Outline the current pattern of disability in the UK
- Impairment – Any loss or abnormality of psychological, physiological or anatomical structure or function
- Disability – Any restriction or lack (resulting from an impairment) of ability to perform an activity within the range considered normal for a human being
- Handicap – A disadvantage for a given individual resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal for that individual
- What are the most common causes of disability? Healthcare systems, malnutrition, civil war, landmines, genetics, technology, spinal injuries, RTAs, arthritis
- How do they vary by age and gender? Older people more likely to have rheumatoid and osteoarthritis. Amongst adults: diseases of musculoskeletal system and connective tissue. Women in general have more disabilities than men at every age. Diseases of the ear and mastoid processes. Then diseases of the circulatory system, respiratory system then eye. a
Identify the implications of statistical power in interpreting research findings.
Statistical power is the probability of rejecting a null hypothesis when it is false - and therefore should be rejected. In general, the statistical power increases with your sample size. Also called ‘power’ or ‘test’
Outline the range of resources available to provide continuing care community.
- Using examples of a chronic disease such as diabetes, back pain or mental illness can you describe the different organisations and professional groups (both within and outside the NHS) involved in providing care? Multidisiplinary team. Diabetic clinic, specialist diabetic nurse, GP, practice nurse, receptionist, friends, family, neighbours, Diabetes UK or other support groups.
Appreciate the biomedical and social models of mental health illness.
- What are the strengths and weaknesses of these different ways of thinking about mental health? BioPsychoSocial Model Of Health and Mental Illness – “An approach in which health and/or illness are seen as a product with a number of interacting factors relating to the individual.” These include biological, psychological and social factors.
- Biological factors underlying mental illness – predisposing factors e.g. genetics – precipitating factors e.g. acute illness – mediating factors – neurotransmitter changes
Management – Treat disease e.g. electroshock, pharmacological intervention
- Psychological factors – predisposing e.g. childhood neglect – precipitating e.g. psychological stresses – maintaining e.g. dysfunctional thinking or behavioural maladaptations
- Management – alleviate identified stresses and psychological therapy e.g. CBT
- Social factors – predisposing e.g. physical depravation, poverty, poor diet etc
- precipitating e.g. life event such as loss of partner, job, changes in circumstances - maintaining e.g. poor finances, unemployment, lack of support
- Management – understand the nature and meaning of life events in order to address them appropriately. Problem solving advice and advocacy regarding the practical problems so financial advice, housing etc a
Understand the iceberg phenomenon of disease.
- The “Symptom Iceberg” - Symptoms themselves do not cause people to visit a doctors
- Most heath care work is undertaken by lay people
- What is going on for people “out there” in the community?
- What makes people go to the doctor?
Outline the epidemiology of learning disabilities.
- What are the major causes of learning disability?
- Metabolic – Lack of enzyme leads to build up of phenylalanine causes microcephaly/epilepsy/autism
- Toxic – Alcohol and lead
- Injection – Rubella, syphilis
- Neoplastic process – Epilepsy and autism
- Trauma – Hypoxia during birth
- Chromosomal and genetic – Downs Syndrome
- Defintion: Learning disability requires an IQ less than 70 and impaired social function and impairment occurred before the age of 18. After 18 it is “an acquired brain injury”. IQ less than 50 is “a severe mental disability”.
Understand the rationale and principles of qualitative research.
- What do you understand by the term qualitative research? How do people feel about certain treatments and outcomes. Makes a value judgment. Concerned with the meanings that people attach to their experiences. Studies people in natural settings. Systematic process. Uses several different methods e.g. observation, focus groups and interviews.
- Can you describe the main ways in which data is collected in a qualitative study? Observation (participant/non participant), focus groups and interviews, analysis of text and documents and recorded speech/behaviour.
- Can you give some examples where qualitative research can provide evidence that quantitative study designs could not? Could be used to identify how individuals search for health information on the internet. How diagnosis and interpretation of behavior may be affected by context. The experience of patients hospitalised with a mental illness. “The patient’s perspective”.
Describe the role of the organisation of mental health services.
- What aspects of mental health services are provided: by organisiations outside the NHS, by the community and acute sectors of the NHS?
- Community Support: Primary Care, crisis intervention, community based alternatives to acute care, assertive outreach, support with daily living, generic community mental health services
- 24 hour care: Housing with intensive support, sheltered accommodation, group home/shared housing, medium support hostels, residential homes, high support accommodation, 24 hours nursed accommodation, acute inpatient care, low secure units, medium secure units, special hospitals.
- Daycare and daytime activities: Ordinary employment, supported employment,
adult education, employment rehabilitation places, clubhouse, day centre, day hospital and drop in centre.
