PUBLIC HEALTH AND PRIMARY CARE
“People, Practices and Populations”
FOURTH MEDICAL YEAR SMALL GROUP ATTACHMENT
COURSE HANDBOOK
2012 - 2013
Student name:
Student no.
Tel.
1
Introduction
Welcome to the Department of Public Health & Primary Care. This course handbook is an essential
document and you will benefit greatly from reading it over the course of the two month attachment. It
describes the rationale for the course, the content and learning objectives of the various seminars and
information about the exam process. Since 2003 the School of Medicine in Trinity has had a combined
Department of Public Health & Primary Care. We believe there are many benefits in having a combined and
integrated department. It is also important to understand that there is a difference between primary care
and general practice, which is a medical speciality. The teaching on the course is an integration of public
health and primary care.
Primary Care
Definition: The most wisely accepted definition of primary care is ‘first contact, continuous, comprehensive
and co-ordinated care provided to individuals and populations undifferentiated by age, gender, or organ
system.’ - Barbara Starfield. In Ireland at present it mainly comprises GPs and practice nurses, community
nurses and public health nurses although primary care is expected to grow over the next decade.
For most of the time in your medical training you will be taught by specialists. In this attachment you are
about to be taught by generalists and the teaching will be outside the hospital setting. It is only in recent
times that medicine, in hospitals, has become sub-divided into a number of specialties. Such divisions make
the generalist even more important as you will find out in this attachment.
The community based attachment is the main opportunity that you will have to see illness which presents
outside the hospital walls, e.g. see patients in a setting less controlled by the medical system – in an
environment closer to their own. Your learning will be guided by GPs on a one to one basis working with
other members of the practice. You will see that the GPs time is heavily committed and you will have to be
flexible in fitting in your learning needs around patient care and the smooth running of the practice. It is
however very important that you take an active role in your own learning and this handbook is designed to
help you get as much out of this attachment as possible.
The aim of the GP attachment is for you to see and ideally to try out the practice of medicine in the context of
the community. Here you will see illnesses that are new to you. You will also see illnesses at a different
stage from those seen in your hospital attachments. Students always remark on the undifferentiated nature
of the symptoms and signs presenting to the GP, which is in stark contrast to, say a cardiology or respiratory
clinic.
By and large GPs know the patients well and you will see some social interaction during the consultation. You
will be closer to the patient’s environment and you should be able to see the psychological and social
implications of illness. You will be able to talk to the patients at home and in the consulting room in a more
intimate way than you can in hospitals and you will find that patients can be less submissive and less inhibited
than in a hospital setting.
You will notice that the doctors will have had to modify their approach and clinical methods to take into
account the physical, social and psychological impact of illness. You will also notice that general practitioners
use time differently perhaps by seeing the patient more often or on a continual basis with repeated short
consultations.
You will get experience of history taking and clinical examination in general practice which is designed to be of
value to you in the other parts of your clinical course. The experience should also prove to be of value to you
in helping you to decide on a subsequent career. You will also get an opportunity to see innovations in out of
hours care through the KDoc GP co-operative. It is more acute in nature than usual general practice and
students enjoy it greatly.
2
Public Health
Definition: Public Health is the science and art of preventing disease, promoting health and prolonging life
through the organised efforts of society.
In this attachment you will also get experience of the population aspects of healthcare. The
population as a whole, rather than the individual, is “the patient”. You will see the importance of
deprivation and social class in both the occurrence and management of illness. This component of
the attachment will be delivered primarily by epidemiological, public health and statistical staff in the
department. It will consist of a number of theoretical and practical seminars together with an
emphasis on data collection and analysis both in the practice populations that you will visit and in
relation to data from your own country. The learning objectives of the population component of the
attachment will be explained during the course introduction. In relation to the data to be collected in
general practice for the population health component of the attachment this will be explained in detail
at the course introduction. You will be required to collect patient data while visiting each general
practice location. In addition all students will be asked to fill out another data sheet see page 17 of
log book. This relates to health data from your own country and feedback will be given by you at the
public health system seminar in this attachment.
3
Objectives of this course
At the end of this attachment you should be able to:
i)
ii)
describe the context of primary care and general practice in the community.
describe the presentation and management of common problems encountered in general
practice.
carry out a consultation which demonstrates appropriate medical interviewing skills,
eliciting the patient’s ideas, concerns and expectations and arrive at a decision that
involves the patient.
list the major health problems that occur in Ireland and in other countries and analyse the
determinants of health status..
describe the variety of illness seen in general practice.
describe the impact of chronic disease on the individual and their families.
analyse and describe the epidemiology of disease and the impact of socio-economic
status on health and illness.
become familiar with the process of professionalization.
experience out of hours care in general practice.
reflect on events that change your views of medicine.
analyse the role of the media in health and healthcare.
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
Specific learning objectives in General Practice
a)
b)
c)
d)
e)
History taking – through active listening
Describing the main reason for the consultation
List treatments given
Describe non-drug management
Describe referral options
Basic examination and clinical skills
a)
b)
demonstrate appropriate history taking
physical examination to include BP, fundoscopy, urinalysis, ENT, cardio vascular, respiratory,
digestive, lymph nodes, weight (BMI), paediatric measurements and pregnancy
Literature relevant to general practice
a)
awareness of guidelines on asthma, cardiovascular disease, prevention, diabetes, hypertension,
vaccination schedules
Social aspects of medicine
a)
b)
describe important social factors in the development and presentation of disease in general
practice
the importance of deprivation and social class in illness
Basic therapeutic skills
a)
b)
c)
building on skills learned in the clinical skills laboratory
venesection, injection
procedures such as wax removal, minor surgery
4
Ethical issues
a)
b)
c)
demonstrate due respect for patients
identify emotions and reasons for them e.g. anger, sadness
identify ethical dilemmas presenting during your attachment
Basic practice management
a)
b)
roles of GP, nurse, secretary, receptionist, manager
role of GP as patients advocate
Importance of disease prevention in primary care
a)
b)
role in prevention of different members of the practice team
describe primary, secondary and tertiary prevention
Instructions for your practice attachment
You will be provided with details of your assigned practices and you will be expected to make specific
arrangements regarding time of arrival. Students are expected to attend all sessions that the tutor makes
available during normal working hours and also any teaching in the department. We want to ensure that
you will gain sufficient knowledge and practical experience – not only to pass your exams but also to be of use
during your internship year and beyond.
Each tutor is given information on our educational aims. The tutors have been informed that you learn by
doing but you will also need to observe an experienced GP at work. A great deal depends on your own
initiative. You will be expected to direct your learning towards the general aims and learning objectives
outlined in this handbook with the help of the tutor, the course materials and departmental teaching
sessions.
We will expect you to keep a learning log of at least 12 consultations in which you have taken an active part in
each practice. It is likely that you will experience 200 – 300 patient contacts during your attachment in the
practice and you will be exposed to illnesses you have not seen before. It is important that you use the
facilities of the practice, department and library to look these illnesses up in terms of presentation,
epidemiology and outcomes.
It is particularly important to maintain the standards of courtesy and confidentiality that are expected of the
medical profession while you are in the practices.
It is important that you bring a stethoscope and a diagnostic set with you during your practice attachment.
GPs generally give us positive feedback about Trinity Students which is a great source of pride to the Medical
School.
5
Etiquette in a general practice setting
You will be attached to a practice and will work with the GP on a one to one basis. You will also have close
contacts with other members of the practice and it is essential that you are aware of, and observe, basic rules.
i)
Always tell patients you are a medical student as well as telling them your name. If you have a
unusual sounding name it is alright to give the patient the less complicated version.
ii)
Always ask the patients permission to interview and examine them and thank them when you
have finished.
iii)
Always observe the guidelines concerning patient confidentiality.
iv)
Be neatly, tidily and professionally dressed appropriate to the setting in which you are working.
Please wear ties, minimum jewellery and no bare midriffs! No need for white coats.
v)
Always carry basic medical equipment that you need such as a stethoscope and an ENT set.
vi)
Always arrive on time and give as much notice as possible if you are to be late or absent.
vii)
Be aware of the contents of the most recent Guide to Ethical Conduct and Behaviour published by
the Medical Council. www.medicalcouncil.ie.
COURSE MATERIALS
a)
b)
c)
d)
e)
The course handbook. This is intended to lay out explicitly the minimum we expect you to learn
from the clinical attachment and to provide some background material to primary care and to
public health medicine. It also sets out the practical tasks and the assessment procedures for the
attachment.
Text books. The essential text book for this attachment is ‘General Practice Medicine’. Ross J
Taylor, Brian R McEvoy, Tom O’Dowd. Churchill Livingstone 2003. This book is written
specifically for medical students in order to provide a roadmap through the clinical content of
general practice.
Public health/epidemiology
See reading list and relevant websites.
