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Christine Phillips
LECTURE #1: Biomedicine as a cultural system
1. Biomedicine can be regarded as a cultural system BECAUSE
A. It is only used by specific cultural groups in Western society
B. Its scientific knowledge base is based on hypotheticodeductive reasoning, and is
capable of being disproven
C. It incorporates a set of transmissible knowledges that frame the worldview of
believers
D. It is used more frequently in Western society than ayurvedic medicine
E. Many biomedical practitioners incorporate in their practices activities which are
not evidence-based.
ANSWER
If you answered (a): You were wrong, because biomedicine is the world’s most widely
disseminated medical system and is used by many cultural groups.
If you answered (b): This is true, but a knowledge system is a component of a cultural
system, but not the sum of one
If you answered (c): YOU ARE CORRECT. Cultural systems are comprised of
knowledge, customs, beliefs and there are systems for transmitting them (in the case of
medicine, through medical schools, through popular books about health and illness,
through everyday “commonsense” discussions about sickness and health). They frame
the worldview of believers to such an extent that we often do not even notice the
assumptions within the cultural system
If you answered (d): This is true, but doesn’t answer the question
If you answered (e): This is also true, but is a tangential point. .
2. Crazy Little Thing Called Love. Are Ben Lee and Paul Coelho diseased?
Ben Lee’s song Catch My Disease (2008 – those of you who don’t remember it can look
it up on YouTube) is about his own feeling of overwhelming goodwill.
In one of his 29 books Paul Coelho writes “Love is a disease no one wants to get rid of.
Those who catch it never try to get better, and those who suffer do not wish to be cured."
(The Zahir, 2005)
Using the definition of disease and illness that we use in this lecture, does either of these
gentlemen really have a disease? Does either of them have an illness? Why or why not?
[NB: This question does not ask you to express your opinion on the music of Ben Lee or
the writing of Paul Coelho]
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Christine Phillips
ANSWER:
Ben Lee has neither an illness nor a disease. He speaks of the condition he has in very
positive terms, suggesting that it is not an illness (which is the lived experience of
unwellness or unease). If Ben Lee had a verse in which he referred to the part of his
brain (possibly the amygdala, the frontal cortex or the ventral basal ganglia)1 which was
responsible for engendering bonhomie and positive thinking, and suggested that this part
of his brain was biologically different than most people’s brains, then he would be able to
state that he had a disease. Not surprisingly, Ben Lee did not introduce this cumbersome
concept into a three-minute pop song.
Love as described by Paul Coelho is not a disease, as it is not due to a biological
dysfunction. Nor is it an illness because there is no subjective sense of being unwell
(“those who have it do not wish to be cured”).
The fact that the conditions are “catchy” is not in itself evidence of disease.
3. What are the foundational disciplines of biomedicine and why?
ANSWER
The foundational disciplines of biomedicine are anatomy, genetics, immunology and
physiology. These tell us about the body and how it works. These form the scientific
knowledge base of biomedicine. The related disciplines that flow from this are pathology
(disorders of anatomy) and pathophysiology (disorders of physiology).
4. “The doctor said I must have had breast cancer for two years, but I just kept on with
my career because I felt fine” [Kylie Minogue]. Assume Kylie had been in France two
years before being diagnosed for one month, and then travelled to the US which had a
higher incidence of breast cancer for six months. She then lived in the UK for seventeen
months. Assume also she has carried the gene which pre-disposes for breast cancer since
her birth in Australia. In what country did she become ill?
ANSWER
Kylie became ill in the France, after she had lived there for one year and eleven months,
when she was diagnosed with cancer. Prior to this (by her own account) she had felt very
well, and therefore was not ill. It is possible that she may have had the lump for a longer
period, and therefore was diseased before she was ill. If you subscribe to the school of
thought that carrying the BRCA-1 gene for breast cancer constitutes a disease, then she
has had a disease since conception.
1
We are uncertain about the neurobiological basis of happiness, but it seems likely there is some biological
component. These elements of the brain are the current ones thought to have some influence, since if they
are damaged, people are functionally less able to generate happiness and functionality.
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Christine Phillips
LECTURE #2: Hidden values in biomedicine
(More than one answer may be correct)
1. Cogito ergo sum (“I think therefore I am”) means:
A. When we use our powers of reason, we can understand others better
B. Our ability to reason enables us to recognise that there are dual perspectives on
everything
C. Our ability for rational thought sets us apart from animals
D. Our ability to think rationally limits our ability to see things as they truly are
E. Our ability to reason is the basis of our selfhood.
ANSWER: E. The other answers are wrong because:
(A) Unfortunately our powers of reason do not necessarily lead us to greater empathy
(B) It may! Our ability to reason may enable us to do this. This is an application of
the Cartesian cogito.
(C) Descartes did say that animals lacked consciousness (ie selfhood) because they
lacked language and reason but this is an illustration of the Cartesian cogito.
When we argue that we won’t eat animals that are clever (eg dolphins) but will
eat ones we think are stupid (eg sheep) we are implicitly making an argument that
draws on the Cartesian cogito – dolphins are held to have more selfhood than
sheep2.
(D) This isn’t Cartesian, it’s a type of neo-Platonism.
2. The implications of the Cartesian cogito for medicine are that
A. The emotions are not integral elements determining who we are
B. What people say they feel is as trustworthy and valid as what the doctor can
deduce from examination and interrogation
C. Brain-dead people are not fully human
D. The mind and the brain are similar concepts
E. Bodily experience (of the patient) is secondary to cognitive understanding (by the
doctor or the patient)
ANSWER: A,C,E. The other answers are wrong because:
(B) Patient’s statements about their subjective life (their feelings) are subordinated to
the rationality of the doctor
(D) The mind is rationality (and the self), the brain is the body. Mind and brain are
two different substances according to the Cartesian cogito.
3. Psychosomatic medicine was an attempt to integrate the experience of the body into
the how illnesses and physical disabilities are caused and/or maintained by psychological
dynamics. It was intended to recognize the integration of the patient’s experience of
illness into the ways in which the illness or disease became expressed.
Peter Singer’s approach to animal rights has been categorised as neo-Cartesian. An alternative (and quite
non-Cartesian) approach is offered by Buddhism and Jainism, where animals are viewed as being imbued
with sentience (ie subjectivity) irrespective of whether they have any objective cognitive ability.
2
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Christine Phillips
This category of illness failed in its quest to find equal space within medicine for the
lived experience and organic dysfunction because:
A. Patients saw themselves as not having a valid illness if they were told it had a
non-organic component
B. Doctors did not see that their role extended to managing illnesses that may not
have an organic component
C. Attempts to manage psychosomatic illness continue to use attempts to impose
rational thought upon the experience of the body, thus reasserting the primacy of
rationality over suffering.
D. Alternative therapists have taken over dealing with psychosomatic illnesses.
E. Psychosomatic explanations for illness behaviour are outdated with advances in
neurobiology.
ANSWER: A,C. The other answers are wrong because:
(B). Doctors in practice are very aware that their roles encompass managing
illnesses which may not have a known organic component.
(D) May be true but is not the reason for the failure of the category to meet the
needs for which it was created.
(E) Advances in neurobiology are still very tentative; however they may be
reinforce the psychosomatic disease category
4. Who said what?
I suppose the body to be just a statue or a machine made of earth.