- Financial support: Welfare advice centre
Be aware of service user involvement in provision of services
- Can you give an example of involvement? Service User Involvement is ‘the involvement of service users in the management, design and delivery of services’. This definition emphasises that involvement should encompass the full range of people’s experiences - not just the things that workers or planners think are important - and operates at various levels of involvement: giving people information is a start, but involvement can develop into service users planning work themselves or delivering services.
For example, principles of Service User Involvement are absolutely applicable to operational tasks such as making and taking referrals, doing assessments and forming care plans - a ‘person-centred approach’.
Recognise stress and ways of coping in students own personal and professional lives.
- What are the possible consequences of stress on personal performance?
- Improvement, no change, sub-par performance. Impact on personal health.
What facilities are available to help both during training and for practicing doctors? -
Personal tutors, university counseling services, Nightline, BMA counseling service. Treatment from doctors outside your local area to save embarrassment.
Describe approaches to distinguish causal from non-causal associations
- Bias - Systematic error in the collection or analysis of information. Researchers not blinded to the source of information my treat results differently, consciously or sub-consciously
- Confounding - Both factors are not directly associated but are linked by a third factor
White hair and Type 2 diabetes are both linked to age. People moving from Hull to Beverley will live longer, but this is confounded by wealth
- What factors do you need to take into account when assessing whether an observed association is causal? The Bradford-Hill Criteria
- What are the ‘Bradford Hill criteria’?
- Strength of association – The greater the risk the more likely causation
- Temporal association – Does the result always follow exposure?
- Consistency – Is the relationship seen in different cases and different places
- Theoretical plausibility – Can we see the biological pathway e.g. tar and carcinogens
- Coherence – Does the association make sense or is it confounding?
- Specificity – How much effect is there when you remove the cause?
- Dose response relationship – Does risk increase with increased exposure? - Experimental evidence – Does an animal model exist? What does it show? - Analogy – Are there similar studies with similar results?
Interpret the output of linear regression.
- Can you interpret the coefficient (b) and intercept (a) of a simple regression equation: y=a+bx? Regression: Finds the best mathematical model to describe y, the outcome, with respect to x, the exposure. The most common form is linear regression. The regression co-efficient is an estimate of the change in outcome (y) for a unit change in exposure (x) according to the equation is y=a+bx, where a is the intercept and b is the slope. The regression line is a diagrammatic presentation of a regression equation. The steeper the gradient (coefficient) the more effect x has on y.
Interpret a correlation coefficient
- What is a correlation coefficient, what does it tell you about the nature of the relationship between two variables? Correlation co-efficient: A measure of association that indicates the degree to which variables change together. The stronger the relation ship the closer it is to one.
Describe using examples, the application of evidence in practice (guidelines and protocols)
- What is the National Institute for Clinical Effectiveness (NICE)? Produces guidelines and provides advice to clinicians about best practice
- What does NICE do?
- Technology appraisals of new and existing health technologies - Clinical guidelines for the management of specific conditions
- Interventional Procedures Programme
- Topics are signed off by politicians (selection groups include NHS Academic, NICE and
Department of Health staff)
- What is the Cochrane Collaboration? The Cochrane Collaboration is an international non-profit and independent organisation, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. The Cochrane Collaboration was founded in 1993 and named for the British
epidemiologist, Archie Cochrane.. The major product of the Collaboration is the Cochrane Database of Systematic Reviews which is published quarterly as part of The Cochrane Library.
Can you draw a diagram of the steps involves in a systematic review?
- Well Formulated Question
- Comprehensive Data Search
- Unbiased Selection and Abstraction Process - Critical Appraisal of Data
- Synthesis of Data
- Interpreting the findings
- Structured Report
- Systematic Review (SR)oComprehensive identification and synthesis of all relevant studies on a given topic, maybe RCTs, maybe other studies
- Meta-analysis is a statistical technique to combine the results of several suitably similar studies into a single numerical estimate
How would you interpret a number needed to treat (NNT)
How to interpret? As you say NNT is the inverse of risk difference (not by the way risk difference/rate difference - not sure where you got this from). So in the thrombolysis example above, risk difference for mortality between having thrombolysis and not having it is 2%. Therefore the NNT is 1/0.02=50. How to interpret - well this is saying (on average) you have to give 50 people thrombolysis before one benefits. Put another way, 49 in every 50 people given thrombolysis don’t get any benefit - in fact it’s a bit worse than that as there are a small number of people who are harmed by thrombolysis. How do we use this in clinical practice? Well NNTs can help doctors and patients come to decisions about treatment, if the NNT for a treatment is very big, say 400, we know that few people will benefit. If the treatment has a downside like a side-effect we might judge that as a patient we didn’t fancy being one of the 399 in every 400 people who get no benefit. Some people find NNTs easier to grasp than the risk difference. NNT’s can be either NNTB (number needed to benefit) or NNTH (number needed to harm) depending on what the outcome is in a study, and whether it is a good or bad outcome (NNTH would be what you would look at as a way of expressing chance of getting an unpleasant side-effect).