Course material which will be posted on the College network in \\ntserver-usr\get\amealy
Knowledge of the content of these lectures is necessary to fulfil the course objectives.
Log book
How you will be assessed at the end of the course
1.
Written examination
100 multiple choice questions (T/F format) – 40% of available marks at the end of the year.
Short MEQ paper, 4 questions – 40% of available marks at end of each rotation.
2.
Continuous assessment - logbook
This is important as it is a record of what you have seen and done in your practices. It is to be
handed into Ailbhe Mealy at or before the exam which takes place at the end of each rotation.
This attracts 20% of the overall mark.
3.
Vivas
There will be vivas for students who get less than 50% overall. There will also be vivas for
those students who are borderline pass to 2nd honours, and borderline 2nd honours to 1st honours.
Those students with an unsatisfactory log diary will also have a viva.
de Renzy prize
Those with highest marks in the exam will be called for a viva to decide the de Renzy prize.
6
Requirements for satisfactory completion of the course
a)
Attendance. Much of the tuition on the course is interactive and learning occurs in each seminar that
is not obtainable in books or through other sources. For that reason you are required to attend all sessions.
This applies to the classroom sessions at Trinity College and other locations and also the sessions within your
four week attachment in general practice. A roll call is taken at each seminar and an unsatisfactory
attendance may lead to a decision not to allow a student sit the examination at the end of the attachment.
This is in accordance with the regulations of Trinity College that students must satisfactorily complete the
course in order to be able to sit the examination. Absences through ill-health must be covered by a medical
certificate. Any other request for absence, such as a bereavement or serious family circumstances, must be
applied for through the Department in advance.
b)
Satisfactory completion of your logbook
YOUR EVALUATION OF THE COURSE
Small Groups
You are asked to score and comment on, all of the small group sessions and general administration of the
course at the end of the two month attachment.
General Practice Attachments
You are requested to evaluate the usefulness of tasks undertaken during your general practice attachment.
7
PUBLIC HEALTH & PRIMARY CARE
SMALL GROUP ATTACHMENTS 11/12
Please note the following start dates:
September / October group
Monday 3rd September 2012
November / January group
Monday 5th November 2012
February / March group
Tuesday 5th February 2013
April / May
Tuesday 2nd April 2013
Start Venue for all groups will be in the Trinity College Centre for Health Sciences, Tallaght.
Any changes will be notified to you, in advance, through email by Ailbhe Mealy amealy@tcd.ie
8
Core Seminar Leaders/Lecturers, Department of Public Health & Primary
Care :
Dr Tom O'Dowd, Professor of General Practice
Dr Joe Barry, Professor of Population Health Medicine and Consultant in Public Health Medicine, Health
Services Executive
Dr Alan Kelly, Head of Department, Senior Lecturer in Biostatistics
Dr Fergus O'Kelly, Clinical Professor in Primary Care and Director, TCD GP Training Scheme
Dr Marion Dyer, Lecturer in Primary Care
Dr Kieran Harkin, Lecturer in Primary Care
Dr Fenton Howell, Consultant in Public Health Medicine, Health Services Executive
Dr Lelia Thornton, Consultant in Public Health Medicine, Health Services Executive
Dr Alex Reid, Occupational Health Physician, AMNCH
Dr Conor Teljeur, Health Information and Quality Authority
Dr Fergus O’Ferrall, Adelaide Lecturer in Health Policy
Dr Catherine Darker, Health Psychologist, Lecturer in Primary Care
Dr Bobby Smyth, Consultant Child and Adolescent Psychiatrist, Health Services Executive
Dr Anne O’Farrell, Researcher, Health Services Executive
Dr Howard Johnson, Consultant in Public Health Medicine, Health Services Executive
Dr Brendan O’Shea, Assistant Director, TCD GP Training Scheme
Dr Darach O Ciardha, Assistant Director, TCD GP Training Scheme
Dr Aisling Ní Shúilleabháin, Assistant Director, TCD GP Training Scheme
Dr Udo Reulbach, Research Fellow
Ms Sara Burke, Health Policy Analyst
Ms Jo-Hanna Ivers, Research Assistant
Course Administrator:
Ailbhe Mealy, Department of Public Health & Primary Care, Trinity College Centre for Health Sciences,
AMNCH, Tallaght, Dublin 24.
Tel: 01- 8961087
Email: amealy@tcd.ie
9
GENERAL PRACTICE ATTACHMENT
Learning Expectations
1
Seeing common clinical conditions
2
Seeing chronic disease cases x 2 (1 in each practice)
3
Seeing patients on your own for history and examination
4
Present cases to GP
5
Complete log diary
a. Clinical conditions checklist
b. Consultations record – 25 x each practice for health information seminar
c. Complete international health seminar page
d. Compare and contrast both GP practices (refer to page 7)
e. Chronic disease case x 2
f. Professional insight
6
Understand role of team in care of patient
7
Core skills – list
8
Able to compare and contrast attached practices
9
Reflect on an event that changed your view of the world of healthcare
10
PUBLIC HEALTH:
PUBLIC HEALTH AND HEALTH STATUS
Seminar Leader: Prof. Joe Barry
Definition: Public Health is the science and art of preventing disease, promoting health and prolonging life
through the organised efforts of society.
Learning objectives:
At the end of the small group session you should be able to:
1. Analyse how the political process impacts on health.
2. Compare and contrast health and healthcare indicators in Ireland and other countries
3. Examine how marginalisation can impact on health.
4. Differentiate between individual lhealth and population health.
Objective 1 and 2
Decisions made by practically all government departments have an impact on health; examples include
provision of better education services, public policy that promotes public health (this is the exception rather
than the rule) and housing and transport policies that impact positively on health (again this is more the
exception than the rule). In a parliamentary democracy all funding for public services comes through the
political process. Therefore, politicians need to be convinced of a case for improving the health of the
population through public policy before funding will be allocated.
Objective 3
Universally, marginalized groups have worse health status that the general population in any country. This is
also true within Ireland. Health promotion campaigns tend to be targeted at the majority population and
thus have minimal impact on marginal groups. In addition, marginal groups tend to be underrepresented in
parliament and among health care workers.
Objective 4
The big difference between public health practice and other specialities of medicine is that in public health
the “patient” is the population.
Key functions of public health are to advocate on behalf of the population rather than on behalf of individuals,
to ensure that better health data and information is available, to make sure that health promotion and
preventive health care are facilitated and to see that inequalities in health are on the political agenda.
11
HEALTH INFORMATION SYSTEMS
Seminar Leader: Prof. Joe Barry
Without robust health information (health statistics) it is very difficult to plan health services effectively and
to measure outcomes. It is also impossible to describe the health status of a population. The production of
quality health information takes resources and historically these have not been provided within the Irish
healthcare sector. This is currently being addressed through the implementation of a national health
information strategy.
Learning Objectives
At the end of this seminar students should be able:
1.
to describe the importance of health information as a resource.
2.
to outline sources of health information (data) in a healthcare system.
3.
to analyse the legal and ethical aspects of health information
HEALTH SYSTEM ANALYSIS AND HEALTH POLICY
Seminar Leader: Dr. Fergus O’Ferrall
Learning Objectives
The learning objectives for this 3 hours seminar are:
a
The Irish Health System in a Comparative Setting
The students will be able to:
(i)
describe the components of the Irish Health System.
(ii)
describe how the Irish health system is financed.
(iii)
identify some key issues which arise in Irish healthcare in terms of equity, effectiveness and
efficiency.
(iv)
compare the Irish system broadly with other major health systems.
b
Health Policy and Practice
The students will understand:
(i)
what health policy is in terms of definitions.
(ii)
how health policy has evolved in terms of major health policy statements.
(iii)
how health policy is made and the possible roles of the various stakeholders in relation to
policy development and implementation.
(iv)
how health policy is currently seeking to address some of the key issues which arise in the
Irish context.
The seminar will utilise policy and practice from the Irish context in relation to primary care, general practice,
and secondary and tertiary care.
12
HEALTH INFORMATION: GENERAL PRACTICE
Seminar Leader: Dr Conor Teljeur
The lack of nationally collected general practice data hinders evidence based planning of services
and resource allocation. Data are collected in each practice, however, enabling a study of practicelevel patient characteristics. Using existing survey data and information on GP locations it is possible
to describe the existing service distribution and utilisation.
Learning Objectives
At the end of this seminar students should be able:
1. to describe the demographic and illness profile of a typical practice population
2. to understand the variability in populations across practices
3. to understand the implications of patient socio-economic status on general practice utilisation
4. to comment on how the demographic and illness profiles presenting to general practice differ
from those in hospital
5. to comment on geographic access to GP services
13
Patient Data Entry Instructions
There are 26 rows in the patient data sheet. Take the first 5 consultations each day in the first week of the Dublin practice
and in the week of the out of Dublin practice. That will give 25 records for each practice.
Example of how data should be entered into a spreadsheet:
 Missing data should be entered as a full stop
 Where age is known in weeks or months, it should be expressed as a fraction of years (i.e. 15 months is 15/12 and should
be entered as 1.25, 8 weeks is 8/52 and should be entered as 0.154)
 Y/N and M/F columns should be entered in upper case
 Diagnosis category (column G) should be determined using the diagnosis categories listed in the table below
ICD Categories for Classifying Diagnoses
Category
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
ICD-10-CA Category Name
Certain infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
Endocrine, nutritional and metabolic diseases
Mental and behavioural disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective tissue
Diseases of the genitourinary system
Pregnancy, childbirth and the puerperium
Certain conditions originating in the perinatal period
Congenital malformations, deformations, and chromosomal abnormalities
Symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
Injury, poisoning and certain other consequences of external causes
External causes of morbidity and mortality
Factors influencing health status and contact with health services
Morphology of Neoplasms
Provisional codes for research and temporary assignment
When complete, workbooks should be saved to Ailbhe Mealy’s Put folder.
14
HEALTH ADVOCACY
Seminar Leader: Dr Fenton Howell
Learning objectives of this seminar