[On humans] "Oh, there's a brain all right. It's just that the brain is made out of meat! …Yes,
thinking meat! Conscious meat! Loving meat. Dreaming meat. The meat is the whole deal!"
We exist as material beings in a material world, all of whose phenomena are the
consequences of material relations among material entities.
One of these is by Descartes, one is Richard Lewontin, the evolutionary biologist, and
one is an alien describing humans3.
The first is a Cartesian perspective (note how the “I” who supposes is separate from the
body). The second and the third are materialist perspectives.
What is the relevance of materialism in medicine? When (if ever) might a dualist
perspective be useful?
Spend five minutes reading Terry Bisson’s classic short story “They’re made of meat” here
http://www.terrybisson.com/page6/page6.html
3
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Christine Phillips
ANSWER:
[First answer is Descartes, second is Terry Bisson’s alien, third is Lewontin]
Materialism is the philosophical position that all that all that is is material, and that
everything that occurs, including consciousness and self-awareness, is the result of
material interactions. The scientific underpinning of medicine is materialist in
philosophy.
The Cartesian viewpoint foregrounds the role of reason in biomedical practice. Using
reason to think our way through dilemmas of disease, illness and their management
enable us to not be overwhelmed by our patient’s emotions, nor by our own emotional
responses to our patient’s suffering. We shall discuss in many of the SFM lectures the
drawbacks to this approach – how doctors can use it to blind themselves to patient
suffering or the real world that their patients live in – but this is not a failure of
Cartesian thinking so much as a reluctance for us to use it its full extent. We can use
reason to develop empathy through learning how to take someone else’s perspective,
and to understand why people behave the way they do.
On the other hand, the Cartesian viewpoint when used in the construction of biomedical
knowledge tends to devalue the subjective experience of the ill patient in favour of the
objective perspective of the doctor. This is a problem with conditions our patients have
which may not be immediately apparent to the objective perspective of the doctor. The
most obvious example of this is pain. Pain exists entirely within the subjective
experience of the patient, and has been one of the most poorly handled aspects of
biomedicine knowledge and therapy.
Materialist thinking in medicine - encoding the scientific basis of medicine – need not
be a value-laden enterprise. All activities, including illness experience and selfawareness can be regarded as material phenomena. One of the risks of this type of
thinking is that it can be used to produce pseudoscientific rationales for behaviour or
things we don’t understand, which then get spurious authority as “medically proven”.
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Christine Phillips
LECTURE #3: Biomedical nosologies in social and cultural context
(More than one answer may be correct)
1. A nosology is a branch of medical science dealing with:
A. The distribution of diseases
B. The classification of diseases
C. The nature and effects of diseases
D. The phenomena that contradict physical laws
E. The treatment of disease
ANSWER: B. The other answers are wrong because:
A. = epidemiology
C. = pathology
D. = parapsychology
E. = therapeutics
2. Which of the following is a nosology?
A. SLUDGE – Salivation, Lacrimation, Urination, Defecation, Gastrointestinal
Upset, Emesis
B. The lymphatic system
C. WHO Classification of Myeloid Neoplasms
D. The Pharmaceutical Benefits Scheme Schedule
E. Adult Disability Assessment Tool in the Social Security Act 1991
ANSWER: C. The other answers are wrong because:
A. is a mnemonic
B. is an anatomical system
D. is a list of drugs that the Commonwealth subsidises
E. is a tool for calculating loss of function attributable to disability for the purpose of
granting disability support pension
3. Whether or not alcoholism should be classified as a disease was the subject of a great
deal of conjecture in the early twentieth century. McGoldrick (1954) makes the “no”
case: “Alcoholism is no more a disease than thieving or lynching. Like these, it is the
product of a distortion in outlook, a way of life bred of ignorance and frustration.” A
century and a half earlier, Trotter made the “yes” case: “In medical language, I consider
drunkenness, strictly speaking, to be a disease, produced by a remote cause in giving
birth to actions and movements in a living body that disorder the functions of health.”4
(a) On what grounds would alcoholism be considered a disease? If so, how should it
be classified?
Alcohol dependence can be considered as a disease on two grounds: (a) it results in a
set of symptoms reflecting the end-organ impacts of excessive chronic alcohol abuse
4
Quotes lifted from The Natural History of Alcoholism Revisited, by G. E. Valliant (Harvard University
Press, 1995) which is a terrific overview.
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Christine Phillips
(such as confabulation, liver cirrhosis, and cerebellar damage) (b) the compulsion that
drives people to continue to drink excessively may reflect a cerebral dysfunction.
If we focus on the end-organ impacts of alcoholism, it can be located in many different
disciplines (eg alcoholic cirrhosis belongs to the classification of liver disorders,
alcoholic cerebellar dysfunction belongs to the classification of neurological
disorders). If we focus on the compulsion, alcoholism can be viewed as a psychiatric
illness.
In fact, in current medical nosology, alcoholism is classified as a psychiatric disease.
Alcohol dependence is classified by DSM-IV as a disease if it meets the following
criteria.
1. tolerance, as defined by either of the following: a need for markedly increased
amounts of the substance to achieve intoxication or desired effect OR markedly
diminished effect with continued use of the same amount of substance
2. withdrawal, as manifested by either of the following: the characteristic
withdrawal syndrome for the substance OR the same (or a closely related)
substance is taken to relieve or avoid withdrawal symptoms
3. the substance is often taken in larger amounts or over a longer period than was
intended
4. there is a persistent desire or unsuccessful efforts to cut down or control substance
use
5. a great deal of time is spent in activities to obtain the substance, use the substance,
or recover from its effects
6. important social, occupational or recreational activities are given up or reduced
because of substance use
7. the substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (e.g., continued drinking despite recognition that an
ulcer was made worse by alcohol consumption)
Interestingly, most of these criteria are not organically based, and reflect illness rather
than disease. This critique can be made of many of the classifications in DSM-IV,
reflecting the fact that nosological categories in medicine often deal in illness
(subjective experience) rather than disease (bodily dysfunction).
(b) The Women’s Temperance Union (an organisation that advocated prohibition) was
very active in promoting the view that alcoholism was a disease. Why do you think
this group would take this view?
The alternative presented at the time was alcoholism as a moral or social failure. If
one took this view, options for rehabilitation were limited, and the dominant approach
was punishment. To recast alcoholism as a disease was to emancipate the condition
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from moral censure and to adopt a more positive attitude about the possibility of
rehabilitation. Arguably, this fitted more with a Christian ethic of redemption. The
Women’s Temperance Union was a hands-on outfit which provided lots of close
support to families affected by alcohol, and they may also have become reluctant to
judge and dismiss the alcohol-dependent person.
4. When AIDS was first recognised in the 1980s a dispute broke out about whether this
should be classified primarily as a haematological, immunological or infectious (or
tropical) disease.
