Patient presents with symptoms and doctor tries to treat disease, despite there not being one
What is disease?
• Discrete pathological processes within the body with clinical signs
What is illness?
• Sufferer’s subjective experience
What is stress?
• An imbalance between the demands made on us and our personal resources to deal with these demands
What are negative coping strategies to illness?
• Problem focused - Focuses on problem, unlikely to help reduce stress
What are positive coping strategies to illness?
•
Problem-solving - Controlling problem and reconstructing it as manageable, seeking information and support
• Emotion focused - Involves managing emotions and maintaining emotional equilibrium
What are Leventhal’s 5 dimensions to illness cognition?
- Identity
- Consequences
- Cause
- Control/cure
- Timeline
What is illness cognitions?
• A patient’s own implicit common sense beliefs about their illness
How do medically unexplained symptoms arise during times of stress?
- Misinterpretation of normal bodily sensations
* Exaggeration of minor pathology due to stress
Primary vs secondary appraisal of stress?
- Primary - Appraisal of event
* Secondary - Appraisal of personal coping skills
What is symptoms amplification?
- Misinterpretation and amplification of symptoms due to stress and other psychological factors
- Occurs due to tendency to worry, mental illness, illness beliefs
What are the 4 components of the stress response?
- Emotional - Feeling sad, over-reacting
- Cognitive - Cannot concentrate, sensitive
- Behavioural - Eating, smoking
- Physiological - Heart rate, breathing, perspiration
What is risk?
• Probability that an event will occur during a specific time
What are the types of stigma?
- Discreditable - Keeping stigma hidden
- Discrediting -Stigma that can’t be hidden
- Felt - Shame you feel as a result of stigma
- Enacted - Discrimination by others
- Courtesy - Felt by someone with a person who is stigmatised (eg parent of autistic child)
What is the process of producing stigma?
- Labelling - Label human difference
- Stereotyping - Differences link to characteristics
- Othering - Separating yourself, ‘us and them’
- Stigmatising - Devaluing people based on ‘undesirable’ attributes
- Discrimination - Acting differently towards people based on attribute/behaviour
What is stigma?
• A mark of disgrace associated with a particular circumstance, quality or person
What is social constrictionism?
• The enactment of stigma is about social interaction - It is about people’s responses to behaviour or physical appearance
What is cultural iatrogenesis?
• The destruction of traditional ways of dealing with and making sense of death, pain and sickness
Stigma
What is social iatrogenesis?
• Results from the medicalisation of life
What is clinical iatrogenesis?
• The injury done to patients by ineffective, toxic, and unsafe treatments
What factors did McKeown he argue improved health?
- Environment - Nutrition and hygiene
- Behavioural - Reproduction
- Medical - Immunisation
- Public health
What is pharmaceuticalisation?
• Transformation of human condition into opportunities for pharmaceutical intervention
What is medicalisation?
• Non-medical problems become defined and treated as medical problems
What is the precautionary principle?
• Action shouldn’t be taken if the consequences are uncertain and potentially dangerous
What is Beck’s risk society?
- The manner in which modern society organises in response to risk
- Risk now viewed as a product of human action
What are the paradoxical outcomes of risk assessment?
• We feel more vulnerable to risk
What is justice?
• Treating people in a way that is fair and equitable
What is the Libertarian argument?
•
Some people are poor because they don’t work hard enough, or cause their own needs (eg by smoking)
How can you decide ways to distribute healthcare?
- QALY calculation
- Waiting list
- Likelihood of complying with treatment
- Lifestyle choices of patient
- Ability to pay
What is the difference principle?
• Only permits inequalities that work to the advantage of the worse off
What is the needs-based assessment for distribution of healthcare?
• Health care distributed to those who need it most
What is equity?
• Fairness or impartiality
What is equality?
• Being the same in quantity, amount, value, intensity
What is distributive justice?
• How we distribute resources that are finite in a fair way
What is a lifestyle-based assessment?
• Allocating resources should take into account lifestyle choices patients make
Arguments for lifestyle-based assessment
• People who contribute to ill health are less deserving of resources for treatment than those who don’t
• Deterrence - It is more likely to deter people from damaging their health
• You are also more likely to get more benefits from a treatment in people who don’t
What are the main 2 aims of the human rights act?
- To make it possible for people to directly raise or claim their human rights within complaints and legal systems in the UK
- To bring about a new culture of respect for human rights within British Law, not just about public authorities complying with the law
Why are rights important?
- You know where you stand in society as a citizen, and you can feel secure
- Protective boundaries - Limits actions of others
- Sets minimal standard
What are passive rights?
• The rights not to be done to by others in certain ways
What are active rights?
• Allow people to act or not act as they choose
What are negative rights?
• Others have to refrain from doing something
What are positive rights?
• Confer some sort of duty to someone
What are instrumental theories?
- The purpose of rights is to promote a certain state of affairs which is seen as good
- If we have a system that recognises rights, it will lead to a much happier society
What are status theories?
• Humans have certain qualities/attributes that make it fitting to assign rights to them
What rights does a person have in relation to resource distribution?
- Legal rights
- Natural moral rights
- Human rights
Arguments against lifestyle-based assessment
- Not everyone purposely engages in high risk behaviour and is not responsible for their actions
- Unfair to punish people
- Deemed unacceptable by the GMC to use lifestyle based approach
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
What employment related policies are there for carers?
- Time off for dependents
- Flexible working regulations
- Work and families act 2006