Articulate what is meant by public health advocacy
List examples of public health advocacy
Describe the essential elements of an advocacy campaign
Describe the process which led to the passing of the smoking ban(You may prefer to use the
official designation!)
SURVEILLANCE AND CONTROL OF COMMUNICABLE DISEASES
Seminar Leader: Dr Lelia Thornton
Learning objectives of this seminar:
The objective of this session is to introduce the student to the surveillance and control of infectious
diseases at population level in Ireland and internationally by:





Describing the objectives and principles of surveillance of infectious diseases
Outlining the legal and structural processes for infectious disease surveillance and control in
Ireland, the European Union and globally
Demonstrating a specific surveillance system
Discussing scenarios where clinicians would or would not need to contact public health
Participating in a practical exercise in managing an infectious disease outbreak
Useful websites:
http://www.hpsc.ie
http://www.ecdc.eu.int/
http://www.who.int/csr/ihr/en/
Suggested reading in advance of the session:
CDC. Principles of Epidemiology. 3rd edition. Chapter 6. Investigating an outbreak. Available at:
http://www.cdc.gov/training/products/ss1000/ss1000-ol.pdf
15
HEALTH PROMOTION – THEORY, POLICY, PRACTICE AND EVALUATION
Seminar Leader – Dr Catherine Hayes
Learning objectives
The objective of this session is to introduce the student to the broad topic of health promotion at
population level in Ireland and internationally. At the end of the session you should be able to




Describe the basics concepts of health promotion and the underlying theories that influence
public health practice
Understand how health promotion policies influence practice
Give examples of health promotion practice across a broad range of topics
Understand the necessity for and the complexity around evaluation of population health
promotion initiatives.
Useful websites
www.healthpromotion.ie/
www.phac-aspc.gc.ca/hp-ps/index-eng.php
IMPLEMENTATION SCIENCE
Seminar Leader – Dr Catherine Hayes
Learning objectives
Implementation research is the scientific study of methods to promote the systematic uptake of
research findings and other evidence-based practices into routine practice, and, hence, to improve
the quality and effectiveness of health services and care.
The objective of this session is to introduce the student to the theory and practice of
implementation science. At the end of the session you should be able to :




Understand the core thinking and theoretical concepts of implementation science
Understand the application of implementation science across multi-disciplinary and multiorganisational settings
Explore the principles of putting implementation science into practice, by providing examples
of good practice nationally and internationally, through case studies
Analyse the factors that facilitate and impede implementation in a variety of settings
Useful websites
Centre for Effective Services. www.effectiveness . org
National Implementation Research Network (NIRN) nirn.fpg.unc.edu/
Implementation Science Journal www.implementationscience.com/
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HEALTH INTELLIGENCE UNIT SEMINAR
Seminar Leaders: Dr Anne O’Farrell and Dr Howard Johnson
Learning Objectives
•
•
•
To be able to ask a “focused/answerable” question
To be aware that there are many different sources of health information and how to access
them
To understand the potential of Health Atlas and run some queries on health related data in a
demonstration environment.
HEALTH CARE OF DRUG USERS
Seminar Leader: Dr Kieran Harkin
The use of illegal drugs, particularly heroin, is an increasing problem in many parts of the world. It has been
estimated that there are approximately 13,000 heroin users in Dublin. The provision of health care for this
group is often controversial and problematic.
Learning objectives of this seminar:
At the end of the seminar you should be able to:
1. Articulate your own attitudes towards drug misusers.
2. Identify and analyse how attitudes of both health professionals and drug misusers help or hinder health
care of this group.
3. Explain the concept of ‘harm reduction’ in the context of health care for drug misusers.
4. Describe the issues raised by methadone prescribing.
17
TREATMENT ADHERENCE
Seminar Leader: Dr. Bobby Smyth
Doctors give advice about health and in most cases this advice is evidence based. Despite this, many people
do not adhere to the healthy behaviour encouraged by doctors. Most of us engage in activities which put our
health at risk. Many patients who have illnesses fail to adhere to the treatment prescribed. While doctors
usually respond to treatment failure by exploring other treatment options, they often fail to check whether or
not the patient has actually complied with the initial treatment regime.
Learning objectives:

At the end of the small group seminar, you should be able to:-

Describe adherence to health advice at the population level and at the individual level, and the
consequences of non-adherence

Discuss the factors which influence treatment adherence

Describe the factors associated with non-adherence to healthy behaviour, using teenage binge drinking
as a case example

Identify the advantages of illness over health

Explore with patients their adherence to treatment
THE ROLE OF MEDIA IN IRISH HEALTHCARE AND HEALTH POLICY
Seminar Leader: Ms Sara Burke
This session will get participants to tease out what is ‘media’, what is the role of the media, who
owns it, who decides what’s ‘news’ and not ‘news’, how to understand the media.
It will look at if, and how, the media influences Irish health policy and how people interact with
health services.
Participants will brain storm and discuss the pros and cons of doctors engaging with the media.
At the end of the seminar you should be able to; Describe the role of the media in health and
healthcare Analyse the influence of the media on healthcare List the pros and cons of doctors
engaging with the media
Sara Burke is a journalist, broadcaster and health policy analyst. She has a weekly health slot on RTE
Radio 1’s Drivetime with Mary Wilson programme. She has written a book on the Irish health system
called Irish Apartheid, Healthcare in Equality in Ireland. She is co-author, with Sinead Pentony, of
Eliminating Health Inequalities. A matter of life and death.
www.saraburke.com
18
EPIDEMIOLOGY
Seminar Leaders: Dr Udo Reulbach
The epidemiology course consists of web lecture slides, computer assisted learning (CAL) and one seminar.
The aim of the course is to provide a broad overview of the concepts of epidemiology and principles of
research design and to introduce students to clinical epidemiology.
Course goals and objectives
Goals:
To provide the student with:
 an understanding of the concepts and methods of epidemiology and their application to clinical and
preventive medicine.
 knowledge and skills to critically evaluate journal articles.
Objectives:
To know:
 principles of experimental design, including RCT
 most commonly used rates
 main sources of data in Republic of Ireland
 main observational research designs
o appropriate analyses
o strengths and weaknesses
o appropriate interpretations (bias)
 principles of screening
 definitions and relevance of sensitivity, specificity and predictive values.
To appreciate
 need for evaluation of literature
 problems with assessment of causality
 problems of diagnosis.
19
EPIDEMIOLOGY COMPUTER ASSISTED LEARNING (CAL) SEMINAR
Seminar Leaders: Dr Udo Reulbach
This seminar is to assist you to become familiar with "Studying Populations," a computer assisted learning
package. The software consists of a series of short 'lectures' supported with examples, interactive exercises,
graphics and self assessments. The first 30 minutes of the seminar will be spent demonstrating the package;
the next hour or so you will work in pairs on selected topics; the last 30 minutes will be for feedback on these
topics.
This software provides a self-learning tool for the basics of clinical epidemiology, back-up for the
epidemiology seminar, and for revision. It can be accessed in the Tallaght PAC room (and possibly other PAC
rooms) at times convenient to yourself. A copy for personal use may be downloaded to your own PC.
Students are expected to study the following topics using this software and/or textbooks:
Treatment evaluation