(a) Complete the following table by filling in the discipline under which you would
classify AIDS depending on what you used as your classificatory criteria
CLASSIFICATION BY
Aetiology
Symptoms
Clinical distribution of
cases1
Disease mechanisms
CATEGORIES OF
BIOMEDICINE INTO
WHICH HIV COULD BE
CLASSIFIED (eg
gastroenterology,
respiratory medicine)
Infectious diseases medicine
Gastroenterology, infectious
diseases, neurology,
dermatology, respiratory
medicine
Tropical medicine; drug and
alcohol medicine; sexual
health medicine
Immunology, haematology
1
In the early 1980s, AIDS was said to affect Haitians, heroin addicts, homosexuals and
haemophiliacs. This posed a tricky problem as it could not be classified as a geographic disease
(cf “Asian flu”, or “Lassa fever”). WHO is now quite careful about geographic classifications –
note how SARS (Sudden Acute Respiratory Syndrome was given a name that did not indicate
country of origin, in order not to stigmatise China)
(b) Why did it matter to the medical profession how AIDS was classified?
The dispute about who should “speak for” AIDS was not just about turf warfare.
There were concerns that the needs of substance using patients or homosexual
patients might be sidelined if it was classified primarily as a haematological or
immunological disease. At the time there was a lot of discussion about “innocent”
victims (those who had contracted AIDS via medical procedures) vs “culpable”
victims (everyone else), which introduced a moral dimension to an awful illness –
classifying it as a haematological disease might have reinforced this distinction
between legitimate and illegitimate sufferers. Classifying it as primarily an infectious
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disease emphasised its riskiness to the general public, but on the other hand ID
specialists were used to dealing with blood borne viruses which could be transmitted
through multiple ways. This may seem simple semantics, but in the 1980s, when this
epidemic was evolving in rapid and uncertain ways these were very public and heated
debates.
(c) The first Chairperson of the AIDS Taskforce in Australia in the 1980s was
Professor David Penington, a haematologist. He became the public face of Australia’s
pragmatic and successful campaign to control the spread of HIV-related infection.
Apart from his intrinsic qualities, why was a specialist from this background chosen to
be the public face of the AIDS response?
This Taskforce was given the task of leading Australians to engage in a public health
program that was pragmatic about sex and injecting drug use, focusing on harm
minimisation rather than abstinence. Having a haematologist at the helm was
important because his discipline was one widely trusted by the public and regarded as
morally neutral (cf immunology – too complex, drug and alcohol medicine – too
shady, infectious disease medicine – too scary)
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Christine Phillips
LECTURE #4: Embodiment of sickness and distress
1. Embodiment refers to:
A. The bodily aspects of human subjectivity
B. The political control of bodies through exercising control over citizens’ liberty
C. The arrangement of anatomical organs within the body
D. The physiological function of organs within the body
E. The ability to enter into others’ subjectivity
ANSWER: A. The other answers are wrong because:
B. Refers to deprivation of liberty (political theory)
C. Refers to anatomy, an objective biomedical science
D. Is the physiological variant of C.
E. Refers to intersubjectivity which theoretically could occur without bodies (as it does
for the “battery humans” in the movie The Matrix)
2. It’s Happy Hour in heaven. Merleau-Ponty and Descartes meet to share a bottle of
Merlot5. Who says what?
“I particularly enjoy this wine because of its provenance; the grape comes from the
vineyards of Orange and the production process was especially fine.”
Nothing. He is too busy feeling the taste sensations from different parts of his palate.
ANSWER
The first is Descartes, the second Merleau-Ponty. Descartes’ pleasure draws on his
knowledge of oenology (the science of wine-making) and is highly cognitive and rational
(ie he would be drinking the wine that got the good reviews). Merleau-Ponty draws on
the world of sensation (ie he would be drinking the wine that smells and tastes good).
3. Bodily expressions of illness draw on cultural repertoires of distress and the social and
political contexts that shape them. The following are generally considered to be culturebound illnesses (ie they only occur in some cultures). Match the illnesses to the social or
cultural context.
ANSWER
Susto6
Female-subordinate culture in which
religious healing is commonly practised
5
Thanks to Tim Lovell for suggesting this problem as a memory aid
Susto = an illness attributed to a frightening event that causes the soul to leave the body, leading to
symptoms of unhappiness and sickness (Latin America)
6
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Koro7
Cultural preoccupation with male sexual
performance
Running amok8
Strongly networked society with social
expectation of outbursts
Political and entertainment culture that
popularises violence
Cultural equation of thinness with beauty
Going postal
Bulimia
Is it correct to term these conditions culture-bound syndromes? Why or why not?
NB: “Going postal” is the phenomenon of workers in low status employment, generally
male, committing mass violence usually with a shotgun in a crowded environment. Often
culminates in suicide.
ANSWER
Many of these are not strictly speaking culture-bound syndromes any more, if they ever
were. In a globalised community, koro has been described in many different cultures in
Asia. Disorders of body image and associated behaviours such as anorexia or bulimia
were once the sole province of the West, but are now described as rampant in postCommunist countries of eastern Europe and even in some parts of Asia. This does appear
to accompany an orientation of the culture of the sufferer toward the West, with all the
icons of anorexia being thin white celebrities (eg Victoria Beckham or Mary-Kate Olsen).
This is not to say that there aren’t specific cultural “takes” on these illnesses. While there
are similarities between running amok and going postal, the cultural readings are slightly
different – running amok is a culturally-recognised way that constrained individuals
“break out” from highly socially constrained societies for a short period. Going postal,
on the other hand, is often a parasuicidal behaviour which includes a ploy for recognition
and fame; the violence is imbued with meaning in a way that the violence of running
amok isn’t.
4. “At home, no one can hear you scream.” Post-natal depression has been described as a
Western culture-bound syndrome. If so, what cultural repertoires of distress does it draw
on, and how does post-natal depression reflect its social and political context?
ANSWER
The cultural repertoire of distress referred to is sadness or anger expressed through a
discourse about the loss of identity.
7
Koro = period of intense anxiety associated with belief that penis is retreating into body and will cause
death (Malay word, found in many regions of SE Asia) – occasionally occurs in epidemics of panic, eg in
Singapore in 1967
8
Running amok = a dissociative episode characterized by a period of brooding followed by an outburst of
violent, aggressive, or homicidal behavior directed at people and objects. The episode tends to be
precipitated by a perceived insult or slight and seems to be prevalent only among males.(Malay)
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The social context reflects (a) the expectation that rearing small babies should be
positively rewarding (b) the expectation that parents raise their children without external
support. We tend to have smaller sibling networks, smaller extended family networks,
and because of delayed parenthood may have older grandparents who are not able to
provide the kind of deep social support to rear children that other cultures have9.
Consequently parents of young children may feel very isolated and unsupported in their
endeavour.
The political context reflects one in which mothers lose status when they give birth and
raise children. Most women suffer a loss of income to have a baby in Australia, and we
still do not have paid maternity or paternity leave. Many women are used to external
markers of their worth (ie through work achievements) which they no longer get from a
baby.
5. Pediatric plumbism is endemic in some indigenous communities, but is rare in nonindigenous communities. Although plumbism is not an idiom of distress (rather, an oldfashioned term for an overload condition), the behaviour that led to it has arisen in a
particular social, cultural and political context. Identifying these contextual layers is
important for a nuanced public health approach to this youth epidemic.
(a) What is plumbism?
ANSWER
Lead poisoning. Symptoms include ataxia, seizures, intellectual impairment, and
anaemia. In this case it comes from petrol sniffing (NB: petrol also contains
hydrocarbons, which result in another set of symptoms including euphoria).
