aleena
MBBS
PRE-CLINICAL
CPH/PPD/PSAH
NOTES
By Murtaza Kadhum
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Contents
SEM 1 & 2
3
SEM 3
18
SEM 4
39
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SEMESTER
1&2–
PPD
Consent
Patient must not be pressured into making a decision either from family or from the doctor. They
must be given the opportunity to say ‘no’.
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Consent means a voluntary, un-coerced decision made by a sufficiently competent or autonomous
person on the basis of adequate information and deliberation, to accept rather than reject some
proposed course of action (Gillon 1986)
Valid consent
Information
Voluntariness
Competence
COMPETENCE: Mental Capacity Act 2005 requires the following from a patient when making
decisions about treatment:
1.
2.
3.
4.
Patient must understand
Retain information
Weigh up information
Communicate their decision
INFORMATION: GMC says the patients must understand in broad terms the nature and purpose of
treatment and should be aware of any significant risks. This is enough to avoid battery.
VOLUNTARINESS: Free choice important here, free of coercion or undue pressure or perceived
coercion.
Importance of consent:
•
•
•
•
•
Legal requirement
Respect patient autonomy
Respect for persons
Establishes relationships of trust with patient
Benefits patient
a. Subjectiveness of ‘benefit’ (e.g., Jehovah’ Witness)
b. More realistic expectations (pt. feels they are in control)
c. More co-operation (e.g. they will fast before surgery)
If a patient refuses beneficial treatment, the doctor must assess if the patient is COMPETENT and is
giving VALID CONSENT.
COMPETENT ADULTS CAN refuse a life-saving procedure, even if this may appear irrational to the
doctors. E.g. woman refusing life-saving treatment even if her foetus dies (surely irrational?) but her
decision counts
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Exceptions where consent not needed:
•
•
Necessity: Where treatment is best option and patient is NOT COMPETENT to give consent
Emergency: Dr must act (e.g. ambulance brings patient  hospital in A&E) to prevent harm
Children and when patients pose risk to others (TB)
Introduction to Ethical Practice
When making PRActical decisions consider:
•
Moral Perception – consider ethical dimensions which may not be apparent at first sight
Moral Reasoning – The 4 principles:
Autonomy – respecting the decision-making capacities of autonomous persons; enabling
individuals to make reasoned informed choices (TRUTH/CONSENT/CONFIDENTIALITY)
Beneficence – this considers the balancing of benefits of treatment against the risks and
costs; HCP should act in a way that benefits the patient
Non-maleficence –avoiding the causation of harm; the healthcare professional should not
harm the patient. All treatment involves some harm, even if minimal, but the harm should
not be disproportionate to the benefits of treatment
Justice – distributing benefits, risks and costs fairly; the notion that patients in similar
positions should be treated in a similar manner
•
Moral Action – actually implementing the ethical practice independently (should do  must
do)
ETHICS: Professionalism
Attributes of a HCP:
•
Belong to an organisation (NHS)
Exercise autonomy over their work
Pledge assistance to those in need
•
Possess ‘esoteric’ knowledge – deep knowledge understood by few
•
•
Licensed by state
Duties of HCP:
•
•
•
Moral duty – is it the correct ethical expression? (guilty)
Professional duty – what does the regulatory body say (GMC)? (sacked)
Legal duty – is it within the boundaries of the law? (jailed)
MODELS OF HEALTH & DISABILITY
Consider the bio-psycho-social model when interviewing patients with a chronic illness or a disability
as this may be a particularly relevant to their condition/lifestyle.
Also consider patient-orientated care e.g. GP, district nurse, family/carer etc. – Primary Care Team
CONCEPTS OF PSYCHIATRY
Stigma (A dynamic process of devaluation that discredits an individual in eyes of others’):
Discrimination (having +ve/-ve actions towards someone.)
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Ignorance (Having slanted views on X people)
Prejudice (A +ve/-ve attitude towards someone)
Mental Illness – abnormalities of behaviour (related to abnormal/distressing experience). Types of
mental illness: Organic: physiological explanation e.g. multi-infarct dementia and Functional: no real
explanation, e.g. anxiety
Organic leads to Psychosis – Unable to distinguish between reality and fantasy. Insight impaired.
Hallucinations.
Functional leads to Neurosis – You can make the distinguish between the reality and fantasy. Intact
insight. Anxiety, low mood, obsessions.
Felt stigma  you feel that people discriminate against you because of your illness, and the
perceived social rejection. Disabled individual at an interview may feel he is discriminated against,
but isn’t.
Enacted stigma  when you are actually discriminated due to your illness and the social rejection it
involves. Disabled individual at an interview is discriminated against.
Adv/disadvantages of classifying mental illness:
Advantages
–
Frames problem, therefore can aid diagnosis.
–
Prognosis
–
Guides treatment (e.g. CBT, REBT)
–
Aids communication (e.g. in court, Helps explain to patient or family) and
encourages concordance.
–
Research purposes
–
Demystify mental illness/challenge stereotypes by normalising in comparison to
other health problems.
Disadvantages
–
Detracts from personal issues (Holistic approach)
–
Stigmatisation/labelling
–
Not always possible to classify (no 2 people have all symptoms). Spectrum of
diseases is present.
–
Blame (people faking symptoms)
ETHICS: Children
Minor – A patient below the age of 18
Consent for children
•
Gillick (Fraser) competence for consent to treatment if <16 yrs old. Child understands…
– Benefits, risks and complications (e.g. of treatment failure) of that treatment option,
another other treatment options, inaction.
–
BUT parent can override <16yr old refusal to treatment
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EVIDENCE AND PRACTICE
The International Statistical Classification of Diseases and Related Health Problems 10th Revision
(ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social
circumstances and external causes of injury or diseases, as classified by the World Health
Organization (WHO).
GMC – a legal body which deals with complaints about doctors (police)
Gives doctors general guidance on practising medicine and outlines the duty of a doctor, register the
F1 doctors, to ensure the public receive suitable care. Although guidance produced by the GMC
creates no legal duty, it does carry weight in law and the Courts have recognised the importance of
such guidance.
BMA – group of doctors, philosophers, lawyers, theologians and lay people (family)
The BMA has a medical ethics department that answers individual ethical enquiries from doctors,
and produces guidelines and books on ethical issues.
PSYCHOLOGY OF MEMORY/LEARNING
Three stages of memory:
Encoding (putting info in memory)  Storage (maintaining info.)  Retrieval (recovering info.)
Atkinson-Shiffrin Model (1968) for the structure of memory
STM: working memory is a temp store, decays rapidly, refreshed by rehearsal. No changes to
synapses.
LTM: requires consolidation, long term store, decays slowly, changes top synapses occur.
Short Term Memory:
•
Need to attend to a stimulus
•
•
Encoding occurs but limited capacity chunks
Info is active when conscious
•
Can last for life, large capacity.
•
•
•
Requires consolidation of info
Involves the hippocampus in the brain
Info needs to be retrieved
Long Term Memory:
Retrieval may require cues. At the point of encoding, if you repeat and organise the info to be
stored, it is more easily retrieved. Being in the same context also helps (same place, emotional
state). Forgetting is decay, displacement, retrieval failure or interference.
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Implicit memory (non-declarative/procedural) e.g. motor skills “draw the shape” - MEMORY FOR
SKILLS
Explicit memory (declarative) e.g. verbal skills “describe the shape” - MEMORY FOR FACTS
There is different memory for facts (explicit) than skills (implicit). In amnesia motor and perceptual
skills are preserved. Semantic knowledge (general knowledge) is spared but episodic memory
(personal) is disrupted. Anterograde: inability to learn new things, whilst retrograde: is inability to
remember old memories before the injury.
Patients are more likely to remember when:
•
•
•
The information at start and end of consultation
Statements which are perceived to be important by patient
When total amount of info is less to remember
•
•
•
When short words and sentences, and no jargon is used.
Material is organised and repeated
Higher IQ
Classical conditioning(Learning by association)
Acquisition  Reinforcement  Extinction  Spontaneous recovery  generalisation
Unconditioned stimulus usually leads to an unconditioned response passively. A conditioned
stimulus (when a previously neutral stimulus – a sound – is associated with unconditioned stimulus)
will lead to a conditioned response (learned response to previous neutral stimulus. E.G. Patient
attending hospital for chemotherapy becomes nauseous on just entering hospital.
Classical conditioning can be intervened by systematic desensitisation. This is quite obvious, and an
example can include a gradual exposure. E.g. arachnophobia – you would present small spiders, and
as the person becomes more confident you get a larger spider and so on.
Operant Conditioning (operate) (learning by consequences)
Behaviour that becomes more or less frequent depending on the stimulus that follows it.
E.g. Patient in need of social interaction visits GP frequently, if the GP provides the social
stimulation.
STRESS, ILLNESS & COPING Stress
and disease:
•
People under stress alter their behaviour, which affects their health for example by taking up
risky behaviour as a type of coping mechanism e.g. smoking.
•
Stress may influence perception of symptoms and complaint behaviour leading to higher levels
of medical consultations and detection of disease.
Stress (Situations that the average person would appraise as threatening and exceeding his ability to
cope. Traumatic stress involved real physical threat of serious injury or death like combat. Non
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traumatic stress is threat to social self, self identity, self esteem or confidence like bereavement or
poverty), a distinction needs to be made between:
•
stressors - external events that may cause stress (e.g. life events, daily hassles, chronic
stressors).
•
stress responses – behavioural, emotional, cognitive, physiological responses to stress
strain - the effect of stress on a person.
...Because stress is poorly defined and used to mean a lot of things. Can also help with
understanding responces and creation of theories. Also aids communication between individuals or
for teaching lay or professional people.
Theories to the approaches to Stress:
1. The General Adaptation Syndrome – focuses on the response to stress
Alarm, the fight or flight response mobilises the body to defend against the stressor.
Resistance, if the stress continues, the body goes into a stage where arousal remains high and the
body tries to defend/adapt to the stressor
Exhaustion, where physiological resources are very low, the ability to resist may collapse, and
disease or death may result
-ve: stresses of same magnitude (milk gone=no phone battery=ran out of food i.e. all stresses same)
-ve: does not consider cognitive appraisal of a person’s response to stressors e.g. Person A knows
there is an escaped criminal and Person B does not. They live separately. There is a noise in the
garden of both Person A and B. Person A is more alert and scared as they are aware of the existence
of an escaped criminal, whereas Person B does not know this information. So, Person B is not
alarmed by the noise.
2. Life Change Model / Life Events approach – focuses on stress as a stimulus
Accumulation of life events and continuous adjustment is then thought to have an effect on health.
To measure stress, you can count the number of events that have occurred in a period to an
individual. Examples of life events are death of a spouse, divorce, marriage, retirement, a new family
member, changing jobs, injury or illness etc. Research has found that life events are associated with
many illnesses, such as heart disease, cancer and depression. Questionnaires which the patient ticks
on a scale and then if the overall rating is high, then this predisposes the person to conditions. -ve:
(milk gone does not = the same stress as no phone battery...I can grade individual stresses) -ve: not
all events in the list are bad, divorcing wife may be a good thing.
3. Transactional Model – focuses on stress as an interaction between the person and the
stressor
The demands do not match the resources. Perceived demand of the stressor can be balanced by
person’s ability to cope. Ability to cope can include coping strategies, changes in personality or
support. When perceived demands outweigh perceived resources this results in the psychobiological
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stress responses. The individual then tries to cope and the results of these efforts may affect the
stressor, or the perceived demands and perceived resources.
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For example, examinations are stressful for most
university students; a student who copes by revising
thoroughly will be more confident in their ability to pass
so the exams will appear less threatening. In contrast, if a
student copes by avoiding thinking about the exams and
not revising or preparing for them, then the threat of the
exams will increase as they draw nearer.
-ve: Doesn’t account for sudden stressors e.g. Knocking
over a pan of boiling water. Lack of empirical evidence.
•
Cognitive behavioural therapy (CBT): Help person to SEE the thoughts that accompany –ve
emotions/behaviour, e.g. make them keep a diary.
Coping (constantly changing effort to manage external and internal demands, that are appraised to
be exceeding the resources of a person. You can do this by reducing demand, increase resources or
dampen stress responce by e.g. medication)
How individuals cope with health events is very varied and is affected by differences in the type of
health event faced, the course, prognosis, and individual differences in resources and coping styles.
Individual differences in coping style are typically divided up into:
•
•
Problem-focused coping: coping with the stressor itself.
Emotion-focused coping: coping with the emotional reaction to the stressor.
Acute Health events:
•
Extent of stress determined by novelty, predictability and controllability.
•
If a stressor is novel, unpredictable and uncontrollable, then a larger stress response will be
elicited. E.g elective surgery vs car accident.
Chronic Health events:
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•
‘Crisis’ model: after being diagnosed with a chronic illness, individual loses their social status
(you can’t work etc.)
–
•
•
This can lead to ‘biographical disruption’ (bad) or ‘negotiation’ (good)
Biographical disruption
–
Enacted stigma: occurs when a person experiences actual abuse &/or discrimination
(finger pointing)
–
Felt stigma: When a person feels he is being discriminated against when actually he
is not.
–
Different conditions have different social meanings. E.g. cirrhosis means alcoholic
–
Therefore these conditions hold stereotypes
–
Impairment or disability (e.g. HIV) leads to restriction in activities and social roles
(due to recurrent infections). This then leads to negative labelling, which is enforced
by negative social stereotypes transmitted in everyday life or media such as drug
users (for HIV). This will diminish patients self esteem and cause felt stigma, leading
to isolation and withdrawal from social life which eventually causes a lack of
confidence and loss of skill.
Negotiation
–
Person has difficulty maintaining ‘normality’ with time
–
BUT they refuse to accept labelling and stigmatization; they preserve their identity
When faced with the demands of chronic illness, patients have to make large adjustments (Moos &
Schaefer). They need to:
•
•
•
•
Adjustment to symptoms and incapacities of illness
Adjustment to treatment procedures and hospital environment
Developing and maintaining relationships with health care providers
Preserving a reasonable emotional balance
•
Preserving a satisfactory self-image and a sense of competence and mastery (POSITIVE THINKING)
Sustaining positive relationships with family and friends
Preparing for an uncertain
future.
Type A Behaviour – (Pissed off) – Hostile/Impatient/competitive (learn these exact words) Leads to
higher risk of CHD
Type B Behaviour – (Relaxed) – Self-evaluative/imaginative/creative (learn these exact words)
INTRODUCTION TO HEALTH PSYCHOLOGY
Psychology ( ) is the formal study of normal and abnormal behaviour using systematic measurement
and experiment, among representative samples. Health psychology addresses psychological
influences on and consequences of physical illness. It has a role in prevention (changing health
behaviours such as less smoking), consequences of illness (e.g. assessment of these) and treatment
(e.g. psychological therapy like counselling).
Models of health & illness:
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Bio(medical) model: Health and illness can be explained purely by disturbances in physiological
processes (e.g. resulting from injury or biochemical imbalances)
Bio-psycho-social model: Health and illness affect and are affected by physiological, psychological
(e.g. coping mechanisms) and social factors (e.g. social norms).
The most common research methods are:
 Randomised controlled trails(RCTs) – e.g. effect of stress management training on pain
reduction
 Longitudinal surveys (e.g. do higher levels of physical activity in pregnancy prevent the onset
of depression – following a group throughout a period of time)
The typical measures are:
•
Cognitive tests (IQ )
•
Observation ( e.g. hostility in patients)
•
Biological markers (cortisol)
Main Areas of study

