CPP Y1 Karan PDF

Karan Dahele CPP Y1 16/17 CPP Y1 e-Health The information revolution Definitions: o e-Health - collective use of information systems and electronic communica...

Karan Dahele CPP Y1 16/17 CPP Y1 e-Health The information revolution Definitions: o e-Health - collective use of information systems and electronic communication for supporting and facilitating the efficient provision of health care and health research o Precision medicine – treatment that considers individual variability in genes, environment, and lifestyle for each person o M-health – mobile health Levels of calculation: 1. Frontline practitioner level – calculate risk for a certain patient based on information they give you – important in choosing between drastic and gentle treatment options 2. Higher level – analyse date to improve overall service – eg calculate standard mortality ratios (SMR) for different hospitals – patient experience is data you analyse in health informatics 3. Population level – analysis of large groups, on data that already exists – eg the “General Practice Research Database”, which has 590 primary care practices and 5 million patients Ethics and law Ethics and Law in Medicine Capacity: o Case: C was schizophrenic and had gangrene but wanted to prevent amputation. Turns out he was competent to reject treatment 1. Understand information 2. Retain & believe information 3. Weight it up and make decision o Mental Capacity Act 2005 altered criteria 1. Understand information 2. Retain & believe information 3. Weight it up and make decision 4. Communicate decision Adults by default are assumed to have capacity Criminal Civil Punishment Compensation Jury decides Judge decides Beyond reasonable doubt Balance of probabilities Duties, rights, defence o Duty: must do it, either enforced by GMC (professional) or law (legal), but rarely absolute o Right: can choose to do it o Defence: may go against normal guidelines, but there is adequate reasoning Karan Dahele CPP Y1 16/17 Duty of care Legal duty of care = obligation to care to prevent harm being suffered by another person No ‘Good Samaritan’ law in the UK In emergency: o Legally – no duty o GMS – professional duty Legal duty: o GP – registered on its list & emergencies for anyone in area o NHS trusts – vicarious liability – liable for employee negligence o All doctors – offer help & offer accepted → legal duty of care established (R vs Bateman 1925) Successful clinical negligence claim: o Barnett vs Chelsea – can be negligent, but unless it leads directly to harm, claim fails 1. Duty of care established 2. Duty of care breached (negligence) 3. Breach led to harm Standards for breach of duty 1. Bolam vs Friern (1957) – not negligent if: 1. “Ordinary” level of skill 2. Accordance with a body of medical opinion – opinion can be in minority 2. Bolitho vs City (1997) 1. Just having a body of medical opinion isn’t enough 2. Actions also need to be logical 3. Not lower for an inexperienced doctor 1. Should seek help 2. If not adequate help not provided, hospital is liable Personal and professional values - Confidentiality When to break confidentiality? On death: o Law – no confidentiality after death – so no legal right o GMC – still right to confidentiality - so factual right Duty: o Ordered by judge/court o Parliamentary statutes Notifiable diseases (Public Health Control of Diseases Act 1984) – not HIV ▪ MMR, rabies, plague, acute meningitis, cholera, diphtheria, invasive Strep A, malaria, campylobacter, TB, shigella, invasive S. pneumoniae, VZV, tetanus, C. botulinum, Brucella + others – ie most serious infections are notifiable ▪ TB – can be detained in hospital and examined without permission, but can’t be treated without consent Karan Dahele CPP Y1 16/17 Road traffic accidents, knife/gun wounds, and terrorism → notify police 1. Duty of care to patient first – eg make police wait until patient is well enough to see them 2. Minimum information (unless in public interest, then defensible) 3. Patient can refuse to speak to police Defence: o W v Egdell (1990) – defence of breaking confidentiality in public interest o GMC requirements: 1. Serious immediate risk 2. Try to seek consent 3. Warn patient 4. Only to necessary people 5. Minimum amount of information (eg police – only that there is a stab wound, no past medical history etc, unless it’s in public interest, then potential defence for it) 6. Anonymise as far as possible o Informing DVLA of epileptic patient o Venereal disease – can inform if partner in danger and ^defence criteria are met Family/friends – GMC: doctors should be considerate, don’t refuse to speak to them based on confidentiality o Establish what patient would like to disclose before they become more ill and potentially lose capacity o After losing capacity, reasonable to share relevant information with close family unless strong reason to believe patient wouldn’t