(b) How do the subjective feelings of someone with plumbism reflect their social,
political and/or cultural context?
ANSWER
Petrol sniffing in indigenous communities is a very complex situation, and the contextual
issues differ between communities.
Maggie Brady in her work (eg Heavy Metal, 1992) suggests that the following contextual
issues help frame petrol sniffing:
* lack of employment opportunities in indigenous communities (this of course reflects
larger socio-political inequalities)
* with self-government, control of the community being vested in senior men who may
limit dispersal of funds to young people (she gives the example of communities where
50% of the community is under 19, but only 3% of mining royalty payments to the
community are allocated to young people; or communities with a fundamentalist
9
My refugee patients are constantly astounded by how difficult it is to raise babies in the West compared
with in their own countries where family members clearly take on a large role in the raising of very young
children.
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Christine Phillips
LECTURE #5: The nature of the medical encounter
1. Match the type of doctor-patient relationship to the presenting clinical condition. Give
your reasons for choosing the one that you chose.
(a) A patient, aged 72, comes to you with a problem of escalating anxiety. He has pages
of Internet print-outs on different drugs and wants to discuss with you in detail the
right medication. When he was in Serbia he was given a really excellent medication
that he could take whenever he was worried10 and he would like to have this
prescribed here. His English isn’t very good.
POSSIBLE ANSWERS:
You might have answered consumerist mode (OK answer) or partnership mode (better
answer).
Consumerist mode: The patient has come in with Internet print-outs suggesting that he
has already been researching the best treatment for his condition, and he is asking that
you act as medical adviser to assist him to make the best choice.
Partnership mode: Although the patient has approached this consultation as an active
health consumer, this may be a reflection of his level of anxiety. He already has in his
head a medication that he wants, and you as his doctor may not necessarily want to
prescribe this medication. You are going to have to negotiate to reach a satisfactory
outcome and it is best to be upfront about this and try to develop a therapeutic alliance in
which he can come to the most appropriate management strategy for anxiety, which may
not necessarily be pharmaceutical.
Interprevist mode is not supported by the clinical history given, though it may indeed be
that the trigger for his anxiety lies in the social circumstances of his life and personal
history. For this mode to work you need to build upon trust built into the doctor-patient
relationship, and at this stage you would be trying to build the trust through the
consumerist or (better) the partnership mode.
Parentalist mode is incorrect. This clinical situation suggests that he is not acutely
unwell, and is not requiring or asking for medical directiveness. The fact that he doesn’t
speak good English should trigger you to get an interpreter on the phone, rather than to
be decisive and directive in the consultation.
(b) A 15 year old girl presents to request going on the pill. Her girlfriends have been
talking about it and she wants the one that will stop her having acne. She has only
mild acne. She isn’t sexually active.
10
This is almost certainly a benzodiazepine, and you may feel some concerns about prescribing a
potentially addictive anxiolytic.
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ANSWER:
This patient is seeking on the history given, a consumerist mode.
Consumerist mode. This girl does not have an acute illness. She is seeking medical
advice on a health condition for which the oral contraceptive pill is regarded as one
treatment (though not generally for mild acne). She would need to have the options
presented to her and helped to make a decision on the best treatment for her. (NB:
assuming she is Gillick competent, she is able to make her own decisions about her health
care and her parents do not have to give consent).
Partnership mode: Could also be used here, though the history suggests that she really is
asking for customer information rather than a patient-doctor partnership. You might
argue that she could be asking for the pill for acne as a cover for a request for
contraception. If she was asking for the pill for contraception, partnership would be the
correct mode, as there are complex discussions about sexual health which will need to be
held, and you will hopefully continue to be her doctor at a time of some risk for youth
health.
Parentalist mode: Not indicated. The fact that she is a minor does not mean that you
automatically adopt a parentalist mode. In fact, with most adolescents who are not
acutely ill, the one mode that is guaranteed not to work is the parentalist mode.
Therapeutic modes adopted by the doctor are attuned to the clinical condition and not
the age of the patient.
Interprevist mode. You could only argue this by over-interpreting the clinical history (eg
by suggesting she may have a negative body image as her acne is mild; her girlfriends
have bullied her or demeaned her by commenting on her acne).
(c) A 37 year old woman presents for a health screen at the behest of her work. The
only thing of note is that she is very obese (BMI 39). She says that she tries to be
good, but she is always hungry and can’t stop herself.
ANSWER: You could answer partnership or interprevist mode.
This is a complex case in which ongoing trust between patient and GP is necessary. The
clues that a interprevist mode may be needed are her moral language about herself and
eating (“being good” is “not eating”), her statement that she “can’t stop” eating (ie eating
is an inexplicable compulsion). These statements point to the fact that size and eating are
vested with moral meaning and untangling these is going to take time, and trust.
The partnership mode is acceptable too but it isn’t going to get to the deeper issues of
why the patient eats or needs to be the size that she is. However, the non-judgementalism
implicit in this mode is a useful first base upon which to build a psychodynamic mode.
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We should also be aware that patients may be unwilling to accept the psychodynamic
mode as it may be perceived as obtrusive.
Parentalist modes are often used for patients with obesity, and are generally
inappropriate11. The patient already feels out of control and doesn’t know how to lose
weight. Being told by a doctor that they are fat, likely to get diabetes etc etc and need to
exercise more is very unlikely to result in the patient losing any weight.
Consumerist modes, similarly, aren’t called for. She hasn’t come asking for consumer
advice; in fact her real concern is her eating behaviours.
(d) A 28 year old man is brought in by his workmate after he had a funny turn at work.
He can’t remember what happened, but is now feeling well if a little tired, and is
keen to get back to work. His workmate’s description of the funny turn is that he
suddenly slumped over his desk and seemed to twitch one of his arms. This occurred
shortly after a phone call from his mother.
ANSWER: Parentalist mode
Parentalist mode. This is an acute event (a presumed fit), and the patient may not have
complete insight into what has happened. A decision about his safety and need for
further investigation needs to be made, and the doctor will need to provide some direction
around the decision (including such points as telling the patient that he can’t drive home;
shouldn’t be working this afternoon; if he goes home, should not be alone in case he fits
again; and needs medical investigation)
Interprevist mode isn’t called for. You may have thought that the fact that he had a
(presumed) fit after a phone call from his mother is significant; however at this stage he
needs a more directive mode.
Consumerist isn’t appropriate. Partnership at this point isn’t appropriate, though will be
if this person is given a diagnosis of epilepsy and will need to improve his selfmanagement capacity.
2. What is the practitioner-patient relationship which tends to be used by alternative
practitioners?
A. Consumerist
B. Parentalist
C. Partnership
D. Interprevist
11
Medical practice does tend to licence doctors to use the parentalist mode for patients with obesity
(“You’re far too fat, stick to this number of calories a day), which may be one of the reasons why medical
consultations for obese persons are widely regarded as ineffective.
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ANSWER
This is a trick question! A good alternative practitioner will use ALL these modes
depending on the clinical presentation. One of the determinants of the success of
alternative medicine is the excellent consulting modes of the practitioner.