Health/Clinical : psychological illness (‘socially unacceptable behaviour’)


Developmental : psychological development (studies how we change with time)
Neuropsychology: behaviour and neurology (the brain and diseases associated)

Social : interaction between individuals

Cognitive : human information processing (IQs etc)

Occupational : psychology in the workplace (e.g. reducing absenteeism)
Health Psychologist are often Clinical Psychologists who specialise in helping individuals who are
suffering from psychological consequences of physical illness or who need psychological help with
managing a physical illness. GP’s refer patients to these if patient has anxiety or depression.
INTELLIGENCE
Intelligence is the general ability to understand and use information, to think logically and adapt to
new situations.
Intelligent Quotient (IQ) is the index of intelligence derived from intelligence tests. Performance on
these may be improved by confidence to do well, familiar with concepts of exam and materials used.
Heritbility: the proportion of variation in intelligence attributed to genetic variation in the population
(usually 0.4-0.6)
Clinical uses of IQ tests:
• Assessing intellectual impairment following trauma.
• Assessing intellectual impairment associated with disease processes.
• Diagnosing and quantifying extent of learning disabilities.
Seven domains of intelligence: Spatial
Interpersonal
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Bodily Kinaesthetic
Linguistic
Logical
Intrapersonal
Musical
Intelligence can be determined by the following:
•
•
•
•
•
•
poor childhood nutrition
exposure to environmental toxins (lead)
exposure to certain drugs in utero (alcohol, cocaine)
lack of exposure to an intellectually stimulating environment in childhood
neurological injury or disease
genetic disorders affecting brain development
LAY HEALTH BELIEFS
Lay-health beliefs are beliefs which the lay public hold used to account for their material, social and bodily
circumstances. They are based on knowledge and from information passed on from word-ofmouth, general
knowledge, professionals and other areas. (Stacey 1988). The Public Health White Paper – ‘saving lives: Our
healthier nation’ (1999) was produced by the DoH and described that patients have an active role in
implementing lifestyle decisions which affect their health.
Sociological conceptions of lay-health beliefs
1. Health as functional capacity (Blaxter 1982)
i.
‘Health is the absence of disease’ as well as ‘health in disease’ (Blaxter 1990). ii.
Largely a working class conception, but also found in those with chronic ill health,
who were less likely to define health in terms of illness.
iii.
Being able to fulfil social and work roles is the main criterion of healthiness iv.
‘Never having a day’s illness’ is used as a (positive) moral individual
characteristic.
v. Seeing ‘health as coping,’ related to this health is the idea of health as ‘reserve’, as a
‘cheerful stoicism’, even when physically ill.
2. Disease as candidacy (Davidson, Davey Smith & Frankel 1994)
i.
Used in lay health beliefs of relative risk of disease and effectiveness of preventive
health behaviours
ii.
Constructed from the appearance of the person and the circumstances surrounding
the event
iii. Can support or challenge biomedical aetiology iv. Identification of those ‘disease
candidates’ retrospectively and/or predicatively i.e. “He was fit, skinny and
young...He was the last person you would expect to have a heart attack”
v.
This is essentially teleological explanation of illness i.e. “there was a meaning or purpose
underlying his/her illness”
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Zola (1973) – five decisions which trigger seeking medical care, emphasises importance of lay referral
system
People actively seek information from both multiple professional and non-professional sources. New
technologies may extend and enhance the lay referral system. For example, it has been found that
with information sourced from the Internet, people often make a provisional self-diagnosis that could
be confirmed by telephone consultation (i.e with a nurse via NHS Direct), and so do not ‘have to waste
the doctors time’. This last finding demonstrates that in many ways that certain cultural assumptions
and values around the sick role continue to prevail. So for example, callers to NHS Direct were found
to be eager to preserve their status as ‘deserving patients’ i.e not to use up resources unnecessarily.
Expert Patients Initiative (DoH 2001) aims to recognise the intimate (and rational) knowledge and
experience that patients have of their illness, and encourages patients to take an ‘active role in their
own care’. This in principle will lead to the development of ‘user-led self-management programmes’
concerned to increase patient ‘self-efficacy’ and enable them to take more control of their chronic
illness condition.
•
Understanding the ways in which lay beliefs differ from the clinical perspectives of HCP’s help us
to communicate more effectively and encourages concordance.
•
Understanding lay beliefs regarding health maintenance and disease prevention is important to
health education.
•
To understand health seeking behaviour.
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LOSS, BEREAVEMENT, GRIEF
•
Loss is important only if it is something to which we are attached
•
The attachment gives us some security
• this may include the security of self esteem
Loss can be applied to things other than just people. Loss is an inevitable part of life, some people
cope with it better than others, others find role change very difficult and some experience severe
loss of self esteem with role change.
Loss – The state of being deprived of something or someone one has had
Grief – The painful emotions associated with bereavement: sadness, anger, guilt, shame and anxiety.
Mourning – Psychological processes triggered by loss and process of recovery. The act of expressing
grief.
Bereavement – state of having lost someone or something to which one is emotionally attached.
The closer one is with someone, the more vulnerable that person will be if they experience
bereavement.
Acute Response to Grief – includes crying, hallucinations, agitation, aimless actions (up to 6 weeks)
Longer Term – social withdrawal, sleep disturbance, depressed mood (last 3 – 12 months)
Stages of grief:
STAGE 1 – numbness, shock, (DISBELIEF)
STAGE 2 – Anger
STAGE 3 – Yearning and searching(hallucinations)
STAGE 4 – depression
STAGE 5 – Acceptance / reorganisation of mental model of world.
Pathological grief:

Absent grief – Failure to display symptoms of grief – may result in
‘delayed’ grief or anxiety problems.

Prolonged grief – initially seems normal LIKE NORMAL GRIEVING. Intense
grief persists and is distressing and disabling. Disabling symptoms at high
levels, persisting at least 6 months after death and associated with
functional impairment.
Immune response to bereavement includes HIGH levels of ACTH & Cortisol and reduced levels on
Natural Killer (NK) cells. Therefore there is vulnerability of the immune system and increased stress.
Therefore there is increased physical health morbidity, consultations, medication and hospitalisation.
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Mortality after bereavement is higher due to : Change in usual health practises of individual,
neglecting of early signs of disease, unstable management of chronic diseases like diabetes, alcohol
and drug abuse and loss of care by the deceased. Also self harm or suicide.
HEALTH BEHAVIOUR
Health behaviours consist of any behaviour that has an impact on health, whether positive or
negative. Several models have been proposed to try and account for health behaviours:
•
Health Belief Model (HBM)
•
Theory of Reasoned Action (TRA)
•
Cognitive Dissonance Theory
Health Belief Model:
*Family hist?
How bad the
disease is? *
•
Advantages
–
Identifies physical barriers (cost/travel/withdrawal) and their importance
–
Compares ‘power’ of different factors, e.g. cue > cost Disadvantages
–
Doesn’t explain irrationality in health behaviour (delay in obtaining medical advice
following symptoms)
–
No mention of emotion & habits
–
No mention of social factors (e.g. If your main social is going to the pub) – Doesn’t
explain all health changes (exercising for 6-pack vs reducing CV disease) – Threat
does not always predict behavior change for many health behaviors e.g.
smoking.
Theory of Reasoned Action/Theory of Planned Behaviour:
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–
–
–
–
Individual attitudes: your own beliefs about health behaviour & knowledge of
consequences (e.g. I’ll be fine if I reduce my drinking a little)
Social influence: Beliefs about others’ opinions (e.g everyone knows I drink)
Perceived control (often wrong): How much control people think they have. (I am
confident I can control my alcohol intake)
All these affect intention and this will influence Behaviour (e.g. To control
consumption of alcohol)
Advantages:
 Identifying perceived control
 Identifies social norms
Disadvantages:
 People don’t always do what they intend (especially habits)
 Doesn’t take into account addiction (no barriers), habits or beneficial factors such as
social support.
 Doesn’t take into account future (anticipatory regret)
 Different morals determine different behaviours
Cognitive Dissonance Theory (Prime Theory):
Cognitive dissonance Theory: ‘guilty feeling’ or dissonance when 2 cognitions are in conflict
Example:
–
Cognition 1: I am a heavy drinker
–
Cognition 2: drinking excessively is bad for health
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An example would be someone who is alcohol dependent and who holds the beliefs that 1) drinking
excessively is bad for the health and 2) he/she is a heavy drinker. The resulting dissonance might be
reduced in several
· Changing one or both cognitions: e.g. convincing yourself that you feel much better when you are
drinking, that the benefits outweigh the costs and that you do not drink as heavily as many people
that you know.
· Eliminating one or both cognitions: e.g. Convincing yourself that the dangers of drinking are
exaggerated.
· Avoiding thinking about the cognitions: e.g. Avoiding discussing your drinking problem.
· Adding a cognition that allows the two conflicting cognitions to be reconciled e.g. 'I will reduce my
drinking in the new year' or 'I am addicted and it is out of my control'.
· Changing behaviour e.g. Reducing alcohol intake
Advantages: Easy to use in practice, making someone guilty (cognitively dissonant) is easy all you
have to do is add a cognition, used in counselling.
Disadvantage: no social/emotional factors or barriers, purely individual and cognition focused.
RISKY HEALTH BEHAVIOUR
•
Epidemiological approaches are based on risk assessment/analysis i.e. calculate the damage
by behaviour (e.g. smoking 1 pack a day = life shortened by 10 yrs)
•
Disadvantages
–
Assumes risk is controllable (e.g. I could give up smoking tomorrow)
–
Doesn’t take into account immeasurable social factors (e.g. how many friends have
to be smokers before you start)
–
Assumes that all risk is down to the personal choice (e.g. it’s your fault you took E in
the club, despite the fact everyone was on it)
–
Statistically significant, but silly associations (e.g. single mothers are most likely to
smoke…why?)
Sociological & social-psychological models to explain risk behaviour:
•
•
Cognitive social psychological models = focus on i) social cognition & ii) choice in behaviour.
–
Utilise the principles of social cognition to emphasise the character of risk behaviour.
–
This approach privileges an individual’s perceptions or beliefs over group influence –
Examples are the Health Belief Model and the theory of reasoned action.
Disadvantages…
–
Separate social & cognitive components in risk behaviour
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•
•
–
ignore the affective component of behaviour
–
–
Assumes risks are outside of social context
Explains the benefit to individuals of doing risky health behaviour e.g. risking HIV
infection to gain intimacy with partner. This is called situational rationality – assumes
risky health behaviour is rational to an individual given the immediate social
situation, however risky to their health in long term.
–
Assumes a type of economic rationality in decision making, a weighing up of all the
costs to see if the benefits of that behaviour is worth the risks. However risks may be
unconsidered (taken for granted aspect of daily life), especially since behaviour is
social and involves others
Cultural theory of risk = recognition of risk is based on culture
–
Variations in risk recognition, assessment and response is seen to reflect the
differential socialisation in cultures and within social institutions.
–
This theory emphasises the point that what society calls risky is determined by social
and cultural factors.
–
E.G. Pigs are considered as dirty animals
Phenomenology (2 parts)
–
Unconsidered risks: taken-for-granted understanding ( e.g. unprotected sex or only
elderly get cancer.)
–
Assessment of new risks: weighing benefits against risks in novel situations (e.g. I
haven't tried that drug, how safe is it?)
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SEMESTER
3–
CPH/PPD,
PSAH
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WHISTLE BLOWING AND MEDICAL ETHICS
Errors and mistakes are usually systemic, and they are rarely one-offs or due to poor performance. Errors
are made by everybody. It is important to get over the blame culture so that mistakes can be identified are
where relevant, be reported to agencies. Best solution is for systemic improvement such as clinical
governance (E.g. less work hours by EU), adopt safety culture and remove blame culture.
Clinical negligence has legal components:

Doctor has DUTY OF CARE (Doctors have this towards anyone with whom they have a
doctorpatient relationship, easy established, NHS trusts have a duty to provide a good service
and GP’s have a duty to help people in their practise. However are sued directly)

Duty of care was BREACHED (to evaluate this, we need to know what the standard duty of care
is... refer to bolam and Bolitho)

Breach of duty of care caused HARM (Injury/death caused by many factors, causation is easy to
prove but proving the doctors negligence was the cause is harder. An omission is even harder to
prove. “But for” test used “but for the defendents negligence, would the patient have suffered the
injury”.
Bolam v Friern Barnet Hospital Management committee [1957] 2 All ER 118
According to Bolam a doctor is not guilty of negligence “if he has acted in accordance with a
practise accepted as proper by a responsible body of medical men skilled in a particular art”.
Bolitho v City of Hackney Health Authority [1996] 7 Med LR 1
It follows the Bolam test for professional negligence, and addresses the interaction
with the concept of causation. A doctor is not guilty of negliegence if his actions
have a “logical basis”. Therefore, the rationale behind choices by doctors is s
scrutinised.
If negligence is proven, then damages are awarded for both physical and mental harm as well as
loss of earnings.
Keeping notes and records as a doctor can be brought up in court in order to assess the quality of the doctor
(Expertise of doctor also looked at, inexperience is not). Courts look at notes as a discrete heading in
proceedings. Patient notes must be written appropriately (Inclusion of consent, treatment, management
and any changes, legibility, correctly dated etc.) so that if the patient were to access the notes, there would
be no problems or complaints.
If you sign a prescription (even on the advice of another) you are legally responsible Four-fold
duty to check:
•
correct patient name and drug name
- 22 -
•
no comparative or absolute contraindications
•
correct dose and directions given
•
make provision for appropriate monitoring and follow up
The limitation period – action alleging negligence to be brought within 3 years of claimant discovering
damage. In case of neonates, period does not start until 18 (until 21).
Guidelines by definition are not rules, however, if a doctor departs from them, they must be able to justify
why.
In 1998, the GMC stated that doctors should report underperforming colleagues, but this naturally causes
conflicts. It may be that colleagues who are potentially underperforming rather than actually
underperforming that are disclosed. The next issue after identifying a colleague is the person/organisation
to disclose this colleague to.
Court costs NHS a lot.. NHS redress act introduced aimed at anything below 20k, therefore reducing costs
and moves away from blame culture.
Legal action taken more often if: Poor rapport, poor comm, failure to apologise/explain.
A culture of litigation has resulted in the development of “defensive medicine”. This is
“The practice of performing tests as a safeguard against possible malpractice liability rather than to ensure the
health of the patients”
Defensive medicine is generally:
Largely an unstable explanation for action
Makes litigation more likely (extra tests, treatment etc. An act can be proven more easily for
negligence than a omission.
Saturates resources, so people who may actually benefit from them do not.
Very expensive and incurs financial burden to the NHS, who already has a limited budget.
THE ETHICS OF DISTRIBUTION
About 15% of taxpayers’ money (7.5% of GDP) is invested into the NHS. After the 2007 Comprehensive
Spending Review, the expenditure for healthcare services was prioritised for: cleaner hospitals,
greater GP access and innovation within the NHS. Resources invested to the healthcare are not always
financial and also include: time, energy, bed spaces and personnel.
When making a decision there are at least three layers to consider:
Macro – how the overall cake is cut
Midi – how the healthcare budget is allocated
Micro – how clinicians are paid and how much money is spent on individual patients
Questions of allocation of resources involve a range of ethical considerations including fairness,
respect for individual autonomy, responding to individual need and benefiting the whole population.
Difficult choices have to be made where pressing claims are made upon a limited budget. For
example:
- 23 -
• Those who are young and have a longer expected time of survival with treatment?
• Those who are parents with dependent children?
• Treating a greater number of patients rather than fewer patients with a greater need?
• Treatment that prolongs life or treatment that improves the quality of life?
• Established treatments rather than experimental treatments?
Recall the four principles Justice, Beneficence, Non-maleficence and Autonomy.
Justice [distributive] ≡ Equity ≡ Fairness
John Rawls puts forward a concept of a ‘veil of ignorance’ in his theory of justice. In this theory you
are faced with a range of societies to live in. The only catch is that you do not know which position you
hold in that society (status or wealth i.e. if you were old, a pregnant woman or a child). Rawls claims
that most rational people would choose the society where the people who are most disadvantaged
would be as well off as possible, so that if they turned out to be a disadvantaged person, they would
have good treatment.
The Human Rights Act 1998 has several acts, which can be linked to allocation of healthcare:

Article 2 states that there is a ‘right to life’. There is a positive obligation upon the State to
ensure that this right is respected. The positive obligation under Article 2 must be
interpreted in a way that does not impose an impossible / disproportionate burden on the
authorities. Therefore, although the State cannot be expected to fund every treatment, it
must act reasonably in allocating resources.

Article 8 right to private life

Article 12 right to marriage and children

A refusal to fund medical treatment because of the advanced age of the patient could be a
breach of Article 2 and Article 14 (prohibition of discrimination). Article 14 would also be
relevant where resources are not allocated for treatment on the grounds of gender.
Different approaches to rationing:
•
QALY stands for Quality Adjusted Life Year. Let us first consider what the unit of QALY
indicate:
1 QALY
=
=
=
1 year of perfect health
2 years of half perfect health
4 years of quarter perfect health
When a patient is ill they have a rating of less than one, and any change in their health is reflected as
either a rise or fall in the rating.
The general idea is that a high priority health care activity is one where the cost per QALY is as low as
it can be. Also cost-effective analysis is important when choosing different methods of treatment.
Allows for maximisation of utility and benefit from a limited health care budget, but could ignore
need. Also puts a price on life, which is potentially unethical. It also requires calculations to give a
- 24 -
value on health, however different treatments affect people differently and therefore these values
may be inaccurate.
•
The libertarian free market by Nozick says “taxation is slave labour” and there should be no
resources to redistribute. But this may exclude the poor from treatment,
discrimination(gender, lifestyle), inefficient (insurance company bureaucracy)
•
Lottery. Allocate using a lottery, everyone treated equally and no discrimination. Does not
take into account need, cost effectiveness and responsibility.
•
Allocate resources based on need. But is it too simple? How will you define need? Cost
effectiveness?
Social worth. Allocate resources on basis of contribution to society. But this ignores need...
Who decides? Discrimination possible also.
•
•
Personal responsibility. Allocation of resources on basis of life style. Idea that people are
responsible for their health and this gives an incentive for them to behave wisely. However,
not all choices are free (e.g. habits or addictions), this method may be too harsh and lead to
more judgemental doctors and it expects a high level of morality from imperfect human
beings.
•
Democracy. Allocate resources by a democratic voting system. There is a chance of
discrimination, especially when not everyone in population votes. General public are not
specialists in health care and therefore this may lead to bizarre decisions such as in America
where tooth capping was prioritised ahead of appendectomy.
Challenging rationing very rarely goes to court, most common type of challenege:
•
Irrational or unreasonable rationing decision
•
Procedural impropriety in the decision making process
RACE & ETHNITICTY IN HEALTH AND ILLNESS
Ethnicity generally relates to some form of distinctive set of cultural characteristics. These can include
common geographical and ancestral origins, language and cultural traditions. However, often other shared
characteristics such as nationality, migrant status, religion and ‘race’ are used as substitutes for ethnicity.
There are two implicated concepts of ethnicity in use in the health care context:
–
Ethnic group is self-perceived identity and membership of a social group. This is a conception
widely used in survey research including the ethnic monitoring now being carried out within the
NHS.
–
Ethnic origin is to do with a common ancestry or place of origin. This conception thus focuses the
question of ethnicity back in time and conveys a historical and frequently geographical context.
However, classificatory problems arise with this conception of ethnicity in relation to second- and
- 25 -
third–generation people whose parents or grandparents came to Britain from elsewhere but who
themselves were born, educated and socialised here.
This approach assumes that ethnic boundaries are fixed and clear, yet in practice such boundaries are
frequently fluid and imprecise. Ethnic groups have been and often remain the ‘other’ - an identifiable
group or groups who may be blamed for problems within a society or community; who also carry the weight
of undesirable moral, physical, social, cultural characteristics or conditions and may be stigmatised e.g.
‘dirtiness’/unclean-ness, diseases such as syphilis or AIDS, TB or leprosy, ‘immorality’ or ‘ignorance’
Culture - sets of beliefs and ideas that a social group draws upon in order to identify and
manage the problems of their everyday lives. [How does one define problem? Everyone is
different and deals with situations differently]
Both ethnic and cultural boundaries may be constructed and maintained by social groups themselves (due
to pride of a sense of identity). The label of ethnic difference is more usually imposed by the dominant
groups in a society, who construct minorities as the ‘other’.
`Race' like ethnicity is also a social construction which has no distinct genetic basis. The purpose of ethnic
monitoring is to enable the NHS to achieve an equitable provision of services, without racial or ethnic
discrimination. However, problems emerge when putting both the concepts of race and ethnicity into
operation. This process essentially constitutes ‘reification’ (making an abstract concept concrete or real) of
ethnic origin producing a set of categories, for example `Other Asian’ or `Other Mixed Background’, which
are purely artefactual and have no meaning outside the world of health needs planning. However, ethnic
monitoring does potentially have an important role to play in a national screening programme for sickle
cell disease and thalassaemia major
Health professionals need to be sensitive to cultural differences, as well as to the complexities and dynamics
of ethnicity. Such knowledge can provide doctors with essential information about a patient’s beliefs and
practices as they pertain to health and health care (for example, it may be easier to talk to people about
making changes in their diet if the doctor understands whether the avoidance or consumption of particular
foods is religious or cultural). Awareness of cultural difference can serve to challenge the stereotypes that
can all too easily slip into a clinical assessment of a patient (e.g. asian women have problems with
communication). Professional cultures and institutional practices in health care can play an important role
in reinforcing and constructing norms of patient behaviour. It is usually ethnic minorities who are all too
often identified as those groups falling outside of these norms – termed ‘institutional racism’. (E.g. higher
rates of sectioning in psychiatry in minority groups)
SOCIAL INEQUALITIES IN HEALTH
The bulk of the inequality witnessed throughout human history results not from biological differences, but
from social differences existing between individuals and social groups, and results from the structured
social divisions of a particular society at a given time – social stratification.
Socio-economic class is used to investigate the effects this stratification may have for different social groups
e.g. unequal ‘life chances’. The socio-economic model of health adopts the broad position that social
inequalities in health reflect differential risk exposure across the lifespan. This relative health risk is
primarily associated with an individual’s socioeconomic class position (see flowchart in lecture).
- 26 -
The Black Report (1980) examined the association between social class and health, and indicated death the
rate of disease incidence (morbidity) and the rate of incidence of death were not randomly distributed
throughout the population. The report identified a number of types of possible explanation for this finding:
•
Artefact – health results are a result of individual behaviour (coding and human errors also)
•
•
Social/Health selection – those with poor health are downwardly mobile
Behavioural/cultural factors – focus on class differences in health beliefs and behaviour. Also
people with low class more likely to smoke, drink and have poorer nutrition.
•
Material circumstances – social differences in income(which continues to widen due to e.g.
taxation that favours the well off), diet, housing and stressful working environment as key
determinants of inequalities in health
The report found that it was primarily material circumstances that were the main cause of social
inequalities in health.
The main differences in health outcomes that currently exist between social classes in the U.K. are that:
•
Life expectancy is increasing for every social class. However, it is increasing faster in the higher
social groups.
•
Mortality and morbidity has decreased for every social class. However, mortality rates are much
higher in lower classes than higher e.g. rates are 4x higher in lower 10% compared to upper 10%.
•
The social class gradient of mortality and morbidity in Britain holds for most disease
classifications.
The gap in inequality, has been reduced in terms of the absolute number of deaths involved.
However, the gap in health equality in relative terms, has become larger. In 2001, a worker in a
routine or manual occupation was twice as likely to die before the age of 65 than his manager, but
in 2008 that ratio had risen to 2.3 times
•
•
Acheson Report 1998
This showed that since the introduction of the welfare state there was a fall in mortality but the greatest
fall in mortality was in upper classes. Thus, some recommended interventions include:
 Medical Care