want this Data Protection Act 1998 o Patients have right to access health records o But need to submit request o Information that could cause serious harm isn’t given Consent & Autonomy Three requirements for consent: 1. Capacity 2. Non-coercion 3. Well enough informed ▪ Can withhold information if detrimental to patient’s health ▪ Sidaway Case – enough information but should not overwhelm with information (eg no need to give minute risks) Battery – touching in a harmful/offensive manner without consent – doesn’t have to be with hostile intent If doubt about competence or insufficient time for further exploration → life preservation Mill Harm Principle - only stop people if what they are doing is harming other people Mental health The Impact of Family, Culture, Spirituality and Society on Mental Health - Karan Dahele CPP Y1 16/17 How Psychology Relates To Medicine Severity of disease or injury in medical terms does not determine the difficulty adjusting to it Studying psychology as aetiology – measure external psychological factor (eg stress), then measure physiological factor (eg endocrine change or wound healing) Loneliness o Emotional – nobody to confide in/feel close to o Social – lack of broader social group where they belong o Social loneliness + severe depression + male → lethal combination Patients often misinterpret statistics – think in high/low risk, not numbers o Hard to make logical connection of risk with problem → patients disregard it ▪ Eg women reduce smoking in relation to lung cancer, but not in response to risk of cervical cancer Psychological treatment targets: o Freud & psychoanalysis: interpretative, find insight into patient to achieve change o Behaviourism: behaviour and learning directly, often by reward systems o Cognitivism: information and beliefs o Behaviourism + cognitivism = CBT o Humanist & existential psychology: personal growth therapies – encourage potential o Mindfulness & ‘third wave’: calm planned stance, not problem thoughts & feelings Doctor-patient relationship o Patient satisfaction isn’t clearly related to better health outcomes o Disadvantaged people engage less, worse relationship & consultations Representative heuristics – when as a doctor you match the case in front of you to stereotypes – quicker but inaccurate Availability heuristics – things that come to mind more easily are believed to be far more common and more accurate reflections of the real world. Introduction To Psychiatry Types of mental health issues: o Psychosis: loss of contact with reality e.g. delusions associated with schizophrenia o Affective (mood): dramatic mood changes e.g. depression o Behaviour: antisocial behaviour e.g. alcoholism o Organic: structural brain pattern e.g. Alzheimer’s disease o Developmental/genetic e.g. autism, dyslexia, ADHD o Neurosis: distress without hallucinations and delusions e.g. anxiety and OCD Disability Adjusted Life Year (DALY) o Quantify quality of life with disability weighting – 0 = perfect health, 1 = eq. to death o DALY = YLD (years lived with disability = years x disability weighting) + YLL (years of life lost) o Allows comparison of conditions which reduce quality of life with conditions which cause morbidity o Shows depression is single most important contributor to burden of disease in high income countries Child Development Most brain growth occurs after birth, until well into adolescence Temporary imbalances of reward systems may contribute to adolescent risk-taking behaviour Karan Dahele CPP Y1 16/17 Infancy: o Take months to gain voluntary control of reflexes o Blurry vision – but can distinguish patterns o Can distinguish tastes and hear sounds Psychological Concepts Of Health And Illness - Behaviour Change and Adherence to Treatment Up to 50% of patients don’t take treatment as directed Non-adherence can be intentional or non-intentional Stages at which non-adherence can arise: 1. Initiation – collecting and starting treatments 2. Implementation – timing, diet, dose, behaviour 3. Persistence – taking the full course of medicine Adherence is related to: o Doctor-patient relationship, believing treatment is important, social support o Not strongly to: severity of illness, age, socioeconomic status, information about illness – even simplifying treatment doesn’t necessarily improve adherence Measuring non-adherence o Asking – reporting bias/hidden non-adherence? o Blood tests – non-attendance? Causes: o Information-action gap – knowledge is necessary to change intention but not sufficient to change behaviour A Sommerlad – Society, Culture And Mental Health - Life Events and Psychoneuroimmunology Interaction between psychological processes and nervous & immune system ↑ Anxiety before surgery = ↓ recovery Assessment o Exposure to virus → how many symptoms? o Cut → speed of wound healing? Psychological Aspects of Cardiovascular Disease Psychological risk factors: o