COMMON MISTAKES MADE BY STUDENTS IN EXAMS
Questions on this topic are frequently answered poorly by students. Common errors
made are:





Assuming that a child or adolescent is best approached using the parentalist mode
(the doctor-patient mode is determined by clinical condition and patient need
NOT the age of the patient)
Assuming that someone who speaks a language other than English would prefer a
parentalist mode (some do, some don’t, it depends on the cultural background.
The doctor-patient mode is determined by clinical condition and patient need
NOT the fact that the patient speaks poor English)
Assuming that for all patients seen in general practice GPs will adopt the
partnership mode (the doctor-patient mode is determined by clinical condition
and patient need NOT the doctor preference)
Assuming that the best and most respectful way to approach patients is using the
partnership mode (all these modes are ways of approaching patients respectfully)
Assuming that the parentalist mode would never be used with Aboriginal people
because it mirrors colonialism (the doctor-patient mode is determined by clinical
condition and patient need. If a patient is seriously ill, then the parentalist mode
is appropriate. If the patient isn’t, then the parentalist mode is indeed
inappropriate and in this context might be seen as mirroring colonialism)
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LECTURE #6: Suffering and social inequality 1
1.The epidemiologic triad consists of host, agent and environment. Categorise the
elements in the second column according to the component of the epidemiologic triad
that they represent
Host
Agent
Environment
ANSWER
Host
Agent
Environment
Hospital cooling towers
Legionella pneumonia
SARS
The Hulk
Mycelia family
Asthmatic children
Asthmatic children
The Hulk12
Legionella pneumonia
SARS
Mycelia family
Hospital cooling towers
2. The Malthusian argument is
A. that population increases arithmetically while the capacity to support it increases
geometrically
B. that infectious disease should die out with improvements in health technology
C. that ageing humans exceed the capacity of health systems to look after them
D. that reductions in fertility are associated with increases in lifespan
E. that plagues and pestilences are nature’s way of rebalancing population growth
ANSWER: E .
A. is back to front (the Malthusian axiom is that population increases geometrically while
subsistence capacity increases arithmetically)
B. is clearly not true
C. may be true but Malthus lived from 1766 to 1844 and could not comment on health
technology and ageing
D. describes the demographic transition
3. McKeown’s hypothesis is
12
I acknowledge that the Hulk is a fictional character, but in the comic book universe he has occasionally
contracted infections and in this case is functioning as the host . Also as mild-mannered scientist Bruce
Banner he hangs around in a lab where he could contract infections.
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A. that decreases in infant mortality are attributable to changes in the incidence of
infectious disease
B. that improvements in nutrition have led to reductions in the incidence of infections
C. that population increases arithmetically with the increase in the carrying capacity of
the land
D. that decreases in fertility are associated with a population shift from high rates of high
infection to one of high rates of chronic disease
E. an underestimation of the impact of medical technology on reductions in the incidence
of infections
ANSWER: B
A. makes an unproven connection between the epidemiologic transition and the
demographic transition.
C. is a misreading of Malthus
D. epidemiologic transition and demographic transition
E. This is one of the critiques of McKeown’s hypothesis.
4. “Flesh-eating bacteria savages young girl in hospital”: Daily Telegraph headline. The
following are all explanations for this phenomenon. Complete the table listing the
element of the epidemiologic triad invoked and the type of health response that would be
prioritised for each explanation (example in the first row).
Explanation
The young girl was
undernourished, and
therefore prone to serious
infection
The bacteria is unusually
virulent and can attack
anyone
Hospital has poor capacity
to control the spread of this
bacteria
The bacteria has been
allowed to become resistant
to multiple antibiotics
because of high rates of
antibiotic use in the
community
Which element of the
epidemiologic triad (host,
agent, environment) is
invoked in this
explanation?
Host
What is the health system
response triggered by this
explanation?
Review reasons the girl was
undernourished and
promote better intake
Agent
Develop an immunisation
or better antibiotics
Environment
Better infection control
mechanisms in hospitals (or
try to treat patients outside
of hospital)
Educational programs
aimed at doctors and
patients to encourage them
not to use antibiotics for
viral URTIs and to use
narrow-spectrum antibiotics
Environment
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against which resistance is
less likely to occur
Although the community tends to think that the solution to resistant bacteria is a
“blundermycin” antibiotic (ie one that treats everything), in fact Australian public policy
focuses on hospital infection control and better prescribing practice among doctors. All
of us GPs get printouts from the government of our antibiotic prescription patterns and
how we compare with others in our region – a surprisingly successful intervention.
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LECTURE #7: Suffering and social inequality 2: AIDS and other catastrophes
(More than one answer may be correct)
1. In 2005, Goulburn had been in a severe drought for three years and its dams were at
8% capacity. From the perspective of Amartya Sen, why did the citizens of Goulburn not
suffer famine? List four reasons.
ANSWER
1. Distribution of resources to ensure that the vulnerable do not suffer at a time of acute
food shortage (Centrelink and government loans to the rural sector ensure that those
financially suffering in the drought continue to have access to resources to buy food)
2. Capacity to provide food from other parts of Australia when Goulburn cannot produce
its own (even if Goulburn farmers cannot produce enough food because of drought, large
shops, eg Woolworths, will source it from other parts of Australia, making it available to
the residents of Goulburn)
3. Infrastructure to support transport of food into Goulburn (ie we have open roads and
transport systems which can ensure that Woolworths or Coles can access food from other
parts of the country to provide Goulburn)
4. Democratic and open government does not support the redistribution of food and
resources to (for example) the rich people of Canberra in preference to the people of
Goulburn.
2. In an evolving pandemic, there is often a process of locating the cause of infection
elsewhere. Name the virus that caused the following illnesses, and who or what was
being stigmatised as either originating the infection or being the major risk group.
ANSWER
Name for illness
The English
disease
Spanish flu
Virus/Bacteria
Treponema pallidum
(causative organism for
syphilis), in the 16th
century
Influenza A, in the
1918-19 pandemic
Who is being stigmatised and why?
The English, for giving the French
syphilis. This is an example of the
Someone Else Started It tradition in
naming diseases of unknown origin, most
recently seen in the Spanish “poison
cucumber disease” used by Germany to
characterise deaths in Germany of E.coli
induced haemolytic uremic syndrome.
Outbreaks of sexually transmitted
diseases are often attributed to another
country.
The Spanish. This is an example of the
Name it After the Country with the Most
Cases tradition, used often in evolving
respiratory infections (most recently,
“Mexican flu” or swine flu). Actually
India probably had the most deaths in the
1918-19 influenza pandemic, and the first
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Yellow fever
Yellow fever virus, a
flavivirus
Gay related
immune deficiency
syndrome
HIV
The French disease Treponema pallidum
(causative organism for
syphilis), in the 16th
century
Christine Phillips
deaths due to the virus occurred in
soldiers’ camps in Kansas. But an
outbreak with high mortality occurred in
Spain, so Spain was saddled with the
name.
No one. The name is purely descriptive
and refers to the colour of the person
after they have become jaundiced from
liver damage.
Homosexual men. This was one of the
names proposed in the early 1980s for the
disease which was subsequently named
Acquired Immune Deficiency Syndrome.
GRIDS is an example of both the
Someone Else Started It tradition (in this
case, gay men) and the Name it After the
Group with the Most Cases tradition (not
sustainable, as it became clear that the
HIV infection was distributed more
broadly through the community). AIDS,
the name eventually chosen, is purely
descriptive.