at level of morbidity to prevent early death. Improve access to healthcare
 Preventative approaches

to change individual risk
 In workplace

to improve psychological conditions, reduce unemployment
 In social structure

to reduce social and economic inequalities, provide good food at cheaper prices, provide
better housing
- 27 -
PHYSICAL ACTIVITY – Benefits, determinants & interventions
Physical activity is any bodily movement produced by skeletal muscle that results in energy
expenditure. E.g. structured exercises (sports) or lifestyle exercises (walking)
Fitness is where an individual possesses a set of attributes that relate to their ability to perform
physical activity.
Adults are recommended to do at least 30 minutes of exercise for five days in a week, at a moderate
intensity [get warmer, breathe harder, heart beat faster, but able to hold a convo] or 75 mins of
vigorous exercise [same as above but can’t hold a convo] over a 5 day period. Also, PA to improve
muscle strength on 2 days. For children, it is recommended to do at least 60 minutes of exercise every
day of the week, at a moderate intensity. Also, vigorous exercise for at least 3 days a week and to
minimise sedentary time recommended.
Levels of exercise can be measured either by self-report or objectively. Self-report include exercise
diaries and questionnaires (Difficult to recall [recall bias] and bias to overestimate). Measuring
exercise objectively can include the use of heart rate monitors or step counters (over sensitive at
times and expensive).
An increase in both PA and obesity can be explained by:
•
changes in measures of PA
•
changes in peoples’ awareness of what constitutes as PA.
Genetically humans have evolved from hunter-gathers and so should maintain an active lifestyle.
Sedentary lifestyles are a recent thing and can explain the recent obesity epidemic, which are both
due to patterns of behaviour.
Exercising is beneficial:
•
•
•
•
CVS – reduced risk of CVD, reduced BP, reduced body fat, increased HDL and increased
fitness
Psychological benefits – reduced depression/anxiety and increased self-esteem
Other benefits – reduced risk of cancer (colon/breast/prostate), increased immune function
and increased bone mineral density
30% decrease in all cause mortality.
There are proposed mechanisms for the psychological benefits of exercise, which include:
distraction, thermogenic (due to increased body temp), opioids (release of these which make you
happier) and relaxation/stress management (exercise can dampen stress responce).
Being able to perform higher levels of physical activity includes:
•
Male
•
•
•
Non-smoker
Low BMI
Being young
Greater belief/motivation/financial(moral) support for physical activity
- 28 -
Performing physical exercise can occur in several different ways: as an individual (good for flexible
hours), group (good for morale), organizational (designated gym time for colleagues at work) or
society (PE curriculum),
Several techniques can be put in place to help stay committed to an exercise programme. This can
either be a contract at the gym, a personal trainer, a weekly/monthly target or a reward. When
setting a goal it must be specific to an exercise (FITT – frequency, intensity, type, time). Also relapse
procedures must be in place e.g. “If it rains I won’t jog outdoors, I will jog on the treadmill instead.”
To change the sedentary behaviour we should:
1. Conduct research at interventions (but this hasn’t been to successfull)
2. Change environment (e.g. target better PE at school, or work or home)
3. Change culture (To exercise will be a opportunity and not a inconvenience? But, how?)
PAIN CONTROL AND END OF LIFE
Suicide act was made in 1961 which criminalised any aiding, abetting, counselling or procuring the
suicide of another. Max sentence in prison is 14 years.
Debbie Purdy wanted to know if her husband would be prosecuted for assisting her death. She felt
that the director of public prosecution was infringing on human rights by failing to clarify how the
suicide act is enforced. This lead to a consultation that found 6 public interest factors against
prosecution:
1. The victim had reached a voluntary, clear, informed decision to commit suicide.
2. The suspect was motivated by compassion
3. The actions of the suspect, although sufficient to come within the definition of the crime,
were only minor encouragement or assistance.
4. The actions of the suspect was reluctant encouragement or assistance in the face of a
determined wish of the victim with suicide.
5. The suspect had sought to dissuade the victim from taking the course of action of suicide.
6. The suspect reported the victim’s suicide to the police and fully assisted them in their
enquires into the circumstances of the suicide.
•
Doctors should alleviate pain, but also balance potential risks of pain alleviation against the
potential benefits.
•
Why worry about pain: Relieving pain is a core duty, relieving pain can allow autonomous
decision making, pain is subjective, pain is under treated and is often involved in end of life
care.
Doctrine of double effect: Established in law in trail of Dr Adams. Explains a distinction between
foresight and intention. Benefits are intended but side effects although foreseen are not
intended. NB the act must be proportional (you don’t give someone a blatant overdose). For
- 29 -
example, a patient with terminal lung cancer who is in respiratory distress. Dr gives diamorphone
to relieve the distress, diamorphine leads to resp. depression which shortens patients life.
Acts vs Ommisions: An act is when you carry out medical intervention. An omission is when you
withhold medical intervention. Both may lead to same consequence. Active euthanasia is when a
doctor performs an act which leads to death. While, passive euthanasia is when treatment is
withheld and leads to death.
PAIN: THEORY, ASSESSMENT & MANAGEMENT
Pain – An unpleasant and subjective sensory and emotional experience associated with actual or
potential tissue damage. The most common medical complaint, reason for self-medication and
interrupts all other activities. To fully appreciate pain, one must consider psychological processes in
addition to physiological process.
Nociception – involves stimulation of nerves that convey info about potential tissue damage to the
brain
Theoretical approaches to pain:
Specificity model – pain is directly proportional to the amount of tissue damage. Pain receptors
(nociceptors) would fire and pain would be ‘felt’ in the brain [direct link between cause of pain
and the brain]; nociception determining the extent of perceived pain. Also, the idea that specific
stimulus has a specific receptor.
Patterning theory – pain is a result of patterns of neural transmission, as opposed to one pathway
that is unique to pain. This states that there are no specialised receptiors, rather a single generic
nerve which responds different to the different sensations by creating a unique code formed by a
spatiotemporal pattern. Brain has no role.
The limitations of these two theories are that they:
•
•
•
Don’t explain pain without damage
Don’t explain damage without pain
Don’t explain differences in pain perception
The Gate control theory (Melzack & Wall) – allows for the influence of psychological factors [e.g.
happiness closes gate while anxiety opens it] via a neural ‘gate’ mechanism in the dorsal horn,
which modulates the passage of pain nerve impulses from the peripheral receptors to the central
nervous system. Large fibres tend to inhibit transmission and close the gate and vice versa. This
theory accounts for why severe pain can be experienced without organic cause.
Multidimensional model of pain Four
component of pain:
•
•
Nociception/detection (the neural detection of noxious stimuli)
Sensation/experience of pain (e.g. throbbing, stabbing)
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•
•
Emotional response to that sensation (e.g. fear, tension)
Behavioural response (e.g. limping, grimacing)
Biopsychosocial model
Focuses on both the disease (pathology) and illness (biological, psychological [Cognitive appraisal of
pain] and social factors [activities of daily living, family environment or work history]).
Acute vs chronic pain
Acute pain (<6 months): Brief, usually after injury – used for survival.
Chronic pain (> 6 months): No useful purpose, persists after healing. Risk factors for this include
being slow to recover, catastrophizing, depression (in 40% of chronic pain patients), avoidance (fear
of pain more disabling than pain itself – not walking because scared of pain) and poor coping.
Acute to chronic: Pain (harm), initial psych distress (fear), development of psych problems
(depression) and then acceptance of sick role and accommodation to the abnormal illness behaviour.
Chronic pain cycle: Pain, immobilisation, disability, loss of self-esteem, depression, social isolation
and withdrawal, stress, muscle tension.
Measuring pain
Pain threshold – level at which a stimulus is regarded as painful. This appears to be relatively
stable across people and cultures, although tension and anxiety can affect it.
Pain tolerance – the intensity or duration of pain that a person finds unendurable. Typically
measured as the length of time a person is prepared to keep their hand in a bucket of ice and
water. Pain tolerance is highly influenced by culture, context, and psychological state.
Also can measure frequency/intensity of pain, type of pain, level of disability…
Pain can be measured either by self-report, by observing pain behaviours or by measuring
physiological values. Pain varies along a number of dimensions, including intensity, duration and time
course, rate of change and frequency. Response to pain is affected by the events which lead to the
pain and the sensation of pain will be variable between different conditions.
Self-report measures are the most widely used measures of pain.
 Simple measures e.g. simple severity scale (1 to 10)
 Multidimensional measures e.g. McGill Pain Questionnaire which has 20 questions which
identify all components of extent of pain
 Computerised measures e.g. use of visual animations to measure different pain sensations,
such as a picture of a needle piercing skin. Individuals move the needlepoint to indicate the
intensity of their piercing sensations. Useful if there is a language barrier.
Self report measures are not always useful as they are subject to bias & inaccurate recall. Pain is
subjective and also the patient may not include the whole range of pain/emotional response
associated with the pain.
- 31 -
Observing the patient when required to carry out a task such as, walking in a line. The number of pain
behaviours is recorded directly or rated overall by an observer. What constitutes pain behaviour has
to be carefully defined; for example, there are:
 Verbal behaviours (moans, crying out, sighing, grunting etc.),
 Physical actions (limping, rubbing the injury, etc.) and
 Postural indications (not walking upright etc.)
The presence of the observer can change the type or frequency of pain behaviour displayed. Different
observers may define behaviour in a different way (how strong does someone have to exhale for a
breath to become a sigh?). Different conditions will have different behaviours (someone with broken
legs will be unable to walk). Reliability between observers must therefore be considered.
Physiological measures tend to have more reliability than the previous two methods of
measurement. Several measures include:





EMG (muscle tension
EEG (brain activity)
Heart Rate
Skin conductance
Neuroendocrine measures (e.g. hormone levels)
These measures are influenced by other psychological and physical factors, such as mood, stress, diet
and exercise. For example, increased muscle tension is related to anxiety, which in turn is strongly
related to reported pain. Therefore muscle tension could reflect pain or anxiety, making interpretation
difficult.
Psychological interventions can be applied to dealing with pain, such as behavioural or cognitive
approaches (this is in the Psychological Interventions lecture).
INFORMAL CARERS
The Department of Health has reported that there were an estimated 1.78 million clients receiving
services that were provided, purchased, or supported by CSSRs (Councils with Social Service
Responsibilities).
Care provided in the community is carried out by the statutory community services and care by the
community, usually by immediate family, is known as informal care. Informal care is based on kinship
obligations between family members and is the predominant type of care.
Community Care Act 1990 – introduced ‘who provides informal care’
To help priority groups such as the dependent elderly, people with physical and learning disabilities,
people with long-term mental health problems, live as independently as possible, either in their own
homes or in residential care.
- 32 -
Under this act, LA social services departments (SSDs) have the role of `commissioners' meaning they
must both provide services and purchases other services. SSDs and PCTs produce an annual care plan
once having assessed the needs of the local area. The assessment is based upon the resources
available and the needs of the patient. The Community Care Act also instructs that a patient in need
of community care must not be discharged until that resource becomes available. This can however
causes problems with regards to the number of free beds available.
Needs of Carers:
Informal carers reduce the financial cost to the state, however the cost to the person being cared for
and the carer themselves are considerable.
Caring can impose a heavy financial, physical and psychological strain on carers:
Financial:
•
Carers may give up their own career, due to the difficulty of combining the demands of
employment and caring responsibilities.
•
A survey by Carer’s UK in 2005 found that 77% of carers were financially worse off, despite all
receiving carer’s allowance.
Carer’s may also need to purchase certain products or services, such as upgrades in the home
in order to benefit individual being cared for and to improve their quality of life, which is not
funded by the government and therefore leads to greater financial struggle.
•
Physical:
•
The physical labour involved in meeting the activities of daily living for a relatively immobile
person can be considerable, and demanding for carers who are likely to be elderly themselves.
This potentially can lead to the carer’s developing health problems.
•
Changing clothes, showering, eating and other everyday tasks will all need attention and help
to achieve therefore putting a huge burden on carer physically.
•
British Household Panel survey data showed that the health of carers is more likely to
deteriorate over time than the health of non-carers.
Psychological:
•
Giving up own career and taking up unpaid care, remains undervalued in society. Therefore
potential loss of social status (inability to socialise or fulfil roles like normal) and self-esteem.
•
Caring relationships between partners and family are reciprocal (sharing the duties of
everyday life). Tensions can develop due to the changes in role brought about by the
increasing dependency of the receipt of care in the relationship.
•
Individuals who become physically dependent on their partner may feel frustration and anger
with their condition which they cannot express to their carer; although this is possible with a
professional carer. Keeping feelings bottled in can lead to irritability, short temper or even
health problems such as depression.
- 33 -
•
In the case of those caring for family members who have a mental health problem,
relationships can be strained not just because of the pressure of caring in itself, but because
of the ways in which the carers may find themselves stigmatised (by association) because they
are seen in some way to be responsible for bringing about the mental health problem in the
first place
Assumptions underpinning State Policy
•
Relationship between state and family i.e. introduction of the Community Care Act
•
Changing role of family i.e. from extended family (Asians)  nuclear family (modern) so state
welfare system provides care. But this ignores the fact that there has been a absolute decline
in the size of families and a geographical dispersion of households containing related people.
•
Role of women i.e. cannot assume that women will look after dependent, as they have equal
opportunities and rights. As well as demographic changes, shifts in employment patterns, as
well as changes in what are perceived to be acceptable divisions of labour between men and
women all challenge this.
•
Culture i.e. cannot assume care will be readily provided to Asians, even if they know other
Asians. Asian husbands are not providing sufficient support for their wives when looking after
dependent-child. Even if you are Asian in the UK, does not necessarily mean that you will get
informal care readily.
PSYCHOLOGY OF PERCEPTION & MISPERCEPTION (include McGurk effect and Simon & Levin)
Perception and sensation refer to two different processes in psychology.
Sensation = process of detecting the presence of stimuli by sensory organs Perception
= recognition, integration and interpretation of raw stimulus
It is through perception that we develop knowledge and understanding of the world.
Two major theories of perception:
•
Bottom-up theory (proposed by Gregory) – recognition and interpretation of stimuli is a direct
process that is determined by the information presented to the sensory organs. It is the
physical characteristics of the stimuli that result in a particular perception and thus
perception is driven by the physical characteristics of the stimuli. This basic information is
then used to build a meaningful representation of the scene. The information is therefore
drawn only from sensory data and nothing else – limitation.
i.e. square is perceived as a
square because it presents itself with four sides of equal length set at right angles to each
other, by matching these features with stored information, perception can be used to
objectively identify squares in our environment
•
Top-down theory (proposed by Gibson) – simple sensory information is insufficient in
explaining recognition and interpretation of stimuli. Sensory info is combined with
psychological constructs such as expectancies, previous experiences and or other info to
which provides a context. This theory argues that recognition and interpretation is an active
- 34 -
process by our knowledge and expectation of the world
i.e. looking at an optical illusion
and spotting the image hidden, in future you will always notice the hidden image
•
The final perception depends on who you are, whom you are with, what you expect, want
and value. It is a balance of both these theories which allows adaptation to the physical and
social environment otherwise… A complete bottom up approach will mean you will bound
to the same repetitive mundane reality. A complete top down approach would make you
lose yourself in your own fantasy and what you expect and hope to perceive.
Various methods have been devised in order to study perception. The key methods can be defined as
the behavioural approach and the physiological approach. We will consider the behavioural approach,
which focuses on the relationship between the physical properties of stimuli and our perceptual
response to them. The two most widely used behavioural techniques are the phenomenological
approach and the psychophysical method.

Phenomenological (qualities) method – i.e. say what you see or feel. This provides a useful
way in which to obtain descriptive information and is important because of the subjection
nature of perception (e.g. pain perception).

