Block 7 plus additional things

Question 1

1. What is prognosis?
2. Why is prognosis important?
3. How are doctors not always accurate in prognosis?
4. name 3 types of prognostic factors
5. How is prognosis generally examined?

Answer 1

1. assessment of future course and outcome of a patient’s disease, based on information from other patients of a similar demographic
2. patient knowledge; diagnostic and treatment decisions
3. mostly optimistic
4. demographic; disease specific; comorbid
5. cohort and case control studies

Question 2

1. what is the basis of a cohort study?
2. describe comparisson groups
3. what do we need to do to prevent selection bias?
4. what can losses to follow up lead to
5. what should researchers be blinded to?
6. what else do we need to be mindful of during follow up? (2)
7. Name 2 things that cohort studies are useful for

Answer 2

1. prospective natural experiment. Start with risk factors and observe outcomes
2. similar individuals without disease
   similar individuals not exposed to the same risk factors
   individuals with the same disease with different prognostic factors
3. ensure that there are no systematic differences between the two groups
4. bias
5. the patient’s prior characteristics
6. confounding factors
   that exposure to factors may change over the course of the study
7. timecourse of outcome development
   rare exposures

Question 3

1. what is the basis of a case control study?
2. name a consideration when selecting controls
3. name 2 ways bias can be introduced in case control studies
4. what are case control studies good at looking at

Answer 3

1. retrospective observation study; start with outcome, look at exposures
2. they should be from the same population as cases
3. recall bias
   measurement of exposure to risk factors may be biassed by the presence or absence of outcome
4. rare outcomes

Question 4

1. how can health inequalities arise from poor communication with homosexual/bisexual people? (3)
2. what is biphobia?
3. name 2 other types of discrimination that homosexual/bisexual people face

Answer 4

1. • missed opportunities for interventions around risk behaviours
     - sense of a homosceptic environment
     - lack of opportunities to discuss health issues
2. discrimination towards bisexual people from both homsexual and heterosexual communities
3. homophobia
   heterosexism - the widespread assumption that heterosexuality is taken as normal, natural or right

Question 5

1. how is sexuality relevant to healthcare (7)

2. name 3 recommendations of the sigma report

Answer 5

1. vulnerable to a range of STIs;
   intimate disclosure
   more likely to smoke
   bacterial vaginosis more common in lesbians
   higher rates of breast cancer in lesbians
   poorer mental health
   addiction
2. increased meaningful communication
   develop and display equality policies
   adhere to confidentiality guidelines
   staff need to adhere to all guidelines, including those on confidentiality.

Question 6

1. what is falsifiability?
2. what is chance?
3. what is bias?
4. what is confounding?
5. Name the Bradford Hill Criteria for causation (10)

Answer 6

1. to have credibility, a hypothesis must be discreditable
2. the occurrence of an event in the absence of obvious intention or cause
3. systematic error in collection or analysis of information
4. both factors are not directly associated but linked by a third factor

4. strength of association
temporal association
dose response relationship
confounding
consistency
analogy
experimental evidence
theoretical plausibility
coherence
specificity

Question 7

1. what is medicalisation

2. name 2 reasons as to why medicalisation is not necessarily a bad thing

Answer 7

1. the process whereby some aspects of human life are considered as medical problems, when they were not previously considered pathological
2. leads to humane treatment
   validation of felt state

Question 8

1. what is the deployment of sexuality?
2. name the 4 types of human subjects that were regulated during the 17th century
3. describe 4 ways in which medicalisation of sexuality changed in the 19th and 20th centuries
4. Describe 3 aspects of contemporary understanding of sexuality
5. what does current medicalisation of sexuality focus on?

Answer 8

1. anything that deviated from normal was underpinned by a biologically driven pathology
2. hysterification of women
   pedagogisation of children’s sexuality
   socialisation of procreative behaviour
   psychiatrisation of perversive behaviour
3. deployments in sexuality changed - increased illegitamacy, open discussion of tabooed subjects, challenged gender boundaries
   radical sex reforms - legalising abortion and availability of contraception
   emergence of various movements, including the gay rights movement
   sexological science
4. sex is no longer seen in its relation to marriage
   widening range of sexual behaviour
   regulation of sexual behaviour via sex ed, pregnancy prevention programmes and sexual health clinics
5. interest by pharmaceutical industry in women’s sexuality - women’s viagra
   ideas of what constitutes healthy sexual activty
   emergence of asexuality