Stress o Mood disorder – eg depression o Personality Depression and stress can affect: o Physical activity o Adherence to treatment o ↑ Catecholamines & ↑ Cortisol ▪ Damages immune system regulation ▪ ↑ BP o ↑ inflammatory cytokines Karan Dahele CPP Y1 16/17 ▪ IL-6 – ↑ endothelial activation, more plaque formation ▪ ↑ Enzymes that break down protective surface of plaque ▪ ↑ TF and fibrinogen Social determinants of health CPP1013 Social Determinant of Health - Key principles NCD = non-communicable diseases Mortality: o Amenable mortality - deaths occurring before age 75 from causes that are considered amenable to medical intervention o Avoidable mortality - deaths considered preventable through public health policies Health equity – ‘absence of unfair and avoidable or remediable differences in health’ among social groups CPP1014 Global health: globalisation, transition & burden Disease burden – morbidity + mortality + financial cost o Measured in DALYs – disability-adjusted life years o Disability weighting – 0 = death, 1 = perfect health o DALY = YLD (years lived with disability = years x disability weighting) + YLL (years of life lost) o Globally most DALYs – Ischaemic heart disease, LRTI, CVD, diarrhoea, HIV/AIDS Omran – As a country develops: 1. Pestilence and famine (High death rates, primarily due to infection) 2. Living conditions begin to improve (“receding pandemics” – reduced infection) 3. The age of non-communicable diseases (Cancer, diabetes) ▪ The age of delayed degenerative disease (Alzheimer’s) CPP1023 - History Epidemiology, Public Health and Health Systems Epidemiology - study of the distribution and determinants of diseases i.e. who gets what disease, where, when and why? Drivers of social change o 1848 Public Health Act o The great stink – smell from untreated human waste ∴ made sewage system o Concerns about the productivity of the working classes o Religious ideals Miasmatic theory→ Zymotic theory → Germ theory. Proponents: 1. Ignaz Semelweis – handwashing 2. Louis Pasteur – contamination 3. Robert Koch – discovery of causative organisms 4. Joseph Lister – pioneered antiseptic surgery Others: Chadwick – report on sanitary conditions of working class and hygiene education Farr & Snow – reports on cholera and mortality, how to classify disease, & contributed to zymotic theory Snow – mapped cases of cholera to water pump Nightingale & Farr –link between conditions and mortality in army hospitals Karan Dahele CPP Y1 16/17 CPP1029 - Health and Social Care: Who Cares? Can reduce inequalities in health more by preventative measures than by treatment Funding: o Health budget – government, ring fenced o Social care budget – local authorities from their own budgets o Barker Report – recommended single ring fenced budget for NHS and social care Carer assessment legislation o 1990 – taken into account when assessing disabled person o 1995 – assessed with patients by law o 2000 – separate assessment for carer and disabled person CPP1052 Medicalisation How non-medical problems become defined as medical problems Conrad and Schneider - 3 levels of medicalisation: 1. Conceptually - problem is defined with medical terminology 2. Institutionally - organisations take medical approaches to problem 3. Interactionally - doctor/patient define problem and treat problem as medical Things which are medicalised often begin as “deviances” Rose (2007) - Deprofessionalism o Doctors no longer the only ones to decide what is medicalised o ↓ Lay-professional distinction o Doctors constrained by law and bio-ethics CPP1053 - Social class and health There has been a reduced absolute gap in poverty but inequalities are increasing (Black report) How can lower income impact health? o Main factor (Black report, Marmott review, Acheson report) – material factors such as housing and employment o Acheson – social policy causes health gap – fix by targeting families and education o Job control Marmott review - 6 policy objectives 1. Give children the best start in life 2. Enable all children to maximise their capabilities 3. Fair employment 4. Minimum income standard - having sufficient resources to participate in society, consuming goods and services considered essential in Britain. 