Randomised controlled trials
Prognosis
Cohort studies
Aetiology



Case control studies
Observational vs experimental studies
Causation
Diagnosis and screening




Test validity, predictive values
Disease prevalence, surveys, sources of health information
Levels of prevention
Screen
Additional materials on:
 Outcome measures
 RCTs (intention to treat or explanatory trials)
 Systematic reviews
 Association vs cause
will be available from the web lecture notes.
Must know terms
p, CI
RCT
 Intention-to-treat \ explanatory
 Effectiveness \ efficacy
Incidence & prevalence
RR, OR
Rate difference, risk reduction, NNT
Cohort study, case control study, correlation
(ecological) study
Sensitivity, specificity, predictive values
Systematic review
20
EPIDEMIOLOGY LECTURES
Seminar Leaders: Dr Udo Reulbach
A broad overview of the concepts of epidemiology, principles of research design and introduction to clinical
epidemiology are available in the epidemiology CAL software, in basic epidemiology textbooks, and in my
powerpoint lecture slides on the College network. Some of the powerpoint slides have voice narration which
you can choose to listen to (or not). There are two powerpoint lectures on topics not adequately covered in
the epidemiology CAL software: “Treatment 2” (on types of randomised controlled trials) and “Systematic
Reviews”. These two lectures require special attention.
EPIDEMIOLOGY SEMINAR
Seminar Leaders: Dr Udo Reulbach
There will be one small group seminar for each attachment group. (This may be repeated if the attachment
group is very large.)
N.B. Please bring a calculator and epidemiology lecture notes and / or text books to this seminar.
The aim of the seminar is to illustrate, in a participatory manner, applications of epidemiology and to give the
student practice in understanding and interpreting journal articles. Excerpts from 2 or 3 published journal
articles will be presented. Guided by a series of questions, you will be asked to comment on the design,
analysis, generalisability and ethical issues relevant to each article. Objectives pertinent to each excerpt will
be provided. Different seminar topics may be used for different attachment groups.
Prof Shane Allwright's 4th Med lecture notes and some MEQ examples are available from the PH&PC
web page:
http://www.medicine.tcd.ie/public_health_primary_care/
Go to Courses
Go to Student Area (local access only)
Go to Lecture Material (Notes etc)
Choose Lecture Materials – 4th / 5th Year Medical Students
21
BIOSTATISTICS/EPIDEMIOLOGY
Seminar Leader: Dr. Alan Kelly
Title: What are the chances? Understanding and explaining risk
Seminar aims:
To consider how risk associated with medicines and disease is calculated and presented.
The objective is to enable you to recognise, validly interpret and accurately communicate risk.
Duration: 3 hours
The seminar will address the following issues:
1.
2.
3.
4.
5.
What is risk?
The confusing language of risk
Take the test! Test your understanding of risk
Estimating risk: from the group to the person - understanding the ambiguities in translating
risk estimates from clinical or epidemiological findings to the patient
Communicating risk: Doing it by numbers: Examples – Some simple and some not so simple.
Visualising risk – use of charts.
Putting it into practice - testing your understanding by answreing:
Risk of what? Does the risk apply to me? How does it compare with other risks? Reduced
risk of what exactly? How big a reduction? Risks versus benefits.
STATISTICS
Seminar Leader: Dr. Alan Kelly
Title: How to bluff with statistics in clinical research (Ensuring better research for
better healthcare)
Seminar Aims:
In this seminar we will introduce and illustrate key statistical methods that are essential for good
clinical research practice.
Duration: 3 hours
The seminar will address the following issues:
1. The CONSORT statement
To comprehend the results of a randomized controlled trial (RCT), readers must understand
its design, conduct, analysis, and interpretation. That goal can be achieved only through
complete transparency from authors. The CONSORT guideline was developed to ensure such
transparency.
22
2. Why randomisation is bad for some researches.
Why bother to randomise? How to randomise badly!
3. Being fairly confident
As only death and taxes are certain, just how confident in our results must we be?
4. Finding significance with little p
Publish or perish – how little p can help.
5. Coping with failure: all about power
Is size really important?
6. Practicing togetherness with meta analysis
Convincing evidence comes from many trials – MA and the Cochrane Collection
OBJECTIVE STRUCTURED CLINICAL EXERCISE (OSCE)
Seminar Leader: Dr. Marion Dyer
Learning Objectives
At the end of the OSCE you should be able to
1. Begin to demonstrate the integration of your consultation skills with your knowledge of
clinical medicine and therapeutics.
2. Begin to undertake a series of clinical tasks and consultations
3. Identify where you get stuck in consultations (e.g. because of lack of knowledge, or
difficulties in communication or ethical dilemmas)
4. Write a prescription
5. Be able to identify the elements of a good referral letter
6. Be familiar with the technique and issues related to taking cervical smears.
In the last few years ‘objective structured clinical examinations’ have been introduced by both medical
schools and post-graduate colleges (such as the Irish College of General Practitioners) as part of their
examination system. The OSCE seminar during your small group attachment is not an examination, but we
hope it will give you some idea of what to expect in the future.
Purpose of the OSCE is to
Give students an experience of undertaking a series of clinical tasks from a variety of disciplines, in a short
space of time, rather like a surgery in general practice (compared to an opd clinic in a single discipline)
Contribute to the development of communication and clinical skills.
23
It is NOT an exam, but does give an opportunity to experience an OSCE, which is used as an exam in various
situations.
For the OSCE you will be divided into pairs or threes. You will rotate around a series of between six and nine
stations; play the doctor, the patient or an observer. Each consultation will last eight minutes.
When each group has rotated around the stations you will have an opportunity to discuss what went on, with
the Tutor, in the larger group. When giving feedback please remember the rules.
SENSITIVE CONSULTATIONS
Seminar Leaders – Dr Marion Dyer, Ms Jo-Hanna Ivers
Aims and Objectives
Aims
The aims of this seminar are:
1
Assist students develop empathic consulting skills, to improve the therapeutic quality of
their interaction with future patients.
2
Facilitate students’ reflection on their general practice experience to enable them to
formulate an evidence based judgement of the value of the discipline of general practice.
3
Empower students to disclose their learning needs, assisting them towards becoming
safe, secure practitioners, reinforcing the need for lifelong learning.
Objectives
On completion of this seminar students will be better able to:
1
Adopt a patient-centred consulting style
2
Recognise complex therapeutic opportunities that occur in general practice consultations.
3
Demonstrate reflection on their performance of role play consultations, and identify resulting
learning needs.
The seminar begins with a whole group brainstorm on students’ understanding of the seminar title and
identifying examples of sensitive consultations from their experience in the practices. Common themes are
identified. Through small group exercises consulting skills are developed and discussed.
24
OCCUPATIONAL MEDICINE
Seminar Leader: Dr. Alex Reid
Work is a major determinant of health status. Doctors are frequently requested to comment on both
the effect of work on health and/or an individual’s fitness for a particular job. This may include
advising on the type of work place accommodation required to enable a person to safely discharge
the duties of a particular job.
Where a hazardous occupational exposure cannot be adequately controlled, an understanding of the
health effects allows appropriate health surveillance to be carried out. By accurately identifying the
cause of an illness, doctors are uniquely placed to advise employers regarding the introduction of
appropriate preventative steps to protect other workers’ health.
Learning objectives:
At the end of this module, you should:
 Appreciate the extent and importance of the interface between work and health.
 Have a systematic approach to identifying hazards and managing risks in the workplace.
 Understand the various definitions of causation and have a systematic approach to
diagnosing work-related illness.
 Be able to identify the risks associated with work in the healthcare sector.
 Be able to describe the structure and process of occupational health practice including
communication / confidentiality issues, certification, medico-legal pitfalls and social /
legislative influences.
25
CHRONIC DISEASE WORKSHOP AND LECTURE
Seminar leaders: Prof Tom O’Dowd, Lecture, Prof Fergus O’Kelly,
Workshop
Chronic conditions are health problems that require ongoing management over a period of years or decades.
There has been a dramatic increase in chronic diseases including non communicable diseases, mental
disorders and some communicable diseases such as HIV / AIDS throughout the world. Advances in medicine
and our understanding of behaviour have greatly increased our ability to prevent and control conditions such
as diabetes, cardiovascular disease, HIV / AIDS and some cancers. When patients receive effective
treatments and regular follow-up their outcomes are significantly improved. When patients are involved in
their own management and indeed become ‘expert’ about their own condition they also do much better.
Individual doctors, nurses and other healthcare workers are essential to good outcomes for patients but it is
increasingly being recognised that organised systems of care are necessary for both the healthcare workers
and patients.
During your time in the hospitals you can be forgiven for thinking that most chronic and serious conditions are
managed in hospitals. Yet the reality is that a significant proportion of the general practitioners work in
primary care involves caring for patients with chronic conditions. However, much of primary health care is
oriented towards acute problems that demand one off solutions. A healthcare systems than cannot
effectively manage diabetes, depression, cardiac disease and drug dependency is not very helpful in todays
world.
Patients with diabetes, hypertension and other chronic conditions are usually prescribed essential drugs as
part of their overall disease management. Adherence (formally known as compliance) to long term
treatments is remarkably poor while patients are frequently blamed for failing to follow “doctor’s orders” it is
now recognised that non adherence to medication is fundamentally a failure of the healthcare system.
Patients need appropriate information, support from their doctor and regular follow-up in order to improve
adherence.
Because chronic conditions affect large numbers of people and because they involve the efficiency and
effectiveness of our health care systems they have elements which challenge individual clinicians as well as
being a public health problem.
26
We want you to gain an understanding of a new approach to chronic illness called ‘multimorbidity’ has been
defined as two or more co-existing chronic conditions within an individual. Although multimorbidity is “the
norm” in general practice, research is only getting established.
Multimorbidity is of particular relevance for patients, their carers and healthcare providers as studies have
shown an inverse relationship between increasing numbers of co-existing diseases and health-related quality
of life. Qualitative work has established that the main concerns for patients with multimorbidity are loss of
function, polypharmacy, a negative effect on their well-being and relationships and co-ordination of their
care. You will be able to explore these areas in your visits to the patients with chronic illnesses.
Objectives of Chronic Disease Workshop:
i)
to gain an understanding of the impact of chronic disease/multimorbidity on a patient in the
community
ii)
to explore the impact of the chronic illness/multimorbidity on the patient and on the family
iii)
to investigate the health care support received by the patient
iv)
to look at what the future holds for the patient
v)
to investigate information available to patients with chronic illness
Method:
In each of the practices you are required to visit a patient with a chronic disease preferably in their own
home. You will need to make some notes as you may be required to make a presentation of one of the cases
at the chronic disease workshop in the Department of Public Health and Primary Care. The workshop will
seek to establish common themes from all the cases in order to give you fresh insights into patients with
chronic disease.
The following is a list of conditions we have found give you good insights:
i)
ischaemic heart disease
ii)
hypertension
iii)
diabetes
iv)
chronic pulmonary disease
v)
methadone maintainence
vi)
chronic eczema / dermatitis
vii)
depression
viii)
schizophrenia
27
We find that younger patients and children also give special insights although many patients are older.
Remember if you can find a younger chronic disease patient it complements the workshop well. Also we like
you to concentrate or common or frequently occurring diseases.
Finally for your case we need you to search for a good disease specific website for patients and please list it in
the log book. We also require you to search the web for a good disease specific website for doctors and again
list it in the log book.
References:
1
Innovative care for chronic conditions, building blocks for action.
Report from the World Health Organisation, 2002. www.who.int
2
The expert patient, a new approach to chronic disease management for the 21st century.
www.doh.gov.uk
3
Smith SM, O'Dowd T. Chronic diseases: what happens when they come in multiples? Br J Gen Pract.
2007 Apr;57(537):268-70.
STIGMA
Seminar Leaders: Dr Udo Reulbach & Professor Tom O’Dowd
The stigma seminar consists of a key note lecture and a seminar. The aim of the course is to provide a broad
overview of the concept of stigma in medicine, to raise awareness and to introduce students to basic
intervention strategies.
Course goals and objectives
Goals:
To provide the student with:
 an understanding of the concept of stigma in medicine
 intervention strategies for anti-stigma
Objectives:
To know:
 the definition of stigma
 the relationship between discrimination, prejudice and stigma
 theories addressing the origin of stigma
28