Question 9

1. what is rationing?
2. describe 5 restrains in non-price rationing
3. Describe the stages in rationing

Answer 9

1. when someone is denied or not offered an intervention that people agree would do them some good and which they would like to have
2. • staffing levels
     - availability of beds, equipment, operating theatres etc
     - training
     - percieved appropriate care
     - time of health professionals
3. government decides budget and allocates to CCGs (on the basis of population weighted by need)
   CCGs fund hospitals’ NHS england funds primary care
   Doctors ration patient access to care

Question 10

1. what negative outcome can rationing by ability pay lead to?
2. what is need?
3. How do NICE Guidelines guide rationing?

Answer 10

1. excludes the poorest and discourages the rest from using healthcare
2. need exists when there is an effective and acceptable treatment or cure
3. uses evidence from RTCs and systematic reviews about relative treatment effects on a health related quality
   effective treatments are rated based on QALY - cut off £30000

Question 11

1. name 6 social and cultural constraints on food
2. how can food relate to identity (4)
3. what is food poverty?
4. name 4 reasons in the increase in food poverty
5. name 3 contributing factors to the obesigenic environment

Answer 11

1. religious beliefs 
political beliefs
time and availability to prepare and cook food
identity
advertising and retailers
tastes

2. gender roles
   parenting roles
   ageing
   culture
3. the inability to afford or have access to food that make up a healthy diet
4. decline in rural/urban public transport
   collapse of independent food retailer sector
   food manufacturers push high fat, low nutrition food (particularly at the value for money end of the market)
   low incomes
5. sedentary lifestles
   fast, convenient food
   advertising

Question 12

1. what are guidelines?
2. what are the aims of guidelines (2)
3. describe the process of a systematic review
4. what factors are considered when generating a review question?
5. how is a literature search carried out?
6. what is a meta-analysis?

Answer 12

1. statements that include a recommendation intended to optimise patient care. They are informed by systematic reviews of evidence
2. reduce variability in availability, quality of treatments/care
3. close the gap between what clinicians do and what is supported by evidence

4. P- population
I - intervention
C - comparator
O - outcome
S - study design

5. search all relevant databases
   check reference lists for recent systematic reviews
   check all relevant sources for unpublished data
   apply picos to all
6. comparison of risk ratios between intervention and comparator for all studies
   generates a forest plot

Question 13

1. Describe the following levels of evidence:
   a) 1++
   b) 1+
   c) 1-
   d) 2++
   e) 2+
   f) 2-
   g) 3
   h) 4

2. Describe the following grades of recommendation
A
B
C
D

Answer 13

1a) . high quality meta-analysis of RTCs
b) . well conducted meta analysis
c) . meta analysis of RTCs with a high risk of bias
d) high quality systematic reviews of case controls/cohorts
e) well conducted systematic reviews of case controls/cohorts
f) case controls/cohort studies with high risk of bias
g) non analytic studies
h) expert opinion

2A - directly based on 1++ review or many 1++ reviews
B - directly based on 2++ evidence or extrapolated data from 1++ or 1+ studies
C - based on 2+ evidence
D - based on 3 or 4 evidence

Question 14

1. describe 5 aspects of long term conditions
2. name 4 challenges of LTCs
3. how is the sick role sometime difficult to apply to LTCs?
4. describe the benefits and new challenges of diagnosis

Answer 14

1. can't currently be cured
uncertainty
interraction of biological and social factors
impacts many aspects of life
involves high levels of self care

2. pain
   embodiment - increased awareness of our bodies that we normally do not have
   management
   expert patients

3. good days and bad days
long term
no cure (unable to get better quickly)

4. • can provide access to sick role
     - social challenges - employment, finances, maintaining relationshoips
     - clinical - prognosis, rate of deterioration, complications
     - diagnostic uncertainty
     psychosocial - self and identity

Question 15

1. what is biographical disruption?
2. describe the 3 aspects of biographical disruption
3. what is narrative reconstruction?
4. what may narrative reconstruction lead to?
5. name 3 critiques of biographical disruption
6. name 6 reasons why patients may self regulate their treatment