The French, for giving the English
syphilis. In the 16th and 17th century,
every country blamed other “more
morally lax” countries for syphilis. In
addition to the French and English
blaming each other, the Russians called it
the Polish disease, the Italians called it
the Spanish disease, and the Turks called
it the Christian disease. In fact the
disease probably was brought back by
Columbus from the Americas, where it
mainly existed in mild form.
[STUDENTS: these details are for understanding only and are not examinable]
3. The HIV pandemic is the central pandemic of the modern era. Australia is often held
up as an example of a country which responded rapidly and effectively to the pandemic.
In broad terms, outline the elements of this successful strategy.
ANSWER:
1. Engagement with a broad coalition of groups with higher rates of HIV in planning a
public policy response (including sex worker lobby groups, the IV League, gay men’s
groups, and those who had contracted HIV through blood products)
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2. Pragmatic harm minimisation policy (needle exchange, condom distribution, frank and
fearless discussion of safe sex in schools. )
3. Coordinated leadership from community leaders and from government (eg appointing
Ita Buttrose, much loved editor of the Women’s Weekly, to be the public face of HIV
programs was an inspired choice)
4. Structures to support HIV treatment as it evolved, including hospitals, drug trials and
funding for GP and hospital support – this continues to this day, and you are welcome to
attend regular HIV breakfast meetings at TCH where there are speakers and a group of
interested health workers from across Canberra.
4. In 1996 there was a syphilis outbreak among among the schoolchildren of Rockdale
County in Georgia in the USA. This generated a great deal of concern and publicity in
the US, as they were in their early teens, and had wealthy parents. There was a well
known documentary on this presenting the outbreak as essentially due to parental neglect,
and boredom in a particularly boring part of Georgia. Other explanations may have been:
A.Particularly virulent syphilis infection spread through non-sexual means
B. Reduced capacity among girls to advocate for themselves in sexual situations
C. Rockdale county had a strong Christian community that advocated abstinence
D. Rockdale county public health services failed to perform adequate contact tracing in
the early days of the outbreak.
E. Rockdale county had few youth-friendly health services
F. Penicillin injections (standard treatment for syphilis) are very painful.
G. Some of the children had a genetic predisposition to being super-spreaders of syphilis.
ANSWER D&E
A. isn’t true. (the “I got it from a swimming pool” argument)
B. was argued by the producers of the documentary, who were pretty po-faced about
young people and their orgies. Some commentators have argued that the documentary
was made some years after the syphilis epidemic occurred, and many of the interviewees
now seemed to be ashamed of sexual experimentation which had occurred in their
younger teen years. (syphilis in this outbreak was equally distributed between the
genders). Others point out that young girls in particular often report that they begin
sexual activity because they didn’t know how to decline, rather than actively choosing to
have sex.
C. was not mentioned by the documentary makers, but raised by many other
commentators including CDC. Children growing up in communities where abstinence
models of sexuality are advocated in the USA have been found to have the same rates of
sex before marriage, and higher rates of teen pregnancies, as children where safe sex is
taught in schools. From this perspective, the children of Rockdale County were
insufficiently aware of how to negotiate sex openly.
D. appears to have been true
E. was also true. Rockdale county kids went to their parents’ doctors.
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F. They are, but this wouldn’t have been the reason. There are other less painful
treatments for syphilis.
G. Is a possible area of research interest, though we are uncertain about the role of superspreaders in sexually transmitted infections – index cases who are responsible for lots of
infections probably do so because of the extent of their activities rather than their
genetics.
HOST/AGENT/ENVIRONMENT
A. Agent
B. Host
C. Environment and Host (environment does not support host decisions on safe sex)
D. Environment
E. Environment
F. Agent (refers to the mechanism for attacking the agent)
G. Host (genetic weakness of agent)
WHERE WOULD YOU AS A PUBLIC HEALTH OFFICER PUT YOUR EFFORTS:
Biggest pay-offs go with the most plausible mechanisms. So assume we’ve proven that
it’s not a new strain of virulent syphilis, and assume that we’ve proven that the kids of
Rockdale County don’t have genetic constitutions that are different than everyone else’s.
Assume that you can persuade kids to get penicillin injections, so their painfulness isn’t a
barrier.
In this situation, public health officers went for improving the health services (D). This is
because it’s the easiest thing for them to fix up, not because it’s the most effective. The
schools responded by addressing (B), ie more talk about advocating being more assertive
and telling boys that they were bad for pressuring girls into sex. In the longer run (E)
was set up by the state authorities, but did not have the ability to provide free condoms or
other barrier advice, and instead did STD and pregnancy checking. C was beyond the
power of local authorities to address.
This case study offers a contrast to the pragmatic Australian response to HIV, which was
to: not stigmatise people for having sex; provide information and resources to young
people, in the knowledge that they may have sex and should be prepared; have open
access youth health services that are pragmatic and open; and to engage with religious
leaders about the spread of infection.
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LECTURE #8: The Placebo Effect
1. You have time-travelled to Medieval England. Time-travelling always gives you a
headache, but fortunately you are taken to the village healer, Mad Meg, who treats you
with a concoction of tree bark and bugs. You have never had this treatment and Mad
Meg strikes you as very odd. An hour later you do notice that your headache has
improved quite a bit. List possible explanations for the improvement.
ANSWER:
You got better because:
(a) there was an active ingredient in the tree bark and bugs13
(b) natural improvement in headache symptoms
Placebo effect is possible, but less likely since you have not demonstrated any trust in her
treatment, so the element of expectation is missing. If everyone around you swore that
however odd Mad Meg was, she was very effective in treating headaches, this would
have helped the placebo effect, as there may be an element of expectation, and social
learning. Conditioning is unlikely to explain the improvement as you have had no
previous experience of the medication.
2. Improvements in motor performance in patients with Parkinson’s after sham
implantation of dopaminergic neurones into the brain represent
A. A placebo effect, in that the patient expected to get better and did
B. A placebo effect, in that the patient had been conditioned by their own dopaminergic
neurons
C. A nocebo effect, in that the patient was likely to be disappointed that he had not had
the correct surgery
D. A nocebo effect, in that patients who did have real implantation of dopaminergic
neurones were more likely to be contaminated with prions
E. An opportunity to sue the hospital for failing to provide real medical treatment.
ANSWER:
A and B are correct. The literature on sham surgery of this nature for Parkinson’s disease
suggests that each of these processes may be occurring.
C and D are wrong because the patient improved. Nocebo effects are said to occur when
patients’ health status get worse.
E may be correct but isn’t relevant to the question. (and would you sue if you got
better?)
She’s probably treated you with willow bark, from which we have derived aspirin. The following
medications are also derived from tree bark:
 Cinchona bark: quinine (for malaria)
 Pacific Yew bark: tamoxifen (adjuvant therapy for breast cancer)
13
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3. “Prayer works in mysterious ways”. From a medical perspective, what are these
mysterious ways?
ANSWER:
From a medical perspective, the impact of prayer on recovery from illness reflects a
placebo effect, in which the element of expectation leads to recovery. When prayer
works WITHOUT the patient knowing, and therefore the element of expectation does not
exist, the medical perspective states that the natural history of recovery has been followed
and the patient has just got better, recruiting the natural recovery processes of the body.