how to tackle discrimination
how normalisation can be used for anti-stigma work
how information, media and social work can shape anti-stigma work
To appreciate
 the impact of stigmatisation on patients and quality of care in medicine
 attitudes and factors which are linked to stigmatisation
 difficulties in change of addressing stigma
 the effects of stigma on students and medical practitioners
Assessment:


T/F questions in final exam
200 words assignment in logbook on stigma in healthcare based on a case study from
student’s own experiences
PROFESSIONAL INSIGHT
Seminar leader: Prof Tom O’Dowd
You will make may observations and reflections in this attachments. Reflection is a skill that
requires time and the ability to identify something that change your worldview. This exercise is to
allow you to display your reflections on one key event/processs in the attachment including the
practices that :
i) helped you understand the impact of a psychological, physical or social condition
ii) increased your understanding of a troubling life situation or circumstance (e.g.
relationship/employment problems)
iii) allowed you greater understanding about local, national or international health issues
iv) caused you to understand the limits of medicine or the potential of individual patients
v) exposed you to an ethical dilemma
vi) seemed to tie in the psychological, physical and social aspects of illness
MEDICALLY UNEXPLAINED SYMPTOMS
Seminar leader: Prof Tom O’Dowd
These are symptoms that have no current physical or pathological cause but make up 20% of GP
consultations and up to 50% of outpatient visits. They are a significant source of in-patient
admissions and are a significant cost to our health services. A lecture will discuss those at risk and
various strategies for trying to help such patients.
29
In your log book you will see an exercise which asks you to provide your reflections on medically
unexplained symptoms and for your observations on how the doctor dealt with them. You will also
need to get the doctors views on patients with medically unexplained symptoms. You will then be
asked to describe in some detail a case you identified in each practice and what the records told you
about this patient.
DERMATOLOGY IN GENERAL PRACTICE
Seminar Leader: Dr. Darach O Ciardha
Over 20% of the population have a medically significant skin disorder, making dermatological problems a very
common presenting complaint in general practice.
The session will begin with a review of how to approach patients with a dermatological problem, and how to
diagnose skin rashes / lesions. Slides will be presented showing various skin disorders. Students will be asked
to describe what they see, and try to make a diagnosis. Management of less common disorders will be
discussed briefly. Management of common / important skin conditions, such as eczema and psoriasis will be
discussed in detail.
Aims & Objectives of the Session:
After this session you should:
Be able to take a dermatological history and examination.
Be able to describe a rash / lesion.
Understand how to diagnose rashes / lesions based on their site, morphology and pattern.
Know the descriptive terms used in dermatology.
Know the general management approaches used in dermatology.
Know the basic treatments for eczema and psoriasis.
PRESCRIBING IN GENERAL PRACTICE
Seminar Leader: Dr. Aisling Ni Shuilleabhain
Prescribing is a central task of many general practice consultations, and is used in many different ways. This
session will begin with a look at reasons why a GP might write a prescription and good practice for same
(rational prescribing). We will review how to write a prescription, and look at generic versus branded
30
medications. We will discuss the role of the pharmaceutical companies in Ireland, and patient adherence to
medication. The session will finish with a series of case histories.
Aims & Objectives of the Session:
After this session you should:






Be able to write prescriptions for regular and controlled drugs.
Know the abbreviations used in prescribing.
Understand the principles of rational and cost-effective prescribing.
Know where to get unbiased information on medications.
Know about the various influences on the GP when s/he prescribes.
Understand the barriers to patient adherence with medication.
COMMON CLINICAL CONDITIONS
Seminar Leader: Dr. Brendan O’Shea
This seminar is about the everyday clinical problems seen in practice, both by GPs especially, and also on
general medical and surgical services.
Conditions will be discussed in terms of developing your own clinical approach, based especially on
Definition and Prevalence
Screening and Prevention
Diagnosis
Management: Actions to be taken at initial diagnosis
Continuing Care
Natural History Vs Prognosis under systems of good care
Using the terms above, the following common clinical conditions and their management will be require to be
understood:
Hypertension
Ischaemic heart disease / Angina
Diabetes mellitus
Acute respiratory tract infections (upper and lower)
Asthma
31
COPD
Low back pain
Joint pain / Arthritis
Women’s Health
Men’s Health
The recommended text is the 2010 Edition of The Oxford Handbook of General Practice
At the outset, it should be understood that there is a large element of rote learning in this area of clinical
knowledge, which requires to be carried out in your own time, and which does not lend itself to being usefully
taught in a seminar or lecture format.
A seminar format however is useful in terms of working out your own approach, both to individual patients,
within your own team, and with respect to making sense of the rather large amount of often bewildering
guidelines and protocols which are available.
The emphasis in the seminar will be on equipping you with a clinical approach to patients, and also an
academic approach to the mass of guidelines and protocols which are available, the sheer volume of which
can otherwise be confusing, without having worked out a formal approach.
32
CHANGING HEALTH BEHAVIOURS
Seminar Leader: Dr. Catherine Darker
Changing health behaviours: The role of brief interventions
Over the past century health behaviours have played an increasingly important role in health and illness. An
individual’s own lifestyle and behaviour are key determinants influencing their current and future health
status. Behaviour change is a complex process, often difficult to achieve and sustain, particularly in the area of
alcohol addiction. Students will be provided with an introduction to Irelands alcohol policy agenda and a
review of the evidence for six strategies for alcohol policy. Psychological techniques have been developed
which health-care professional can employ to assist patients in successfully changing their behaviour.
Providing brief interventions in medical settings is a promising approach in secondary prevention of
problematic drinking behaviour.
Learning Objectives
1. Explain what is meant by the term “health behaviours” and describe different types of health
behaviours.
2. To be able to discuss drinking patterns within an Irish context.
3. To critically evaluate the evidence for six strategies that have been used as a basis for alcohol
policy.
4. To be able to discuss reasons for the importance of early recognition and treatment of
alcohol problems.
5. Demonstrate the skill of utilising an alcohol-screening questionnaire.
6. Understand the principles of physician based brief interventions for alcohol abuse.
33
COURSE REVISION – EXAM PREPARATION
Seminar Leader: Prof Alan Kelly
This seminar aims to prepare students for the exams at the end of the attachment and the end of the year.
Students will have an opportunity to practise completing an MEQ and some sample True / False questions
using past papers. The model answers for these questions will also be presented and discussed.
Students will be expected to have reviewed the online lecture series and will have an opportunity to ask
questions about these lectures.
These can be accessed through:
\\ntserver-usr\get\amealy
This is on the Trinity network and can only be accessed through the College network.
At the end of this session the student will be familiar with the examination technique and format and will
have identified priority areas for themselves in relation to preparation for their end of attachment exam.
In this session your feedback on the course will be sought.
34
WHY IS GOOD COMMUNICATION IMPORTANT?
1.
Good communication improves patient care
The doctor can get a better and more efficient history.
The doctor will more accurately identify patient concerns.
The patient will feel freer to ask questions and offer more information which may clarify or
indeed alter the original diagnosis.
There is a greater likelihood that the patient will return (most patients protest with their feet!).
2.
Good communication improves patient satisfaction
Patients feel happier when they sense they are well looked after. They will recommend you and
even if you cannot do much to help their condition physically, (the vast majority of diseases are
incurable or self-limiting), they will be strengthened to cope.
3.
Good communication improves doctor satisfaction
The doctor feels much happier in his/her work.
Emotionally difficult patient interactions are avoided or overcome.
The positive emotional rewards from satisfied patients expressing their gratitude and satisfaction
help the physician feel good about herself and her work.
4.
Good communication prevents litigation
The costs of medical insurance are spiralling. Seventy five percent of patients who complain want
no financial recompense, only an explanation. For every 100 claims, 50 are not pursued because
the patient has not sufficient grounds for litigation - those 50 are seeking an explanation.
5.
Good communication is crucial for working with colleagues.
35
AIDE MEMOIRE TO PATIENT INTERVIEWING
Information to be obtained:
The main aim is to find out what has brought the patient to see you at this point in time. There may be
several problems so prioritisation will also need to be established. Details of the main problems should
therefore be sought as follows:
1
2
3
4
The nature of the problems
•
characteristics
•
onset
•
course of the illness
•
precipitating factors
•
help so far and support available
The impact on daily life
•
on work life
•
on key relationships
•
on social life
•
on mood
The patient’s perception of his/her own condition
•
the nature of the illness
•
the future
Other vulnerability and precipitating factors
•
positive family history
•
relevant social personal history
•
similar illness in the past
•
premorbid personality
Interviewing Style:
A.
Beginning the interview
•
Introduce yourself, put the patient at ease and ask the purpose of the visit.
•
Seating arrangements - ensure privacy, chairs at a comfortable distance and angle.
•
Notes - explain and ask permission to take notes. Most patients readily agree.
36
B.
Interview procedures
•
Listen carefully to the patient
•
Facilitate using both verbal and non-verbal responses
•
Attend to both verbal and non-verbal cues
•
Clarify by use of questions, repetition, summarising, avoiding jargon
•
Avoid premature focus on the initial problem
•
Control the interview by encouraging the patient to keep to the point
•
Use questions appropriately - use open questions before specific questions, use single
questions, avoid leading questions
•
Enhance a positive and supportive atmosphere by:
informality of style
pleasant and warm manner
good eye contact
avoidance of physical barriers
proximity
C.
Ending the interview
•
Summarise the problem
•
Ask if there is anything else troubling the patient
•
Would he/she like to ask any questions?
LITERACY AND COMMUNICATION
The scale of the problem
In the 1997 International Adult Literacy Survey (IALS), 25% of the Irish population were found to be at the
lowest level of literacy. 25% (500,000 adults) cannot perform simple literacy tasks like reading the dosage
from a medical bottle, understanding a bus time table, writing a job application or calculating simple
mathematical operations. The IALS found that only about 10% of the Irish population have advanced literacy
ability. This compares with 25% in Sweden.
The most recent International Adult Literacy Survey, Literacy in the Information Age 2000, shows that there is
no doubt of the need for more creative ways of targeting low literate populations. Some of its key findings
are as follows:


Over half of the Irish population (55%) still do not meet the minimum desirable threshold for
functional literacy in today’s modern society
23% of adults in Britain and 7% of adults in Sweden scored at the lowest level of literacy
Almost two-fifths of Irish people in the oldest Irish age groups are at the lowest level of literacy.
37
Implications for health care
We know that people with weak literacy skills are running into trouble in all areas of their lives: in the
workplace, in the home and also in their health care. Patients are often faced with complex information and
treatment decisions. Health literacy requires a complex group of reading, listening, analytical and decisionmaking skills. Individuals must then apply these skills to the healthcare setting, which can prove complicated
to a functionally literacy adult.
Healthcare literacy issues include:
1
2
3
4
Being able to understand such reading material as:
a. appointment slips
b. medical brochures
c. consent forms
d. doctors directions.
Gaining access to services
The proper use of medication
Being capable of managing self care i.e. following directions
English researchers have identified barriers for low literacy groups in effectively receiving and interpreting
health information.
Barriers identified were:
 Readability of health materials
 Need to improve patient doctor communication
 Public health perceptions of the problem
 Measurements of patients’ reading levels in clinical settings
 How to do effective patient education in clinical settings
Ref. National Adult Literacy Agency
Other seminars which, in addition to reinforcing clinical skills, will
contribute to your appreciation of the importance of good
communication skills:

GP ATTACHMENTS

BREAKING BAD NEWS

PALLIATIVE CARE MEQ

OBJECTIVE STRUCTURED CLINICAL EXERCISE (OSCE)

CLINICAL DECISION MAKING

EXPLAINING RISK

DERMATOLOGY
38

PRESCRIBING

SENSITIVE TOPICS
39
MEDICO-LEGAL ADVICE FOR SENIOR MEDICAL STUDENTS.
There is no doubt that medical litigation is increasing steadily and this section is an attempt to alert you to
some pitfalls at student and junior doctor levels. It is often prolonged, stressful and can be damaging to your
career. In the last decade medical litigation has emerged from near obscurity to the high profile social
phenomenon of today. Patients’ expectations have increased and their willingness to accept complications
has decreased. These factors combined with easier access to legal advice, an increasing desire to participate
in health care decision making and patient advocacy, and, self help groups have led to the increasing level of
litigation.
Confidentiality
Medical confidentiality is keeping secret all information passing between the patient and the doctor in the
course of the professional relationship. It is the fundamental principle of medical ethics and is one of the
corner stones of effective medical care. Confidentiality has no rigid rules and in many areas there is much
scope for differences of opinion, both in and out of the medical profession. It can, on occasions, bring
doctors into conflict with other professional groups (eg, the legal profession and the police). The Medical
Council booklet ‘A guide to Ethical Conduct and Behaviour’ 6th edition 2004 Section E ‘Confidentiality and
Consent’ should be your guiding text.
The doctor has a duty of confidentiality, even after the death of a patient and information should not be
disclosed to any source without the consent of the next of kin or the executors. All staff, including students,
should be very conscious of a duty of confidentiality when they become aware of secret information in the
course of their everyday duties. In general practice you will see particular areas of difficulty such as
telephone discussions, reception area confidentiality and mail opening.
Records
Medical records should be legible, dated and signed with the name and status. It is unlikely that you will be
permitted to make a written or computerised entry in a patient’s file in general practice. It is worth
remembering that as an intern that however strongly you are tempted, do not write funny, sarcastic or
derogatory remarks in the records. Medical confidentiality s the reason we do not permit students to attend
practices in your own home areas. Whatever seems amusing at the time will not have the same effect on
the judge if you have to read these entries aloud in the Court before going on to explain exactly what you
meant, also avoid exclamation marks. It is best to avoid abbreviations where possible, especially those which
are not generally accepted.
Negative findings (eg, ‘urine - no sugar’, or ‘no neck stiffness’) can be of greater significance in some cases
than positive findings. It is therefore important to be aware of the value of making these records. Do
encourage patients to attend for review if the course of their illness is not as expected or advised. This advice
should be recorded eg as ‘review prn’. Records should be written up at the time of the examination or ward
round when the facts are fresh and clear. Obviously records of actions in an emergency cannot be written at
the time but should be entered as soon as practical thereafter. Do not alter records after a complaint or
claim has been made. If you wish to make further comment at this time the addition should be clearly dated
and signed.
Communication again
Lack of courteous, effective communication between patient and doctor is at the root of many medico-legal
complaints and claims. As a senior medical student, you may at times be close to the patient and are most
likely to be asked questions. Be kind, courteous and empathic. Patients will forgive many accidents and
mistakes, but will not forgive being misled or having requests for information ignored.
40
As a student beware of telling relatives medical details. As a doctor good communication with your fellow
doctors is very important,m especially at handover and stand-in times. These are danger times and mistakes
are often made in identifying patients and passing on information. This, when notes are not subsequently
checked, can lead to very serious errors. Effective communication with your senior colleagues is equally
important. Do not hesitate to seek advice. Do not undertake a task you do not feel competent to do, even
when asked by a senior colleague. Far better to explain your misgivings or lack of confidence than make
serious mistakes. Do not delegate any of your duties to other students. Equally important is effective
courteous communication with your colleagues in other healthcare professions. Junior doctors can
sometimes be disapproving of GPs. This is a dangerous practice and may encourage unwarranted criticism.
Remember no matter how plausible the criticisms of colleagues you have only heard one side of the story.
Prescribing
This is an area in which you will receive some teaching in the departmental seminars. You will see that careful
legible writing is vital. Decimal points should be avoided, as should abbreviations. Amounts should be
written in full (eg, micrograms, milligrams).
For future reference: A few dos and don’ts.
 Do realise you are responsible for your acts of omission and commission
 Do be careful
 Do be courteous
 Do seek help
 Do not always accept others’ diagnoses
 Do not rely on your memory
 Do not accept tasks beyond your competence or training
 Do not criticise colleagues without hearing both sides of the story
41
THE CLINICAL CONTENT OF GENERAL PRACTICE
In hospital practice patients are usually sorted along the lines of the consultant's specialty. A cardiologist will
see patients with heart problems, a gastroenterologist will see stomach and bowel problems while an
obstetrician will see pregnant women. In general practice you never know what will turn up in surgery.
Nonetheless patterns emerge from the lifelong observations and records of many GPs (Hodgkin, Fry). Table 4
gives a good overview of the morbidity encountered by GPs in their practices. It is almost impossible to
compare the work of a hospital department with that of a general practitioner. Students and junior doctors
often think that the GP sees minor illness and the really serious illnesses are dealt with in hospital.
Try this opinion out while in your practices.
Table 4.
Patterns of morbidity seen by GPs in their surgeries
Type
% Consults
Commonest
Minor
A. Self-limiting
60%
URTI
Skins
Emotional
Minor accidents
GIT; aches/pains
Chronic
B. Non-curable
25%
Hypertension
Arthritis
Chronic psych.
IHD
COAD: EP. D.M.
Acute
C. Life-threatening
15%
Acute chest: Appx.
CVA: M.I.
Cancer (5 p.a.)
Acute psychiatric,
suicidal intent
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WHY DO PEOPLE COME TO DOCTORS?
The reasons may be briefly listed under the following headings:1.
Reassurance
The first requirement in providing reassurance is discovering people's fears. One of the best questions in a
consultation is “What do you think it might be?”.
How have you observed reassurance being given by the GP?
2.
Diagnosis
People come to doctors for a diagnosis, a label, an explanation. This need relates to the need for reassurance,
but is not always the same. Attaching labels may on occasion allay anxiety - “it is only a simple strain, not
arthritis” - in other circumstances it may be anxiety provoking - “your pain is called angina and comes from
your heart”. Nonetheless labels, even nasty ones, demystify symptoms - “at least I know what is the matter”.
From the doctor's point of view a diagnosis does two things, it provides, within limits, a prognosis and it
indicates a management plan.
How have you seen this work in the practices?
3.
Treatment
This takes many forms.
Can you make a list of the types of treatments used by GPs on their patients?
4.
Problems of living
Some people have 'problems in living with the human condition'. Such people often seek the help of general
practitioners.
Look out for examples in your practice attachments.
5.
Legitimisation of 'sick role'
In our society the only acceptable way of escaping our social obligations such as going to school, going to
work, washing the dishes or doing the shopping, is to declare oneself to be 'sick'. That is, to take up the 'sick
role'. If sickness is proffered as an excuse for more than a couple of days, society demands that the sickness
be legitimised by a doctor. Sometimes this permission may be given by 'writing a cert' but when this is
inappropriate the 'patient' must be 'under treatment' or 'attending the doctor'. Many long term prescriptions
are necessary in order to authenticate 'sick role' rather than for treatment of disease. Some people come to
doctors to be kept sick rather than to be made well.
43
Students often have strong views on this role. Is it abused by patients and their doctors?
6.
Surveillance of chronic disease
About half of all general practitioners' work is doctor generated and an important element in this is the recall
of patients for blood pressure checks, monitoring diabetes and the like. The rate and nature of recall depends
in part on how doctors are rewarded for this work. You will have a special workshop on chronic disease
during the attachment.
Are there differences in the way chronic diseases are managed in general practice and in hospital?
7.
Prevention
Quite apart from doctor initiated proactive care, a minority of people will come to the doctor in the hope that
disease may be prevented. The main characteristic of such people is that they are at low risk of the
unfavourable outcome they fear.