Answer 15

1. disruption to an individual’s sense of “who I am” and “where I am going” that can be caused by diagnosis of chronic illness
2. regarding one’s body - embodiment; body can’t achieve what one wants it to
   biopgraphy - who one is; becoming a person with an LTC
   response - mobilising resources
3. narratives that people construct as they try to make sense of their circumstances
4. may cause someone to refocus on things that are important to them
5. based on adult model
   works well for young/middle aged people who develop a chronic illness
   doesn’t apply well to people born with or who develop chronic illnesses in young age
   ignores illness as a normal crisis for the working class/elderly
6. • perceived efficacy
     - perceived side effects
     experimentation
     reminder of ill identity
     fear of dependence on drugs
     practicalities of treatment regime

Question 16

1. How do you calculate confidence intervals? (equation)
2. Describe correlation co-efficient
3. What is a fancy word for linear regression?

Answer 16

1. mean ± 1.96 x SEM
2. numerical measure of a correlation
   +1 means strongest possible positive correlation
   -1 means the strongest possible negative correlation
3. linear regression

Question 17

Name the 6 aspects of patient centred care

Answer 17

1. explores main reason for visit
2. seeks an integrated understanding of patient’s world
3. enhances health promotion and prevention
4. finds common ground on problem and seeks mutual agreement on management
5. enhances continuing relationship between patient and doctor
6. is realistic

Question 18

1. name 6 proximal, and 5 distal factors that contribute to a patient’s world
2. what do doctors and patients need to find common ground on? (3)
3. how can doctors be realistic? (3 Ts)

Answer 18

1. Proximal:
   - family
   - education
   - employment
   - leisure
   - social support
   - financial security

Distal:

• community
• economics
• healthcare system
• geography
• media

2. nature of problem; goals of treatment; priorities of treatment
3. Time - effective use of consultation time
   Timing - use of multiple consultations
   Teamwork - MDT can increase person centredness

Question 19

1. How can testing based on ethnicity become negative? (4)
2. Name 3 ways (except Barthel’s Index) of measuring disability
3. What is clinical equipose?
4. What is number needed treat?

Answer 19

1. • people may be stigmatised
     - gives impression that ethnic minorities being sicker and bringing disease into the country
     - potential resentment against resources being directed towards ethnic minorities
2. Functional Assessment Measure
   SF-36
   Nottingham Health Profile
3. genuine uncertainty in the expert medical filed over whether a treatment will be beneficial
4. how many people you need to offer a treatment to in order to achieve one positive outcome

Question 20

1. How is MUS linked to stress?
2. Name 5 indirect mechanisms of MUS
3. name 5 factors that affect the illness response
4. What is problem based coupling?
5. What is emotion based coupling?

Answer 20

1. some MUS may arise from normal bodily sensations with misinterpretation
   some MUS may arise from minor pathology and are exaggerated at times of stress

2. poor compliance with medication
increased alcohol intake
increased smoking
reduced exercise
poor diet

3. premorbid personality
prior experience of illness
mental state
childhood difficulties
appraisal and coping styles

4. involves controlling the problem and constructing it as manageable (seeking information and support; learning new behaviours)
5. involves managing emotions and maintaining emotional equilibrium (emotional discharge, making and maintaining supportive friendships)

Question 21

1. What is motivational interviewing?
2. what is change talk?
3. what is sustain talk?
4. what is needed for motivational interviewing (DARNCAT)
5. what are the four fundamental processes in motivational interviewing?
6. What are the four key skills in motivational interviewing?

Answer 21

1. a style of counselling that acts to build and strengthen commitment to change behaviour
2. anything that supports a possibility, hope, aspiration, wish for change
3. arguments for staying the same/maintaining the status quo

4. Desire
Ability
Reason
Need
Commitment
Activation
Taking Steps

5. engaging
   focussing
   evoking
   planning
6. open-ended
   affirming
   reflecting
   summarising

Question 22

1. give a definition of standard error
2. Which legal test is relevant to whether or not treatment is appropriate, in accordance to the standards of the medical profession?
3. give 3 general instances where it might be appropriate to withhold treatment

Answer 22

1. if a population was sampled many times, standard error is the measure of variability of the mean of those samples; shows how well the mean of the sample represents the population mean.
2. Bolam Test
3. law makes provision for conscientious objection
   there may be instances where the treatment is contrary to the physician’s duty of care - e.g. medication that is not clinically appropriate
   there may be instances where requested treatment is illegal (e.g. request for active euthanasia)