Psychophysical method – this enables us to establish quantitative relationship between a
stimulus and perception. Absolute thresholds: the minimum intensity required for the senses
to perceive stimulation, at least half of the time
Vision: a candle viewed from 30 miles on a dark, clear night
Hearing: A watch ticking from about 20 feet away in a quiet room
Taste: 1 teaspoon of sugar dissolved in 2 gallons of water
Smell: 1 drop of perfume diffused around a small house
Touch: The pressure of the wing of a fly falling on your cheek from about 0.4”
Visual perception and perceptual organization – despite the vast amount of sensory information that
is present in our environment we are able to achieve a stable representation of our visual world. This
suggests that our perception is highly organized. Some of the ways in which we do this are through
grouping, perceptual constancies, depth cues, pattern perception and motion perception. Our
perception is not always accurate, however, as the effect of visual illusions demonstrates.
http://www.faculty.ucr.edu/~rosenblu/VSMcGurk.html
Factors affecting perception (PEMPPAD)
Given that perception is to a large extent our interpretation of sensory stimuli it is unsurprising that
we experience stimuli in different ways. Research has identified various factors that influence our
perceptions.
1. Personality – people with different personalities show a tendency to behave differently in different
situations. It also appears that some aspects of personality can have an effect on perception (e.g.
introverts have more sensitive visual perception and are better at perceptual tasks that require
sustained attention than extroverts.)
2. Emotion
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Depression – people suffering from depression show a tendency to interpret ambiguous information
negatively and report pain as being worse than people who are not depressed.
Anxiety – people suffering from anxiety show enhanced perception for threatening information.
3. Motivation
People are often likely to perceive information as relating to their needs. (e.g. Therefore, sometimes
patients may overestimate the benefits of a particular treatment).
4. Perceptual set
Context, expectations and past experience all effect our interpretation of the perceptual information
that we receive. We are prone to seeing what we expect to see and hearing what we expect to hear
(e.g. If we are trying to stop smoking everywhere we look we will notice stimuli connected with
smoking).
5. Physiological – perceptual abilities can be severely affected by injury or disease. For example:
Agnosia – individuals with this disorder are able to see accurately, but have an inability to make
sense of visual information.
Fluent aphasia – results in production of fluent speech in the absence of the ability to comprehend
words.
6. Attention: The vast majority of sights, sounds, etc., pass us by without becoming part of our
conscious awareness. On the whole, in order for us to receive information we must pay attention
to that which is most pertinent. (e.g. clinicians must learn to discriminate the most vital
information when making a diagnosis) Simons and Levin scenarios. Attention is a limited resource
and focusing on one thing reduces concentration from another. Therefore, attention is distributed
towards concern-related cues
7. Demographic
Age – perceptual processing changes with ages. Older people are less able to ignore irrelevant
information and selectively attend to specified information than younger people.
Gender – males have better visual acuity in daylight conditions, while females’ vision adapts more
quickly to the dark.
Culture – individuals from cultures who take part in ceremonies that involve hanging from steel
hooks embedded in their backs report feeling no pain. Less spectacularly, individuals from Western
cultures appear to be more susceptible to visual illusions.
PSYCHOLOGICAL INTERVENTIONS
Why are they needed: Used for mild depression/anxiety, manages symptoms of chronic diseases
(headaches) and used in pre-surgical psychological counselling (reduces stress and anxiety)
Behavioural Techniques – based on learning and for behaviour modifications (e.g. classical and
operant conditioning):
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 Systematic desensitisation – based upon classical/operant conditioning e.g. used to treat
phobias or OCD such as introducing spiders. A method of eliminating fears by substituting a
response that is incompatible with anxiety such as relaxation. Can use flooding (place them
with fear with no escape until overcome) or graded exposure (slowly expose patient to fear
until they overcome it)
 Relaxation – e.g. massage, meditation and progressive muscle relaxation (PMR.. reduces
muscle tension in everyday use, proven to reduce anxiety and improve QOL) o Based on 3
stages: Learning to relax (use of CDs), monitoring tension in everyday life (use of diaries) and
using relaxation at times of stress (dampens down stress response)
o Advantages: Easy to learn, can be used virtually everywhere, once learned relaxation
is rapid, easily combined with other techniques and no special techniques needed. o
Disadvantages: Daily practise requires therefore a high drop out rate, not suitable for
all clinical populations, meditation and PMR take time to learn and does not address
cognitive processes.
 Biofeedback – Records the physiological stress response (e.g. HR and BP). Patient is then
taught strategies to reduce these (e.g. by relaxation). This then acts as positive reinforcement
as patients sees immediate improvement (operant conditioning).
o Proved effective in: hypertension treatment, tension headaches(with relaxation), less
pain/anxiety during childbirth with 30% medication use and 2 hours less duration of
labour.
 Operant Conditioning – uses positive and negative reinforcement to change behaviour. E.g.
use of selective reinforcement (rewarding desired behaviour and ignoring others), modelling
(learning a behaviour by imitating others e.g. in hospital procedures but can lead to social
phobia)
Cognitive Techniques – focus on altering maladaptive cognitions and/or providing adaptive
cognitions e.g. Rational Emotive Therapy (RET). Goals are to relieve symptoms, acquire effective
coping techniques and to modify cognitions. Assumptions made are: that individuals interact with
world though interpretations and evaluations and therefore it is the thoughts, beliefs and meanings
that are attached to events that cause psychological disturbance.
3 main sources of psychological distress are:
•
Avoidance of the feared situation
•
Concealing aspects of oneself that cause shame
•
Procrastination – putting off dealing with problems.
Rational Emotive Therapy (RET)
A – Identify Activating event
B – Identifying Beliefs and thoughts in response to A
C – Identify the emotional and behavioural Consequences of B
D – Dispute the irrational beliefs
E – Effect of therapy is to restructure the belief system to acknowledge rational and discard irrational
beliefs
E.g. coping with pain – Distraction from pain, relabeling pain, distancing oneself from pain, changing
the context
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Cognitive Behavioural Therapy (CBT) – to improve coping skills and reduce emotional distress
Cognitive and behavioural techniques are combined under CBT, usually lasting for 20 sessions.
Keys elements: Identifying maladaptive strategies removing them Teaching positive strategies for
coping/managing
There are three stages:
1. Educational stage (Improve understanding of pain and how behaviour and feelings impact it,
addressing external factors which are stressing patient)
2. Skills acquisition (Pacing skills of work and activities to regulate levels of stress and systemic
desensitisation to tackle avoidance behaviours)
3. Maintenance phase
Features of CBT: Structured problem solving approach, guided discovery, homework, empowering
client, problem solving, goal setting w/ self-reinforcement and case conceptualisation.
CBT can be applied to depression, PTSD, anxiety disorders and chronic pain… E.g. of use = patients
with RA receiving CBT had less anxiety as well as improvements in physical measures of arthritis
activity compared to those receiving no treatment. CBT in GAD is as effective as pharmacological
treatments for reducing anxiety, depression and improving QOL.
Counselling – providing a supportive environment to help people through difficult periods
Stress Management
Encompasses both CBT and counselling techniques, and these are usually tailored to the individual’s
needs. There are three stages in stress management:
1. Understanding cause of stress
2. Developing appropriate skills/behaviours to cope
3. Developing appropriate attitudes and beliefs to cope
Stress management can be for one or all of the following targets:
 Changing the external cause of stress
 Changing the individual’s response to stress
 Providing long/short term solutions
 Preventive or palliative
Stress management can be used to anticipate stress, to help people with ongoing stress (relaxation),
or as interventions following a critical event (critical incident debriefing).
Critical incident Stress Debriefing (CISD) – designed for emergency services workers to cope with acute
traumatic/stressful events e.g. meeting someone else who experienced the trauma (normalise).
Structured educational and supportive group who meet up to work through the following:
1)
2)
3)
4)
5)
Introduction – establish ground rules
Facts – examine factual accounts from victims
Thoughts and sensory perceptions
Emotional reactions
Normalisation/anticipatory guidance
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6) Future planning and coping
7) Disengagement
However the most effective treatment for PTSD is: Trauma focused CBT and Eye movement
desensitisation and reprocessing (EMDR).
Brief Intervention (FRAMES) – used to treat problems e.g. alcohol intake
Feedback about personal health and risk of impairment
Stress personal Responsibility for making change
Advice to reduce the problem or its manifestations
Provide a Menu of alternative strategies for changing maladaptive behaviour patterns
Empathetic interviewing style
Promote Self-efficacy; this leaves the patient enhanced feeling able to cope with their agreed goals
PATIENT ADHERENCE & SATISFACTION
Satisfaction – the difference between perception of actual services vs expectations or ideals.
Therefore the idea of evaluation vs expectation. Satisfaction is specific to different health situations
and is increasingly used as an indicator of quality of health care.
Factors affecting patient satisfaction:
• Interpersonal skills of HCP. Most important factor. Good communication and a patient
centred approach where patients concerns are listened to, and patients have active
participation and agreement in treatment decisions.
• Technical quality (accuracy of diagnosis, medical errors, clinical competence)
• Accessibility (distance from patient’s home, time of clinic opening, car parking, choice of
services)
• Availability (waiting lists, choice of provider)
• Cost (prescriptions, transport, time off work and of special equipment)
• Physical environment (cleanliness, condition of room, quality of food)
• Continuity (number of different carers – patients like sense of familiarity)
• Health outcome (more satisfied if health outcome good)
• Demographics (older patients more satisfied often)
Measuring satisfaction:
 Surveys/Questionnaires (Self administrated, easily analysed, provides qualitative information,
proven reliable and comparing possible between other instutitiues)
 Interviews (e.g. face to face or telephone, more specific information obtained)
 Focus groups (target particular groups, and is least contaminated by user)
 Anecdotal evidence (complaints – most are due to aspects of clinical treatment, comm skills,
cancellations/delays and attitude of staff e.g. willing to help)
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
Consequences of dissatisfaction:
• Changing GP or hospital
• OTC medication with Prescribed medication (25% take OTC
with prescribed medication can lead to side effects due to drug
interactions)
• Using unorthodox treatment
• Poor health status (low perceived health, reduced
QOL
Low adherence to treatment (lack of compliance)
Adherence – extent to which patients action matches the agreed recommendations. At around 60%
currently.
Non-adherence – the point below which the desired therapeutic effect is unlikely (Gordis 1976). At
around 30-50% (4% hospital admissions due to non adherence). Problems arise due to loss of health
gain to patient, loss of resources to health care providers, and failure to reach returns on investment
for pharmaceutical industry therefore affects other drug development.
Measuring adherence: 
Self report
 Prescription refills
 Pill counts
 Physiological measure e.g. blood,
urine
 Health outcome e.g. weight
 Mechanical device e.g. electronic pill
counters
 Direct observation
Creative non adherence – Deliberatly modifying a prescribed regime due to underlying rationale such
as mood or personal theories, which is not related to a lack of knowledge, but may be used to
overcome the loss of control that the illness has caused them. Example is
1/6 of patients take drug holidays 3 times per year with occasional omissions.
The reason patients do not adhere to treatment is usually down to the following (and not the patient
and his personality like clinicians think):
1. The health beliefs of the patient
• Identification and labelling of health problems e.g. do they agree with diagnosis.
Understanding of causes (genetic causes often leave patients feeling
hopeless)
Do they perceive the condition to be curable and controllable?
• What is the timeline – acute (more adherence here) or chronic
2. The characteristics of the treatment regime
• Complexity of treatment
• Duration of treatment
• Side effects of treatment
• Degree on which lifestyle is changed
Evaluation of cost vs reward.
3. Communication between the healthcare provider and the patient (a lot of people don’t know
how long, or how often to take medication or the purpose of medication)
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Consequences of non adherence: Deterioration of health, hospitalisation, increased morbidity and
mortality, increased GP visits, poor QOL.
Adherence can be increased by:
• Improving doctor-patient communication
• Providing CBT counselling
• Tailoring information to the patient
• Patient-centred approach
• Simplify treatment regimes
Monetary incentives.
SEMESTER
4 – PPD
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Confidentiality
•
•
•
Around 50 people see person’s medical notes, ranging from doctors, nurses and students.
Patients often do not know this.
Ethical basis for confidentiality:
o Respect for autonomy and ensures moral privacy o Trust and probity.. enhances
compliance. o May aid beneficence. Therefore benefits patient for example by
increase likelihood to disclose more information to HCP and this can aid treatment.
Certain people with infectious diseases may avoid seeing a doctor, if they fear
confidentiality will be breached and therefore not understand how to treat it or
reduce its transmission.
o Ensures quality of care by showing patients can rely on physicians to maintain privacy
and respect for their care.
Legal basis for confidentiality:
o Mainly common law (by judges in courtrooms) but some statute law (made in
parliament).
o Common law involves:
1. Contract. Only found in private health and not NHS. These contracts have a
part regarding privacy of information, where breach indicates breach in
contract and therefore can lead to a court case.
2. Tort (harm) which involves negligence (of breach of confidentiality). HCP has
duty to maintain privacy. However, any damages is limited.
3. Equity: Equitable obligation to respect private information, even in social
contexts. HCP has a duty to protect privacy regardless of context. Not much
compensation available for breach of confidentiality, but you can request an
injunction before disclosure happens. Not usually helpful for patients, as
they only find out after the disclosure occurs.
o Statute law involves:
1. Data Protection act 1998 which governs the collection, storage and
processing of information.
2. Human Rights act 1998, specifically article 8, stating right to respect for
private and family life. Not absolute and may be overridden e.g. national
security, public safety.
3. Human fertilization and embryology act 1992 e.g. info on assisted