5. Healthy and sustainable places 6. Ill health prevention CPP1054 - Gender and health Women – lower mortality. Similar or possibly higher morbidity o Except in countries where women are fundamentally subordinated o Factor = help-seeking behaviour CPP1059 - Old Age and health Elderly only have slightly more acute illnesses than young people, but many more chronic Mental decline Karan Dahele CPP Y1 16/17 o About 20% of 65+ exhibit psychological morbidity. o Prevalence of dementia doubles every 5 years above 65. Roles of the elderly o Role theory (Parson) ▪ Loss of work/role in society is demoralising → ↓self-esteem → pessimistic about leisure time o Disengagement theory (Cumming & Henry) ▪ Voluntary withdrawal from society, instead preoccupy themselves ▪ Benefits both society and elderly o Structured dependency theory (Townsend) ▪ Old age defined by retirement age – government power over pensions & poverty ▪ Economic burden, excluded from society o Third age (Laslett) ▪ Compression of morbidity → enjoy freedom from family/work o Cultures of ageing (Gilleard and Higgs) ▪ Role of elderly different in each generation Moody’s four scenarios: o Propagation of morbidity – ↑ life expectancy but also longer end morbidity o Compression of morbidity – less change in life expectancy but shorter end morbidity o Lifespan expansion – both ↑ life expectancy and shorter morbidity o Voluntary acceptance of limits – life span extension rejected after certain age o CPP1060 - Ethnicity and Health Differentiation: o Race – genetic. Can only have one race o Ethnicity – how you view yourself – ethnic group has circumstances, eg history, differentiating it from rest of population o Culture – set of shared experiences, beliefs, values Class is a much more important factor than ethnicity in explaining social inequality People of Chinese origin living in the UK – same life expectancy and general health as indigenous population CPP1063 - Medicine as a profession Defining a profession: o Specialist skill o Monopoly over formal training and usage of skills o Autonomy Karan Dahele CPP Y1 16/17 o Strict code of ethics o Status, shared identity & solidarity 1858 Medical Act: forced registration with the GMC, title of Dr. Power approach: medical profession has autonomy and ultimately dominates and outranks all other professions. Challenges: o Poletarianisation thesis: ▪ Managerialism – are managers and targets undermining medicine as a profession? ▪ Deskilling – tasks are increasingly specialised, and the use of technology is increasing o Deprofessionalism: ▪ ICT ▪ Consumers encouraged to take a greater role ▪ Paramedics, pharmacists etc o Embodied trust → enforceable trust (need to prove we deserve trust, not intrinsic) CPP1064 - Doctor-patient interaction and the sick role Jewson (1976) o Bedside medicine – power lay with patient – diagnosis based on what patient says o Hospital medicine – shifted to hospital, so doctors have power and can examine o Laboratory medicine – patient becomes depersonalised, can’t influence diagnosis In addition: o 1995 – surveillance medicine – assessing risk and illness prevention o 2003 – e-scaped medicine – imaging techniques – patient vanishes and feels alienated, and doctors have less voice Don’t memorise, just familiarise: Parson’s Sick role - Patient’s obligations and privileges: (very paternalistic) 1. Must want to get well as quickly as possible 2. Should seek professional medical advice and co-operate with the doctor 3. Allowed to shed normal activities and responsibilities 4. Regarded as in need of care Doctor’s professional role - expectations 1. Apply a high degree of knowledge and skill 2. Act for the welfare of the patient and community rather than self interest 3. Be objective and emotionally detached 4. Be guided by rules of professional practice Doctor’s professional role – rights 1. Right to examine the patient physically and enquire into areas of their personal life 2. Considerable autonomy in professional practice 3. Occupies a position of authority in relation to the patient CPP1065 - Illness behaviour Defining health: o Positively: fitness and wellbeing Karan Dahele CPP Y1 16/17 o Functionally: ability to cope with every day activities o Negatively: absence of illness Clinical iceberg - Professional services treat just the tip of total ill health Why do people see a doctor? o Mechanic (1978) - Behaviour in consultation depends on how others respond to symptoms o Friedson – lay referral system – discuss with family/friends before going o Tudor Hart – inverse care law – need help most = see doctor least o Zola – 5 triggers 1. Interpersonal crises 2. Interference with social/personal relationship 3. Interference with vocational/physical activity 4. Sanctioning – pressure from others 5. Temporalizing – “if I don’t feel better in a week” CPP1066 - Chronic illness and disability ICIDH: o 1. Impairment - At the level of the body 2. Disability - At the level of performance 3. Handicap - At the level of social role oFor example, in arthritis, the impairment is joint pain and swelling. There is a disability if the patient has trouble walking, and a handicap could be social isolation or poverty ICF – about components of health o Impairment to body structures & functions o Limits to activities o Participation in life situations Differences in ICIDH vs ICF: o ICF has emphasis on functional effect o ICF integrates multiple factors, including psychosocial, so it’s a more holistic assessment of the person’s quality of life o ICIDH has functional loss as a direct consequence of disease