An element of social learning may be at play in group prayer sessions with other people
with similar types of illness (this explanation has been used to explain some of the
recoveries that are reported at Lourdes, when even unbelievers sometimes report a lifting
of pain)
4. A 36 year old woman discovers she has breast cancer. She has a biopsy and oestrogen
receptors and has a poorly-differentiated tumour, which has a poor outcome. She begins
treatment with radiotherapy and oestrogen-blockers. She is offered genetic testing for
herself, her sisters and her daughters to see if they carry the BRCA-1 gene, making them
more susceptible to breast cancer. List the occasions in this clinical history where a
nocebo effect may occur, explaining your answer.
ANSWER:
There are numerous points in this case history where skilful management may be needed
to avoid a nocebo effect. The patient has a potentially life-threatening tumour, and is
going to go through some very unpleasant treatment. She has a right to know the sideeffects of her treatment, and the prognosis of her tumour. It is possible to make this
worse through triggering nocebo effects. Risk moments include:

informing her of the prognosis of her tumour type. Although discussing the
prognostic implications of a poorly differentiated tumour is necessary, there is a school of
thought that argues that too precise use of death predictions may limit life expectancy.
(There is little evidence that giving a patient a prognosis does in fact limit life
expectancy)14

treatment with radiotherapy. There is a general understanding in the community
of how unpleasant radiotherapy is, and she is likely to enter the process with expectations
of ill effects resulting from the therapy. Supportive and approachable radiotherapists are
integral to ensuring patient trust in the treatment process and understanding that the side
effects are containable.

discussing side-effects of oestrogen blockers. The patient’s treatment will trigger
menopausal symptoms. Casting the side-effects as “menopause-like” may create an
expectation of dramatic side-effects (depending on the patient’s view of menopause)
14
For an opinion from someone on the receiving end of a consultation about prognosis, see Stephen Jay
Gould’s “The Median Isn’t the Message” http://www.cancerguide.org/median_not_msg.html. Stephen Jay
Gould was diagnosed with mesothelioma, median life expectancy 8 months, and died 20 years later.
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LECTURE #9: The location of death
1. With regard to the location of death in modern medicine, which of the following is
true?
A. We define death as the cessation of the heartbeat
B. Accounts of out-of-body experiences before death support the argument that the soul
may lie in the brain.
C. Bodies that do not putrefy are technically not considered dead.
D. The Cartesian cogito supports the notion of death being defined through cessation of
brain function.
E. Life support technologies reinforce the notion that death is located in the brain.
ANSWER:
The following answers are true: A (NB: we also define death as the cessation of brain
function) D, E.
B is wrong because these experiences are also amenable to a straight biological
explanation reflecting brain death.
C is wrong. Bodies that don’t putrefy are environmentally (or miraculously) preserved
but they’re still dead.
2. At the end of the Edgar Allen Poe’s The Fall of the House of Usher, the last surviving
member of the family, Roderick, reminisces Gothically about his dead sister Madeleine:
“We have put her living in the tomb! Said I not that my senses were acute? I now tell you
that I heard her first feeble movements in the hollow coffin.”
Had Roderick been more prudent, what could he have done to ensure that Madeleine
wasn’t buried alive?
ANSWER
1. He could have had two doctors confirm that her heartbeat had ceased. If Roderick had
access to life support and he wished to confirm that she was brain dead before ceasing
life support, he would have needed two doctors to go through a variety of tests
independently to ensure she was brain dead.
2. He could have delayed her burial to ensure she was dead
3. He could have put her in a patented coffin with an above-ground bell to alert passersby when she regained consciousness.
4. Since she was interred in an above-ground mausoleum he could have left the door open
(this simple expedient would have ensured the continuation of the House of Usher)
5. Cut off her head.
3. Japan, in contrast to most nations with developed medical systems, took many decades
to embrace transplant surgery. List four reasons for this.
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ANSWER:
1. The first cardiac transplant case in Japan was regarded as scandalous, with the surgeon
facing a double murder charge (cf the celebrity status accorded to Christian Barnard)
2. Traditionally families, not individuals, make decisions about the disposal of bodily
parts, and families may over-ride the wishes of individuals for organ donation .
3. The valorisation of organ donation in the Western world implicitly calls on a set of
Christian notions about the giving up of one’s body for others, which may not have as
much meaning for non-Christian countries.
4. Notions that the wholeness of the spirit is allied to the wholeness of the body are more
common in Japan than in the USA where physical and spiritual wholeness can be
separated.
[interestingly, despite, or perhaps because of, Japan’s cultural discomfort with
“mutilating” the dead – and therefore one of the lowest rates of autopsy in the developed
world as well as low rates of organ transplants – one of the most successful manga was
the Black Jack series in the 1970s. Black Jack was a maverick hero-surgeon who could
operate in the dark and transplant limbs, faces and organs]
4. Define the elements of a good death for you. Do they reflect your own personal
experience, or do they draw on cultural notions of the good death? How does
biomedicine define the good death, and are there differences within biomedicine about
what constitutes a good death?
ANSWER
Obviously, there’s no correct answer (cf the Middle Ages with the more prescriptive Ars
Moriendi). However, most people would advance the notion that they would like to have
some level of control over their death, no pain, loved ones with them, and were not in
hospital. In surveys with health professionals, an additional moral element is often
raised: the good death is one in which the dying person “fought” against a disease, using
the medical armamentarium. There is also ambivalence about the degree of control a
person has over their dying, with euthanasia generally being more positively regarded
among the elderly than among their doctors.
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CLINICAL SKILLS SESSION #1: Multicultural health
1. Which of the following is/are correct in relation to the explanatory model of illness?
A. Explanatory models of illness are of particular use for people from immigrant
backgrounds
B. The elements of the explanatory model incorporate questions about the nature of
illness and the person’s interpretation of them
C. The evidence-based perspective that asthma should be treated with relievers (β2
agonists) and preventers (eg steroids) is an explanatory model of illness
D. The belief that epilepsy may result from a curse is an explanatory model of illness
E. To explore an explanatory model of illness it is best to know something of the
culture of the person expressing the belief.
ANSWER: C and D.
A is wrong because explanatory models are used by everyone, whatever their cultural
background. Thus C is an explanatory model as much as D is. The fact that one might
be consonant with biomedical thinking and one isn’t doesn’t change the fact that both are
explanatory models.
B is wrong because the explanatory model doesn’t incorporate questions about the nature
of illness (you should be asking these anyway in the consultation), but rather questions
about the patient’s understanding of illness and its treatment. E is sort of wrong because
if you ask the questions of the EM you should be able to work out what the patient’s EM
is. Knowing something about the cultural background of a person may make you more
prone to make a pre-judgement about the patient’s EM, which might be incorrect.
2. In relation to Australia’s migrant population, which of the following is/are correct?
A. Australia has the world’s second highest per-capita population of Holocaust
survivors outside Israel.
B. Australia and the US are the OECD’s most diverse multicultural societies.
C. One in three Australians was born overseas or has a parent born overseas.
D. The largest influx of migrants into Australia occurred after the Vietnam war with
asylum-seekers arriving by sea.