reproduction is not allowed to be past to GP unless specific consent from
patient.
4. National health service regulations 1974 on STI’s (e.g. health clinic doctors
not allowed to pass info on)
Breaching confidentiality is acceptable in:
o Patient consents.
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o
•
1. If patient consents, then there is no breach in confidentiality. o Best
interests of patient lacking capacity
1. It may be permissible to breach the confidentially of a incompetent child/adult
if this is in best interests of patient. E.g. disclosing health status of
patient with dementia to wife/husband.
Public and private interests
1. Public interest should only be in the most compelling circumstances. There
must be a real and serious risk of physical harm to an identifiable individual
or individuals.
2. Balance (weighing up) is required of public interest in doctors keeping
confidences vs public interest in protecting society or individuals from harm.
3. Need to balance the right to respect for private and family life against other
rights e.g. freedom of expression.
4. Difficult to judge/analyse
5. But gives doctor discretion, control (e.g. ability to weigh up info) o Legal
requirement.
1. Statutory requirement to breach confidentiality if: Notification of
births/deaths, fertility treatment, communicable diseases (e.g. cholera) to
the health authorities not to e.g. wife or other people, termination of
pregnancy, terrorism.
2. Doctor has no discretion or control
3. But it is easier, in terms of simpler w/o need to think much.
Bad but common practice:
o Breaching confidentiality in lifts/canteens, A&E departments and wards,
computers/faxes/printers, trains and parties.
o Taking notes out of hospital (66% of hospital staff) for purpose of research/audit. o
Social media sites. o Trivial information is more complicated, but GMC say “patient
have a right to expect that information about them will be held in confidence by their
doctor”
Confidentiality and death:
o Ethical duty remains the same even after death o GMC state that doctors must
follow same ethical position.
o Legal duty removed after death e.g. public nature of death certificates.
SOCIAL CONSTRUCTION OF GENDER
1. Questions of definition :
The common understanding of differences that may exist between men and women is usually based
upon those biological differences that exist between females and males. Biological sex is the way in
which the sex of an individual is determined on the basis of biological differences (external genitalia).
However, in practice the categories ‘male’ and ‘female’ are not used exclusively to describe the
biological features of human bodies. The terms are also used in the identification of what are
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essentially social and psychological characteristics and attributes, for example, behaviour, attitudes,
and the interaction skills.
In order to be able to distinguish between the biological fact of ‘sex’, and the social and cultural
characteristics associated with being male or female, the term ‘gender’ is utilised. Gender refers to
those social and cultural perceptions associated with ‘sex’ differences, socially constructed as
‘masculine’ and ‘feminine’. For example, masculine is dominant and decisive, while feminine is soft
and weak. However, the difference that is drawn between biological sex and gender is complicated
by the existence of individuals who are not easily categorized by their external (biological) genitalia
and by others who feel their anatomical body is out of line with their subjective sense of being male
or female.
2. The social construction of gender
Gendered social practices are those which shape women’s and men’s bodies in ways that
reinforce particular cultural images of femininity or masculinity.
These then lead to stereotypes which each sex is expected to follow.
Such socially constructed gender identities can result in negation of biology.
Young children have gender identities imposed on them long before they are capable of doing
an act which is attributed to sex of their bodies e.g. reproducing.
The imposition of gender identities is then reinforced though naming or dress (e.g. pink for
girls).
Children then start referring to themselves as a member of their gender, parenting is also
gendered (difference in expectation between mother and father) and work roles have
reflected this.. e.g. women more caring roles.
Gendering is done in all societies and cultures, because gender as a social institution is one of
the major ways in which the division of labour is organised. The alternate will be choosing
people for social tasks based on skill, motivation and talents.
One example of gender difference would be the traditional encouragement of boys (but not
girls) to engage in strenuous physical exercise as girls are seen as weaker (not true most of the
time). The outcome of such gendered social practices can have very real long term effects on
both men and women’s bodies - socially constructed gender identities which can result in a
negation or ‘transcendence’ of biology. This approach challenges the idea that biology is fixed.
According to ONS, 53% of young men carry out recommended PA, but only 33% of young
women. Women have lower mortality, but higher morbidity, and therefore are expected to
live longer in poor health than men.
This can arise from social suppression of bodily similarities and the exaggeration of bodily
differences.
Production of ‘women’ and ‘men’ as separate and unequal social categories, occurs by
converting average differences into absolute ones, and can become self fulfilling prophecies
as physical bodies change to support them.
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Ethics of Elderly Care
What’s different about elderly care:
1. The same ethical duties apply to older people.
2. Older people are usually more respectful to the HCPs.
3. Older patients are more dependent on social and family support, which is extenuated by an
increasing life expectancy due to medical technology. This leads to problems with provision
of resources, so government has passed the Community care (delayed discharge) Act which
fines local authorities for not assessing and transferring patients fast enough out of hospital.
Have more complex health needs (e.g. polypharmacy which leads to drug interactions, side
effects requiring regular review and good communication).
4. May be discriminated against (elderly have a right to choose their accommodation through
the 1948 National assistance act).
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•
•
•
•
•
•
•
•
•
•
•
2 important standards should be maintained in elderly care: o Standard 1 : Rooting out
age discrimination : prevents age related discrimination o Standard 2: Person
Centred Care : supports choice
Consent, capacity and confidentiality should all still be maintained.
Quality of life assessment is difficult, especially with patients that are cognitively impaired.
ADL scales can be used, or social history comprising of their activites, relationships etc. Do
not assume that they do not have a good QoL.
Autonomy is important as allows for right of self determination, allows trust to develop
between doctor-patient.
Capacity can be assessed by the MCA05: Understand, retain, weigh up and communicate.
Capacity can fluctuate in the elderly. No one is allowed to consent for a patient with no
capacity, but action must taken that is in the best interests.
MCA05: A person must be assumed to have capacity unless it is established that they lack
capacity. A person should be not treated as not having capacity due to an unwise decision.
All acts should be in the best interests of an individual, if they do lack capacity. Before final
action taken, regard should be taken on whether the purpose can be achieved in an
alternate way to reduce the restriction of individual on his rights.
Dementia causes a cognitive deficit, secondary personality change and incapacity.
The case for paternalism:
o Autonomy can only have meaning if it is informed o Autonomy may not be valued
as highly by patients as by ethicists and doctors o Emotions, confusion, pain and
distress can compromise decision-making so that it is not truly autonomous
o Autonomy can result in poor and preventable outcomes
Paternalism can be used under National Assistance Act 1947: ‘grave chronic disease’ or
‘aged, infirm and incapacitated’ and ‘living in insanitary conditions’.
Removal should be based on best interests of patient or to prevent harm to others. Eviction
requires a notice to be given to the magistrates court 7days in advance. However, in
emergencies, removal is permitted for up 3 weeks.
Mental health act 1983 can also be used for paternalism if a patient refuses.
Elderly people are vulnerable and should be treated paternistically (benevolent yet forceful)
if the patient clearly does not have capacity. If patient has capacity, they should have an
active role in the decisions in their own healthcare.
Communicating Risk
The goal in decision making is to select health services that increase the chances of valued health
outcomes and that minimise the chances of undesired consequences according to the best available
scientific evidence.
Communication of risk must be achieved in various situations:
•
Timing: Acute illness vs. chronic illness (e.g. heavy bleeding in preg or slowly growing
tumour)
•
•
Seriousness of situation: Screening vs. treatment
Consequences of intervention: beneficial consequences vs. harmful consequences (Always
consider the availability of evidence and if it trustworthy).
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Working in partnership with patient is essential for good care, where doctors must:
•
Listen to the patients and respect their views about health
•
Discuss with patient – diagnosis, prognosis, treatment
Share with patient the info needed for them to make a decision
Maximise patients opportunity/ability to make decision for
themselves.
• Respect patients decision.
• Tailor discussions with patients according to their needs, wishes, priorities, level of
understanding (condition, prognosis), nature of condition, complexity of treatment, level of
risk.
•
Never make assumptions: on the type of info a patient wants to hear, what’s important for
them and what isn’t, and about their level of knowledge.
Consultations should demonstrate honesty, good language, trust, patient centred (patient values)
and time.
Purpose of any test needs to be clear.
Rules for communicating numerical data: use absolute data, use consistent denominators (e.g. 1 in
100), always have a reference group, use visual aids.
High quality decision making (the process of communicating risk):
1. Correct assessment of clinical situation by health professional and quality of evidence
assessed of any solutions.
2. Correct information therapy to communicate situation
3. Patient made aware of consequences of no treatment and treatment
4. Relevant information is required (provide info in format preferred by patient)
5. Give information in form that is understood (check understanding), accurate and unbiased
6. Numeric risks are communicated (in complex information)
7. Patient makes decision based on accurate information and their values (ask patient if the
benefits outweigh the risks)
8. Explore ICE
9. Defer if necessary (refer to more info, use of motivational interviewing or acquiring
deliberation skills)
Population Interventions – flour-folate story
•
•
In 1954, double blind randomised controlled trail of folate treatment before conception to
prevent recurrence of NTDs was conducted in 111 women out of 905. Results showed a non
significant P value (due to small sample size). However, intention to treat analysis was used
and all the NTDs in folate group were in non compilers.
Then in 1983, there was ethical controversy over planned MRC randomised trial, which
aimed to get 2000+ subjects, but only received 132 patients. Shows how non randomised
trials can ruin the prospects for randomised.
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•
•
•
•
•
•
•
•
•
Observation studies of the use of vitamins containing folic acid and the occurrence of NTDs in
the general population were concluded. All had a relative risk below 1, therefore suggesting
folic acid acts as a protective factor, with confidence intervals excluding the value
1.
MRC randomised trial took place with 4 groups (only folate, only vitamins, folate and
vitamins, nothing). The relative risk was 0.28, showing a 73% reduction in NTD with
confidence intervals without the value 1.
DoH issued a statement in 1991, making it essential for women who had previous NTD and
was having a baby to take folic acid.
Another RCT was conducted on the prevention of the first occurrence of NTDs by use of
periconceptual vitamin supplementation in around 5000 pregnancies. This trail had a
significant P value to reduce NTDs.
DoH responce was to supplement all women planning on a pregnancy.
Epidemiology showed that NTDs dropped until the folate was prescribed/OTC where it then
flattened. This may of been due to the scope of folic acid dispensation was only to the health
conscious and not the people at high risk. E.g. people in lower socioeconomic groups did not
take them as much.
Therefore, a population strategy was required as o Evidence of efficancy of folic acid was
conclusive.
o Supplement of 0.4mg required
o Problems with targeting women planning pregnancies as most not aware of
problem, highest risk groups least likely to take supplementations and many
pregnancies not planned. o Therefore, fortify flour with folic acid.
o Requires legislation.
Folic acid supplementation reduced the levels of homocysteine. However, homocysteine was
a non causal marker for CHD.
Folate still not fortified in flour in the UK, until publication of trial of effect of folate on bowel
ca (found to be negative) and a pooling effect looking at impact on CVD (the latter was
negative, as homocysteine was not causal).
To conclude:
o Displays poor public health measures in UK o Useful as telling us the dangers of bad
studies e.g. postpone getting good evidence. o Illustrates the benefits/dangers of
supplementing food e.g. bowel ca o Illustrates the importance of observation and
RCT.
Professional Boundaries
Duty of Care: All patients are entitled to good standards of practice and care from their doctors.
Essential elements of this are professional competence; good relationships with patients and
colleagues; and observance of professional ethical obligations.
Professional Boundaries: Professional boundaries define effective and appropriate interaction
between professionals and the public they serve. Boundaries exist to protect both the professional
and the client. Boundary violations harm the patient and the professional. The ramifications are
widespread. Damage usually extends to marriages, families, other patients, communities, clinics,
institutions, and the profession in general.
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•
Doctors should not treat themselves or their families.
o There is an unhealthy strong culture of self reliance regarding health.
o
Only 50% of doctors have a GP, 90% are happy to manage acute conditions, 25% are
happy to manage chronic conditions, 25% to self medicate, 50% are happy to order
diagnostic investigations on themselves.
o
May lead to inappropriate consulting style – e.g. corridor consulting.
o
Doctors present with higher rates of depression, suicide and substance abuse which
ultimately leads to poorer care to patients. o The family relationship and context,
may deter either party from disclosing information, or acting in an appropriate way.
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o
For example, it may be uncomfortable for either party if a physical examination is
required, or it may be difficult to ensure confidentiality.
o
Family should be registered with different GP to allow for objectivity and reduced
conflict of interests.
•
Confidentiality – Patients have a right to expect that information about them will be held in
confidence by their doctors. You must treat information about patients as confidential,
including after a patient has died.
•
Whistle blowing – You must protect patients from risk of harm posed by another colleague's
conduct, performance or health.
o
GMC ‘act quickly to protect patients from risk if you have good reason to believe
that you or a colleague may not be fit to practice‘ by notifying an appropriate body
at the work first, then to the GMC or professional bodies (BMA). o GMC WILL act
when:

Dr has made serious mistakes in diagnosis or treatment

not examined patients properly;

misused information about patients;

treated patients without properly obtaining their consent;

behaved dishonestly in financial matters, or in dealing with patients, or
research;

made sexual advances towards patients; 
misused alcohol or drugs.
•
Integrity – you must not use your professional position to establish or pursue a sexual or
improper emotional relationship with a patient or someone close to them. Sexual
relationships are considered an abuse of power and serious malpractice.
•
Personal health – must be registered with a GP outside of your family, have appropriate
vaccinations and must consult a qualified colleague if you suspect you have a serious illness.
o
Practitioner health programme - For doctors and dentists in London with mental,
physical health, or addiction problems which may be affecting their work.
Confidential. GMC not involved if there is considered to be no risk to patients
•
Probity – must act with beneficence, and you must not allow any of your personal interests
alter a course of treatment (e.g. if you are receiving gifts from a drug company it does not
mean that you will advertise that drug), but if you do then you must make the patient aware
of this involvement
•
Breaking bad news – HCPs should answer to the patient’s agenda, break any bad news with
empathy, language or professional camaraderie should not exclude patient.
Drug companies:
•
Companies act to have their drugs added to the prescription activity of the doctor through
meeting representatives of that company, free meals, funding for travelling to conferences
or research.
•
These gifts o Cost money (like other advertising). o Influence behavior (like other
advertising).
o
Create obligation, need to reciprocate (unlike advertising). o Create sense of
entitlement (unlike advertising).
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o
•
Erode professional values; demean profession (probably unlike advertising).
Companies influence prescribing, set a different agenda to the doctors, use sophisticated
manipulation. Patients expect prescriptions are not based on conflicting interests.
Summary of points:
•
Doctors must treat themselves, their family, other professionals the same way they treat
their patients.
•
Doctors must maintain professional boundaries.
•
Safety of patient comes first, and therefore you may have to protect the patient from any
risk posed by a HCP.
•
Be aware of influences e.g. financial which may influence your prescribing.. act in best
interests of patients
Screening and secondary prevention
•
•
•
•
Prevention concerned with modifying or removing risk factors that are causally
related to a disease. E.g. age/sex non modifiable.
Primary prevention – removes cause of disease or reducing incidence of disease.
E.g. legislation on driving whilst intoxiciated, immunisations or interruption of STI
transmission by use of condoms.
Secondary prevention – Aims to prevent clinical disease through screening then
appropriate intervention. E.g. Antenatal screening, Heel prick test for
hypothyroidism/phenylketouria, or mammography screening for breast Ca.
Iceberg of disease exists. The tip of the iceberg, or most advanced cases of
diseases, is treated via tertiary prevention. Secondary prevention uses screening to
identify patients with subclinical disease. Whilst primary prevention used for people
with no disease.
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Primary
Secondary
Tertiary
Remove cause of
disease
Screening for early
stage disease
Treatment of
established / late
disease
Outcome on Reduce occurrence
Early intervention /
treatment resulting
in improved
prognosis or less
radical treatment
Manage / control
consequences of
disease
(incidence) of
disease
Type of
prevention Action
disease
•
•
Screening is a departure from normal medicine, as a population eligible for the risk is
tested, high risk individuals identified and then further investigations occur on them.
o “ …. Screening is the systematic application of a test or enquiry to identify
individuals at sufficient risk of a disorder to benefit from further investigation or
direct preventive action, among persons who have not sought medical
attention on account of symptoms of that disorder…” Wald
o Aim of screening is to select people for a diagnostic test therefore, helping to
reduce financial costs or harm or unethical factors. o 3 types of screening
currently in use: breast(mammography), Bowel (Faecal occult blood test) and
cervix (cervical smear).
Screening tests are compared with the gold standard to assess performance.
o Performance can be summarised by 3 measures: Detection rate (sensitivity),
False positive rate (1-specifity), Odds of being affected given a positive result
(OAPR) (positive predicative value)
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Detection rate/sensitivity = It’s the proportion of affected individuals (i.e. with disease) that
screening test. have a screen positive test result. Probability that people with the disease
test positive on
False positive rate = It’s the proportion of all unaffected individuals (i.e. healthy individuals)
that have a screen positive test result. Probability that a people without the disease test
positive on screening test.
Gold standard /diagnostic test
Affected
Screening
result
test Positive
a
Unaffected
TOTAL
bd
a+b c+d
b+d
a+b+c+d
Negative
c
TOTAL
a +c
a
a c
DR = It’s the proportion of affected individuals (i.e. with disease) that have a screen positive test
result
b
b d
FPR = It’s the proportion of unaffected individuals (i.e. healthy individuals) that have a screen
positive test result
OAPR = a : b It is the ratio of number affected to non affected when screen test positive.
*Prostate specific antigen is an enzyme made in the prostate and is used to screen for
prostate cancer (higher levels in patients with cancer). However, raised levels of PSA also
occur in BPH, after ejaculation or prostatitis/UTI. Therefore, PSA has good sensitivity, but
poor specificity to pick up prostate cancer.
*Women with ovarian cancer have higher levels (>35U/ml is positive) CA125.
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Screening
result
CA 125
test
Cancer
No cancer
>35U/L
53
23
<35U/L
52
300
105
323
result
TOTAL
Detection rate = 53 / 105 = 0.50 ... 50% of cases of ovarian cancer had raised CA 125
Levels. Low sensitivity as CA125 raised in endometriosis, 1st trimester preg, pelvic
inflammatory disease.
False positive rate = 23 / 323 =0.07... 7% of those without ovarian cancer had raised CA 125
levels.
Specifity = 1 – False positive rate (FPR) = 1 – 0.07 = 0.93 or 100% - 7% = 93%
Consequences of screening:
•
•
•
No screening, less disease detected early.
With screening, more diseases detected early, but individual without disease will
have to undergo more diagnostic tests (as he is false positive)
There must be a provision of resources, in order to investigate all the screen
positives.
If they are screen positive, the chance of them actually have disease is measured via the
OAPR (odds of being affected with positive result):
•
•
•
•
Can be represented as a ratio
Or a proportion via PPV (positive predictive value) = Number of affected individuals
screen positive results / Total number of people with screen positive results.
PPV= a/a+b.
E.g. PPV of 70%, means that 70% of referrals have ovarian cancer.
The CA125 shows low sensitivity and high false positive rate, therefore is not a suitable
screening tool. However, CA125 with transvaginal ultrasound, shows improvement. Also,
finding cancers early on, may not lead to a better life or a cure.
Antenatal testing for spina bifida:
•
•
•
2 per 1000 births / year
Tested via alpha-fetoprotien in mother’s blood, which is elevated in affected
pregnancies.
A screen positive test, is one with a-fetoprotien of >2 MoM (multiple of the Median).
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•
•
Detection rate = 75%, FPR = 2% (2% of unaffected pregnancies have positive
result)
How would this screening test perform if we were to screen 10,000 women?
Prevalence
2 per 1000
20 OSB
Screening
test
DR=75%
15
10,000
women
Overall approx.
2% of women
are screen
positive & would
go on to have
9980Unaffec
ted
FPR=2%
200
OAPR (odds of being affected
given a positive results)
15:200  1:13
Equivalent probability PPV = 15/215  ~7%
•
•
•
Detection rate and false positive rate are not affected by prevalence of condition
screened for BUT OAPR and PPV ARE affected by Prevalence of disorder being
screened. The more rare the disease, the higher the OAPR and the lower the PPV.
After a screen positive result, a amniotic fluid sample is taken for diagnosis to
measure AFP levels. This has a DR of 95%, FPR of 0.5%.
Remember: Many medical costs in screening, anxiety for women being screen,
ethical debates on terminating a pregnancy, or the anxiety caused by terminating a
healthy baby.
Requirements for a screening programme:
Disorder
Well defined medically
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Prevalence
Known & of public health importance
– should we screen for extremely rare diseases however
devastating they might be to health?
Natural History
Possible to identify early disease from healthy
Treatment
Effective treatment is available
There is no point screening if no treatment exists
risks of early treatment both physical and psychological should
be less than the benefits
Test
It should be simple, safe, easily implemented, acceptable
Test Performance The expected performance of the screening test must be
known
Ethical
The test & procedures after a positive screening test result
should be acceptable to both screener & individual
adequate health provision for the extra clinical workload
resulting from the screening
Access
All people who could benefit should have access to the test
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Financial
Cost-effective
Early detection & treatment vs. late diagnosis & treatment
Costs should be balanced against:(i)
risks - hazards associated diagnostic test, interventions
/ treatment
(ii)
benefits - reduction in morbidity or mortality
PSYCHOLOGY OF AGEING
BIO-PSYCHOLOGICAL APPROACH – the ageing brain determines any psychological changes that occur
with age.
Cross section evidence suggests that there is a decline in cognitive skill with old age due to loss of
brain weight/cell number numbers/brain power. Longitudinal studies decline showed a smaller
decline
Cross section versus Longitudinal studies: Cross sectional accentuates loss, due to cohort
inequalities/confounding variables (e.g. education has increased from 1890s to 1980s, therefore each
cohort will be better educated than previous, sanitation or healthcare). Longitudinal data collection
minimises the evidence of decline, because those who are able to and willing to be retested tend to
be healthier, wealthier and wiser than those who drop out or die. Also as cohort inequalities are
minimised due to each participant acting as his own control.
Intellectual decline is normal:
•
Evidence in age related drop in both cross section + longitudinal
•
Affects tasks requiring speed of processing more than tasks that need acquired knowledge or
problem solving.
•
•
•
More common in 80+ (“old old”), but even in this group some do not show evidence of it.
Abnormal when it is earlier in age, when crystallized intelligence (loss of wisdom) is lost.
Crystallized intelligence/ wisdom does not increase with age!
•
•
Fluid intelligence (loss of wit) is normal.
Use of intellect and enrichment of environment (e.g. good social life, caffeine) across the
lifespan can be protective (therefore less intellectual decline).
decline is irreversible.
Ageing process or the
Bernice Neugartern’s Model (Adjustment)
Ageing is associated with physical, psychological and social decline which require adjustment. Bernice
Neugartern’s model says the life course is bio-socially structured through events such as birth,
marriage, work and retirement. The more predictable the event (e.g. more socially predictable it is),
the less likely it is to demand individual adjustment. The less predictable the event (e.g. death of a
child), the more adjustment needed and the greater risk of being stabilised. Therefore, experiences
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in life effect adjustment either acting as a strength or weakness e.g. Kids growing up during
Depression adjusted better when they became old and had less money.
Socioemotional Selectivity Theory – Carstensen et. al (2003)
Knowledge of how long you have left in life leads to diverting motivation away from trying to gain
knowledge, and putting it towards emotional satisfaction. E.g. in the young, more focus on education
to improve future, which is seen less in the elderly. This may confer defensive advantages in later life,
by positivity effects and therefore is seen by the decreases in prevalence of mental health problems
in old age.
Theory of Third Age – Peter Ladlett (1989)
This theory views later-life as a time of self fulfilment, where one can follow their own projects and
plan their lives. But this can only be possible IF person has physical and material (money) well being.
This then explains that this is the reason why older adults take a active role in their treatment/care.
Erikson’s Theory – Psychosocial develepment
This theory argues that at each stage of life we face a particular type of psychosocial crisis, whose
resolution helps establish an trait or ‘virtue’ that then serves us well in addressing challenges in later
life e.g. young adulthood (intimacy vs. isolation) or infancy (trust vs. mistrust)
Key adult ‘qualities’ are:




Sense of identity (being someone)
Capacity for intimacy (having someone)
Experience of generativity (helping someone)
Acquisition of integrity (taking responsibility)
Older adult assessment is difficult due to underreporting of psychological complaints. Older adults
(males) are at high risk for suicide – “masked depression” – and 50% of suicide victims older than 60
see their GP in the month of their death which highlights difficulty in detection of problems.
QUALITATIVE METHODOLOGY AND RESEARCH [NOT TOO IMPORTANT]
Historically:
•
•
•
•
Health science research has become more and more influenced by the social sciences. E.g.
more focus on human behaviour, thinking, society and culture
There has also been a acknowledgement of the complexity of health and health care,
especially in areas such as patient centred interventions or the patient-doctor relationships.
This lead to a critique of the limitations of quantitative research based upon:
o Epistemology (over reliance on positivism – only scientific data with empirical proof
is valid)
o Observations/empiricism (where there is a over reliance on cause and effect
explanations, objectivity.
o And that not everything can be ‘measured’
Therefore, quantitative research limited the research questions and qualitative research
developed to expand the available research questions.
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•
Interest developed in interpretive approaches, with a focus on different epistemologies such
as lateral thinking – moved away from objectivity.
Now:
•
•
Qualitative research can complement mainstream methodologies of research and types of
research question.
But can also challenge prevailing knowledge by offering alternative perspectives.
What is qualitative research?
•
•
•
•
•
•
•
•
•
Variety of research approaches which collects qualitative data. Collection via interviews,
focus groups, written texts. Usually on a small sample size, as you are looking for specific
characteristics (not all the same) and due to the thick description provided.
Data is then analysed in a way without need of statistics.
Depending on the research question and the methodology chosen, data is analysed for
codes, themes, discourses, discursive interactions, narratives.
There are different methodological approaches in qualitative research such as
phenomenological, social constructionist, narrative.
There is research that is known as little q (instead of a Big Q), where this qualitative data is
collected then is statically analysed.
There are different types of research questions:
o How people experience things (e.g living with chronic illness/pain)
o How people make sense of things (what discourses do health professionals draw on
when working in Black and minority ethnic (BME) communities?)
o Why do people behave in a certain way? (e.g. why is there low uptake for certain
health interventions.
Qualitative research has been useful in areas such as living with chronic conditions,
understanding lack of adherence to interventions, exploring barriers to accessing services,
exploring assumptions of HCPs and providing a alternative explanation to biomedical model
especially in mental health.
o Therefore, qualitative research allows for more engagement with participants,
engagement with language and provides more detail. Examples:
Sexual health in the UK:
o Epidemiological surveillance (and other quantitative research) has been useful in
understanding the incidence of STIs and intervention uptake. But these pose
problems in the ways in which categories such as ethnicity are used as variables,
they miss the important socio-cultural context (e.g. understanding of STIs by people)
and present a particular story (e.g. African heterosexual men are high risk).
o But qualitative research can answer questions relating to the experience and
understanding of STI by people and can be used to focus on young people to aim to
lower STIs.
Allergies:
o Quantitative research has gone into causes/epidemiology and RCTs to test efficacy
of different interventions.
- 59 -
o
•
But qualitative research can explore how patients manage these allergies, how they
make a sense of the interventions or the HCP understanding of managing the
patient’s disease.
Qualitative approaches offers o Interpretation instead of objectivity, where there are
different ways to ask questions as well as different answers. Therefore allowing for research
reflexivity. o A thick description, therefore more detail. o Engagement with participants
instead of observing objectivity from afar.
o Alternative explanations, beyond the normal epistemologies.
QUALITATIVE METHODOLOGY AND RESEARCH 2 [NOT TOO IMPORTANT]
In mental health research:
•
•
•
The biomedical model is still dominant within psychiatry. However, biological explanations
provided are limited and focus on the individual.
There has been a survivor movement, which challenges the mainstream psychiatry especially
in the pathologising of normal reactions.
This has allowed for a shift in epistemology (to e.g. social constructionist approaches), which
allows for different ways to understand mental health.
2 main qualitative methodologies relevant in mental health:
1) Social constructionist approach e.g. discourse analysis
2) Phenomenological approach e.g. Interpretative phenomenological analysis (IPA)
Social Contructionist approaches:
•
•
•
•
Take a critical stance on taken for granted knowledge. Aims to deconstruct this knowledge to
provide an understanding of why it is taken for granted. E.g. mental health issues as
‘illness’
Examines the historical and cultural specificity of knowledge. E.g. Hearing voices in some
cultures is something special and not a disease.
Focuses on the sustaining of knowledge by social processes e.g. by language allowing for
social action.
Knowledge and social go together e.g. in the consequences of particular constructions. E.g.
medical interventions vs challenging society views.
 DA is influenced by Foucault (states the psychiatry is a powerful institutional which can
influence and control people).
 DA focuses on o How language facilitate, limit, enable and constrain what can be said, by
whom, where and when. (Depending on a certain situation, different people will be
dominant in the discourse)
o how ‘discursive objects’ are constructed (e.g. mental health or behaviour) o What
broader discourses are objects constructed within (e.g. biomedical discourse) o
What are the functions or implications of such constructions (e.g. responsibility on
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HCP or drug interventions) o Analyses the available subject positions (e.g. position
of doctors vs patients) and the overall implications for practise of the positioning (e.g.
doctors more dominant).
 Data collection usually by interviews or texts.
Phenomenological approaches:
•
•
•
•
•
Focus on how people experience certain things e.g. illness (therefore their lived experience).
Example is IPA, where the researcher interprets the participants description of their
experience.
Data collection is usually via semi-structured interviews (1 to 1).
This approach can be used in e.g. dementia or AD to study the change of self concept (old
self vs new self, concerns over affect on others, coping strategies), or carer’s perspectives or
experience of service providers.
Implications of phenomenological approaches (they allow for):
o Early intervention strategies
o Carer support o Impact on how practitioners deal with dementia patients on a
individual basis o Psychological support.
Overall implication of qualitative research on mental health:
•
Shift in epistemology has increased understanding of mental health
available such as narrative methods.
Range of methods
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