Important exceptions are, the immunisation of children, 'flu vaccines for vulnerable groups and of course,
secondary prevention. Primary, secondary and tertiary prevention are stock exam questions especially in vivas
and it is best to look out for examples in the practices.
Can you cite important examples of secondary prevention?
44
WHAT CAN THE GP DO?
Listen
Listening is important because in the first place it will usually give a very good indication of what diseases, if
any, people may have and in the second place it will give an indication of their concerns and worries and the
reason that they have decided to consult.
"Tell me about it"
The best opening to a consultation once the 'greeting phase' is over is 'tell me about it'. 'Tell me about it' has
two advantages as an opening, it places the initiative where it belongs, with the patient, it also suggests that
all things are admissible.
Provide empathy
Empathy is not the same as sympathy or compassion. It is the attempt to put oneself in another's shoes. It is
an aid to understanding the fears and hopes of patients, an attempt to see things from their perspective. It is
to some extent an act of imagination and all will not be equally gifted at doing this, nonetheless it can be
cultivated. It may protect doctors from hasty judgements and inappropriate labelling of patients as foolish,
neurotic or hypochondriacal.
Physical examination?
There is almost no place in general practice, (and very little in hospital), for the complete physical.
Examination is directed at confirming or denying the hypotheses (guesses) which have been generated in
response to what the patient has described. It is specifically directed to answer questions, 'is the throat
inflamed?', 'is there evidence of an enlarged spleen?', 'is there evidence of bronchospasm?'.
Investigate
Investigations are, quite appropriately, much less used in general practice than in hospital medicine. This is
primarily because working diagnoses can usually be arrived at on the basis of what the patient says and
restricted examination. There is no place for mindless or routine investigations because these are more likely
to provide false rather than true information. (This is because of the effect of low prevalence on positive
predictive value).
There are, however, many simple investigations which should be available in practitioners' premises. These
might be such things as, simple urine tests, desk-top pregnancy tests, blood sugar estimations, peak flow
meters, electrocardiography, 24-hr blood pressure monitoring.
In addition many GPs have direct access to the laboratory and to simple radiological procedures.
Use time
Provided that acute serious diseases have been excluded, general practitioners often and properly use time as
a diagnostic aid. Waiting to see what will happen is often good practice and many symptoms of uncertain
cause will disappear in the course of a few days.
Prescribe
45
In hospital, contacts with new patients almost always end with investigations, X-rays and blood tests; in
general practice most contacts still end with a prescription.
Hopefully you will develop informed views about prescribing during this attachment.
Refer
For reasons which have been outlined, those who attend hospital, or who are admitted, come either from the
accident and emergency department or by referral from a general practitioner. There are many reasons for
referral.
Students and junior doctors have strong views about referrals. Can you make a list of reasons for referrals?
Referral to the psychiatric services is a special case. In the first instance the emotional consequences of such
a referral are often of a different order from those that surround a referral to an ordinary hospital. Secondly,
on occasion referral may be against the wishes of the patient and at the request of relatives supported by the
doctor. Some so-called voluntary admissions are a response to coercion and the realisation that failure to
comply would result in involuntary removal to hospital.
The Minister has recently introduced changes to the Mental Health Act. How will these changes affect the GP?
Counsel
This takes many forms and GPs often counsel without knowing they are doing it. Non-directional behavioural
counselling is a skill, - a skill in which not all doctors have been trained. Its objective is to assist people to
define their problems in real terms and to generate solutions. It may be used by general practice in response
to those who consult with 'problems of living with the human condition'.
Look out for counselling during your attachment.
Home visits
One of the privileges of general practice is visiting people in their homes. While this is relatively time
consuming it is still a major part of general practice in Ireland. It has a number of advantages for the doctor as
well as the patient. Nothing else gives the doctor such a quick and reliable impression of the social context of
people's lives. The other advantage for both parties is that the patient feels much more secure on his or her
own territory. This tends to improve the content and quality of communication.
Provide continuity
For all of us, if we are lucky, disease and illness are episodic rather than continuous. Most of our contacts
with general practice will be episodic but such contacts accumulate over the years and this leads to at least
some degree of mutual knowledge and to something which can reasonably be described as a continuing
relationship. People are very faithful to their general practitioners. Since, on average, patients see their
doctors three or four times a year at least, some patients and doctors get to know each other fairly well. This
mutual knowledge extends far beyond disease, into relationships, births, marriages, deaths, financial success
and financial disaster.
You may see many examples of this in your attachment.
Give personal care
Most patients when they go to hospital (except perhaps, private patients) refer to it as just that. 'I had to go
to the hospital' not 'I went to see my doctor'. The contract in one case seems to be rather loosely with the
institution rather than with an individual. In general practice, even when the patient does not establish rights
by the payment of a fee, the contract is with a particular doctor. Because of continuity this personal aspect of
46
the relationship can become important. Patients come to depend on particular doctors. Almost all students
writing about the experience of their general practice attachment comment upon the difference between
relationships in general practice and what they have previously observed in hospital.
Keep records
Records provide an aide-memoire and they offer the possibility of communicating information to others.
They also have important medico legal functions, as a good record may be the only evidence the doctor has in
the event of a lawsuit. With the growth of group practices and the involvement of other health professionals,
records as a way of making information legitimately available to others has grown in importance.
Like hospital records general practitioner records can become bulky and unmanageable. There is much to be
said for organising them on the basis of a problem list which facilitates both clear thinking and
communication.
Do you think patients should have access to their own records? What about the patients holding on to their
own records?
Computers
Computers in general practice is a major growth industry, but storing information in computers is by no
means a necessary part of good practice. It does however allow the doctor to sort, with great rapidity,
information about patients into usable categories. For example, it is easy to pull out all patients who have
been prescribed a particular drug or who have the same diagnosis. It also allows the speedy generation of
lists, children who require immunisation, for example. It is worth remembering that the laws safeguarding
the confidentiality of computer held data are more stringent than those which apply to manual records.
Health education
The intimacy of the consultation and the close relationship which may, but by no means always, underpin it, is
an ideal opportunity to offer advice. Advice is most likely to be followed when it is requested. Those who
suffer from chronic conditions are particularly likely to benefit if they are well informed about their disease.
Those who are pregnant and mothers with small children are also likely to be receptive to advice given in an
acceptable and understandable way.
47
4th MEDICAL YEAR
READING LIST 2011/2012
All of the following books should be available in the Berkeley, Hamilton or Lecky libraries, the medical library, Trinity
Centre, St. James’s Hospital and the medical library in the Education Centre, Tallaght Hospital. Essential available from
Fred Hanna Ltd., Nassau Street.
A = Essential
B = Recommended
C = Additional
EPIDEMIOLOGY
A
Clinical Epidemiology, the Essentials.
Fletcher, Fletcher & Wagner
th
4 Ed. 2005 Williams & Wilkins
B.
Basic Epidemiology.
nd
Bonita R., Beaglehole R., & KjellstrÖm T., 2 edition (2006). WHO: Geneva
http://whqlibdoc.who.int/publications/2006/9241547073_eng.pdf
C.
Clinical Epidemiology.
Sackett, Haynes & Tugwell
Little Brown
B.
Epidemiology for the Uninitiated
th
David Coggon, Geoffrey Rose, David G P Barker (2003). Epidemiology for the uninitiated, 5
73)London: BMJ Books.
ISBN 0 7279 1604 1
http://en.book2down.com/Epidemiology-for-the-Uninitiated/29967
C.
Epidemiology and Public Health Medicine
Vetter & Matthews, Churchill Livingstone
GENERAL PRACTICE
A
General Practice Medicine
Ross Taylor, Brian McAvoy, Tom O’Dowd
Churchill Livingstone
B.
How to read a paper. The basics of evidence based medicine.
Trisha Greenhalgh
BMJ Publishing Group
B.
Oxford Handbook of General Practice 2005
Chantal, Everitt, Kendrim
Oxford
48
Edition (pp