E. People born in New Zealand currently constitute the highest population of
residents born overseas in Australia
ANSWER: All are wrong! (NB: you will not be tested on these facts and figures in the
exam)
A. No, Australia has the highest per-capital population of Holocaust survivors
outside Israel. 35 000 Holocaust survivors migrated to Australia after the second
world war.
B. No, it’s Australia followed by New Zealand. 27% of Australians were born
overseas (the proportion increases every census, indicating that Australia
continues to be a country of migrants). 23% of New Zealanders were born
outside the country (though admittedly, many are Australians). The corresponding
percentages for Canada, UK and US are: 18, 13 and 12.
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C. No, nearly one in two. 47% of Australians were born overseas, or have a parent
born overseas.
D. The largest single influx of migrants occurred 25 years ago after the Tiananmen
Square massacre, when Bob Hawke overnight granted all Chinese students in
Australia permanent visas. Per head of population, the largest influx of migrants
occurred during the gold rush, when the population increased seven fold in
Victoria, and doubled in NSW over a period of five years.
E. No, people born in the UK15 form the largest population of immigrants in the
2011 census.
3.
When are the times in health care or life events, when it might be
particularly important to consider a patient’s particular explanatory model?
ANSWER: Childbirth, death, serious illness.
4. What is gratuitous concurrence? (more than one answer may be correct)
A. The linguistic strategy of agreeing to a question even when the true answer would
be no.
B. A politeness convention observed in some cultures
C. The cultural process of needing to have agreement from more than one person
when making a decision of consequence
D. A cultural strategy for reaching a community-based consensus
E. A gratitude convention whereby more than one person thanks the healthcare
provider at once.
ANSWER: A & to a degree, B.
Gratuitous concurrence is a communicative feature of many languages, including
Aboriginal English. It reflects a particular use of silence and a view that the purpose of
communication is partly to proceed in stages through developing a shared perspective and
then moving to other modes of consensus. So it is a politeness convention, but it also
reflects the concept that language is multilayered and has multiple purposes – hence
cultures that use language to orate as well as exchange information often employ
gratuitous concurrence.
Gratuitous concurrence has been implicated in miscarriages of justice and can lead to
unintentional false confessions. In the health sector it can lead to practitioners eliciting,
and having confirmed, incorrect histories.
5. You suspect that gratuitous concurrence is a factor in the responses by the patient to
the clinical consultation. What strategies might you use?
15
Like me!
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Firstly, don’t blame the patient. They are using a linguistic strategy which has a purpose
in their language. This may seem self-evident, but doctors do routinely blame patients
for their communicative responses, when the problem is the doctor’s limited interview
technique. 16
Secondly, don’t couch your questions so that they have yes/no responses (this is a general
principle of good interviewing). English in particular often proceeds through statement
and confirmation, rather than story-telling and listening.
For example: Do you have a cough? Did that cough start recently? Do you cough at
night? are all statements seeking confirmation.
To circumvent gratuitous concordance, you will need to begin by inviting the descriptive
narrative and then seeking clarification.
Eg What does the cough feel like? What does it sound like? When do you cough?
Unless the patient is delirious, be very wary of labelling them a “poor historian.” It gives other junior
doctors permission to not try to get a proper history. And it tells more senior doctors that you’re a lazy or
poor interviewer.
16
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Test Yourself - ANSWERS
SFM
Christine Phillips
CLINICAL SKILLS SESSION #2: Social disadvantage
1. Define:
A. Absolute poverty
B. Relative poverty
C. Transitional poverty
D. Elective poverty
E. Intergenerational poverty
ANSWERS
 Absolute poverty: Living on $1-1.50 per day
 Relative poverty: Living on 50% of the median household income. This is the OECD
definition. Some sources state 60% of the median household income, which is a
lower threshold for poverty.
 Transitional poverty: Temporary poverty, but with prospects of this ending.
Typically applies to students or to people who are between jobs but have excellent
job prospects. People in transitional poverty often retain their non-financial
resources such as friend networks. A good way to work out if you are in transitional
rather than long-term poverty is if you can identify someone to lend you $20 if you
need it for a taxi or to buy you medications.
 Elective poverty: What it says on the label: poverty chosen as a good in its own right.
Examples are people who enter the religious life.
 Intergenerational poverty: Poverty that extends from generation to generation,
reflecting entrenched lack of opportunity.
2. Which of these have/has the largest impact(s) in relation to health care?
ANSWER: A, B and E.
People in absolute poverty clearly have difficulties accessing services, but in Australia
this is a small population. The populations that repeatedly have to make choices about
how, when and to what extent they can access health care are those in relative poverty,
which will include intergenerational poverty.
3. Which of the following would be considered an attribute of someone with poor health
literacy? (more than one may be correct)
A. Inability to calculate a half dose (eg can’t work out that half a tablet = number of
milligrams of a dose)
B. Inability to describe the chambers of the heart.
C. Inability to read at a Grade 6 level.
D. Inability to understand the difference between different cadres of health
professionals (eg nurses and nurse practitioners)
E. Inability to describe how and why one should take prescribed medication.
ANSWER: E.
A is incorrect since it refers to numeracy, not literacy. B is incorrect because this is
common among many people, and is likely to impact on someone’s own health only if
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Test Yourself - ANSWERS
SFM
Christine Phillips
they need to understand this (eg perhaps if they have right or left heart failure). C is
wrong because functional health literacy requires the ability to read at Grade 4 level. D –
can you describe the difference?
4. Explain the elements that you would ask for in taking a social disadvantage snapshot
and why they are relevant to health care delivery.
ANSWER: MESSST
Money: Self-evidently, someone with reduced financial means may have difficulty
affording medications or the cost of health care, if it isn’t bulk-billed. People with family
obligations and reduced financial means often have to make choices about whether they
expend money on their own health. This part of the interview should ask them the source
of their income – Centrelink, or work. If the patient works, find out if it’s casual, parttime or full-time. Casual workers are often likely to prioritise working above resting if ill
because they won’t have sick leave.
Education: Education levels are reflected in a patient’s ability to read, understand and
follow treatment plans.
Shelter: Patients with no fixed accommodation are at serious health risk. (in the ACT,
these people won’t be living rough over winter, but rather couch-surfing every night).
The ACT has a lot of very substandard, near-slum rental properties – including the public
rental accommodation in the inner city and the boarding houses which stretch along
Northbourne Avenue as you drive into Canberra down the Federal Highway. People in
these houses have higher risks of being exposed to violence, and to extreme cold and
mould over winter. The internal temperature of some of the ACT’s public rental
properties drops to -6 degrees overnight in winter.
Someone to look after you This is of relevance because if there’ s no one to look after you
when you’re unwell (eg a family member or friend) then you are likely to have more
difficulty accessing health care.
Someone you have to look after. Many poor people also have very high carer burdens one of the features contributing to their poverty since it stops them from working or
studying. If you have a high carer burden you will often prioritise the health of those you
care for over your own – or be unable to seek care because you can’t cart around all the
children you look after on public transport.
Transport. If you can’t run your own car, in many cities, including Canberra, accessing
health care will be difficult. Many people in Canberra regularly spend 2-3 hours on
public transport every day travelling a distance that would take about 20 minutes to drive.
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