Give brief descriptions of case control studies and cohort studies
- Case control:
- 2 groups of people are compared:
- A group of individuals who have the disease of interest (cases)
- A group of individuals who do not have the disease of interest (controls)
- Data is then gathered on each individual to determine whether or not they have been exposed to the suspected aetiological factor(s) and whether or not a conclusion can be drawn that the suspected aetiological agent is a likely cause of the disease in question
- 2 groups of people are compared:
- Cohort studies:
- Baseline date on exposure is collected from a group of people who do not have the disease in question
- The group is then followed through time until a sufficient number have developed the disease to allow analysis
List 4 possible sources of epidemiological data which may provide information on a specific disease e.g. IHD
- Mortality data
- Hospital activity statistics
- General practice morbidity/disease registers
- Health and household surveys/population census data
- Social security statistics
- NHS expenditure data
Your first patient in the morning surgery is 45yo John Smith, who moved to the UK from Russia 18 months ago and works on an offshore oil platform. He presents with dermatitis affecting his hands and lower arms and tells you that he thinks it is work related.
List 8 questions you would like to ask in John’s history which would help you decide whether occupational contact dermatitis is the likely diagnosis.
- Does he work with chemical irritants?
- How much exposure does he have to these irritants? (intensity/duration)
- Do his symptoms improve when not at work?
- Is personal protective equipment used?
- Does the company enforce PPE use?
- Do other work colleagues have similar symptoms?
- Has he any hobbies/pets/other activities which may be a likely cause?
- Does he use hand cream or other topic agents he may be allergic to?
You provide John with a prescription and advice and ask him to return for review one month later. By this time, his dermatitis is much better, but he has some other issues he wishes to discuss with you. Although he, his wife, and his young daughters are happy in Aberdeen and have adjusted well to life in the UK, John complains that he feels anxious and has difficulty sleeping. As a GP you are aware that offshore oil industry workers may suffer a variety of psychological and/or social issues.
List 8 examples of psychological and/or social issues which may be affecting John.
- Anxiety regarding travel
- Anxiety regarding job security
- Depression, perhaps secondary to loneliness and being away from family
- Stress due to shift pattern
- Pressure to maintain standard of living
- Difficult adjusting back into family life when onshore
- Abuse of drugs or alcohol
- Misses Russian culture or may feel ethnically isolated
List 6 potential difficulies which may arise in any consultation as a result of cultural differences
- Lack of knowledge about health issues and the NHS
- Fear and distrust
- Racism
- Bias and ethnocentrism
- Stereotyping
- Ritualistic behaviour
- Language barriers
- Presence of 3rd party e.g. family members or translator
- Differences in perceptions and expectations
- Examination taboos
- Gender difference between doctor and patient
- Religious beliefs
- Difficulties using language line
Look at the 2 population pyramids for Scotland between 1951 and 2031.
Give 9 possible reasons for the trends shown in the population pyramids.
- Decrease in premature mortality leading to an increased life expectancy
- Decrease in birth/fertility rates
- Migration
- Greater availability of contraception
- Improvements in housing
- Improvements in sanitation
- Baby boom in post war recovery years
- Health education programmes e.g. smoking, exercise, diet
- Improved safety and reduction of injury
List 4 issues this will present to health care services and 5 social issues relating to the trends shown in the pyramids.
- Health care services:
- Increased demand for geriatricians and allied health professionals
- Increased demand for ward/health care facilities for the elderly health care
- Increased prevalence of long-term conditions such as diabetes, CVD, renal disease
- Increased need for specific health promotion campaigns aimed at the elderly
- Social:
- Increasing dependence on families and/or carers who are also ageing
- Demand for home carers and nursing home places likely to increase
- Increasing emphasis on social activities for elderly within communities
- Role of elderly as grandparents and carers of grandchildren likely to change
- Housing demands are likely to change as more elderly people live along
Later in the morning you see Kathy Roberts. She is 50yo and cares for her 82yo mother, Jean Smith. Jean has several co-morbidities and is on multiple medications. She lives with Kathy and her family.
List 8 ways (including a positive way) in which her role as a carer might affect Kathy.