Models of disability: o Medical model - handicaps seen as a direct consequence of biomedical issues, impairments, and disabilities o Social model - disability is caused by the way society is organised, rather than by a person’s impairment or difference – failure of environment to adjust CPP1068 - Variations in CHD Age is the most important factor Migration Karan Dahele CPP Y1 16/17 o Migrants bring CHD patterns similar to home country o Following generations – normalise to general population o Exceptions: south Asians = higher prevalence Ischaemic heart disease - mortality has reduced in the last 10 years o Reduction in risk factors – lower smoking and lower fat intake o More drugs being prescribed – particularly lipid-lowering drugs and anti- hypertensives CPP1073 - Disability and stigma Deviance – blame – breaking societies rules o Primary – original act that causes them to be labelled as deviant o Secondary – label causes them to behave in a way which fits the label Stigma – shame o Goffman: – “process by which the reaction of others spoils normal identity” ▪ Discredited – easily perceived and obvious, so open – eg wheelchair ▪ Discreditable – can be hidden, so secretive – eg mental illness o Scrambler: ▪ Enacted – actual discrimination from someone else ▪ Felt – self-inflicted shame CPP1074 - The body and the cultures of health Cartesian dualism – separation of body and mind Body as a sign of success or failure o Somatic society – political and personal problems are expressed through the body – fitness as a measure of other things o Shift from asceticism to hedonism – body maintenance, ‘To look good is to feel good’ Tallis – neuromania - trying to explain consciousness by physical processes (neuroscience) alone is impossible. Science can’t explain impact of society CPP1076 - Death and Dying Perspectives on death: Authority Coping mechanism Social context Traditional Priest Prayer Community perspectives Modern Doctor Silence Hospital perspectives Post-modern Personal choice Expressing feelings Family – home perspectives Kubler-Ross - Stages of dying 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance Awareness contexts: o Closed – everyone but patient is aware o Suspected – patient suspects they are dying Karan Dahele CPP Y1 16/17 o Mutual pretence – patient and everyone else knows the patient is dying, but both groups pretend the other group does not know o Open context – everyone knows CPP1077 - Limit of Medical Knowledge Kuhn’s theory – science = dogma believed by majority of scientists. Progression is via: o Normal – incremental building on previous dogma o Revolutionary – dogma challenged Foucault’s medical gaze o Knowledge leads to power o Taught to look at science in a certain way ▪ Eg not questioning dogma o Clinical gaze Eg looking at X-rays with a confirmation bias Spacialisation – progression in causes of disease 1. Primary – factors outside body – eg Pew says weather 2. Secondary – within closed system of body – based on symptoms, not aetiology 3. Tertiary – mechanisms and molecular aetiology using technology, not just symptoms Iatrogenesis – medical interventions causing more harm than good o Clinical iatrogenesis - Ineffective, toxic and unsafe interventions o Social iatrogenesis = Extension of interventions into aspects of social life o Cultural iatrogenesis - Removal of other ways of dealing with problems Inequalities in health “Social gradient” Globally, increasing GDP increases life expectancy but only up to a point More power at work = more stress but bigger benefits → higher life expectancy o CHD is lower in high power jobs. Social isolation leads to poor health, as does owning few socially orientated items CPP1087 - Sexuality - CPP1091 - e-Health – a sociological perspective - Clinical skills & professionalism Patient centred consultations Features of a doctor-centred consultation: o Treating patient as a disease o Doctors doing most of the talking and dictating structure of consultation o Coercion How to PCC? o Set the scene – comfortable, warm room o Put patient at ease – Non-verbal cues (body language), reflection on what patient says, active listening Discussing difficult topics - Karan Dahele CPP Y1 16/17 Clinical Skills and Practical Procedures Order of handwashing steps is examinable Professionalism Social media o Can’t accept contact even after doctor-patient relationship ends o Contact either face-to-face, or via email to explain. Can’t message on social media The Johari window Known by self Not known by self Known by others Public self Blind self Not known by others Private self Undiscovered self Reflection o Structured debriefing (Gibbs/Kolb)– description → feelings → evaluation → analysis → conclusions (general) → conclusions (specific) → personal action plans o Hatton and Smith framework – descriptive writing → descriptive reflective → dialogic reflection → critical reflection