- Poor mental health e.g. stress, anxiety, depression, emotional demands
- May have to give up work or reduce her hours
- Financial implications e.g. due to the impact on work or extra expenses have to care for her mother
- Lack of privacy for Kathy and her family
- Restriction on social activities/social isolation
- Less time for hobbies
- Adaptation to Kathy’s house e.g. bathroom modification, stair lift
- Positively - may gain satisfaction from helping her mum, may enjoy her role
Suggest 5 ways in which problems Kathy may experience in her role as a carer could be alleviated.
- Sitter services e.g. crossroads
- Home carers to assist with her mother’s personal care
- Elderly frozen food deliveries
- Day care centre
- Respite care
- Benefits e.g. attendance allowance, carer’s allowance
- Psychological support e.g. carer’s centres, counselling
- Disabled badge scheme
- Physiotherapy/OT assessment and support
- Medication review
- Additional help from other family members, friends, neighbours
Amongst her multiple pathologies, Jean has OA, IHD, T2 DM, and CKD. Her health is rapidly deteriorating. Several members of the MDT are involved in Jean’s care.
List 11 members (other than the GP) of the MDT that could be involved in Jean’s care and give a brief description of their role in relation to Jean’s care.
- District nurse and/or practice nurse:
- Pressure sores
- BP monitoring
- Home carer:
- Bathing
- Dressing
- Pharmacist:
- Advice on medication
- Dossett box
- Social worker:
- Benefits
- Contact with agencies
- OT:
- Stair lift
- Hoist
- Shower room
- Physiotherapist:
- Maintain any remaining mobility
- Walking aids
- GMED/NHS24:
- Out of hours care in unexpected problems
- Nurse practitioner:
- Initial assessment during house call if change in health
- GP supported prescribing
- Dietician:
- Advice on diet to minimise deteriorating renal function
- Practice staff e.g. receptionist:
- Passing on concerns
- First point of contact
- Physician’s assistant:
- GP supported medical assessment and care
Your final patient of the morning is 13yo Jim who is brought by his mother Ann. Jim’s school teachers have flagged up concerns about him recently appearing sleepy in class. Ann is concerned that he may have developed thyroid problems after she was diagnosed with an underactive thyroid 4 years ago.
List 9 factors which may be contributing to Jim’s tiredness other than physical illness.
- Poor diet
- Inadequate sleep
- Excess screen time
- Lack of exercise/too much exercise
- Academic difficulties
- Home/relationship difficulties
- Bullying
- Social isolation
- Mental illness
How many minutes of exercise should Jim be getting per day as suggested by NHS guidelines?
60 mins
How many hours of sleep per night is recommended for teenagers to function at their best?
8-10 hours
Following surgery, you go on a house call to a poorly patient who has just registered with the practice following discharge from hospital. Michael Findlay is a 63yo with severe COPD who has moved in to his 59yo sister’s home to facilitate her involvement with his care. Michael took early retirement from his job as a welder due to his COPD. Although he has now stopped smoking, he was a heavy smoker for most of his adult life. He is severely restricted in his activities of daily living due to his COPD. He is breathless on minimal exertion, FEV1<30%. He spends most of the morning in bed, sits in his chair most of the afternoon, and retires to bed exhausted in the early evening. He receives long-term oxygen therapy. Michael has now had 3 admission to hospital with infective exacerbations of COPD in the last 6 months. It does not take you long to realise that it is unlikely that Michael will still be alive in 6 months or so. You also realise that Michael and his sister are unaware of the severity of his COPD and find yourself in the situation of breaking bad news.
List 9 points to consider when breaking bad news.
- List to the patient and their carers
- Set the scene
- Check whether Michael wants to speak himself or with his sister present
- Find out what the patient already understands
- Find out how much the patient wants to know
- Share the information using a common language and avoid jargon
- Review and summarise the information
- Allow opportunities for questions
- Agree follow up and support
List 9 examples of emotional reactions which may be experienced in a situation of breaking bad news and describe how they may manifest themselves.
- Shock:
- News is completely unexpected
- Patient may be tearful and anxious
- Anger:
- Angry with themselves for earlier health related behaviour e.g. smoking
- Angry with health care professional for being unable to provide a cure
- Denial:
- Patient does not believe it can be true and for a time will fail to acknowledge reality of the situation
- Bargaining:
- If I change something in my life, perhaps I will get better
- Relief:
- Patient glad to finally know what is wrong so they can plan for the future
- Sadness/depression:
- Low mood
- Especially if the patient has been ill for some time
- Fear/anxiety:
- Fear of dying
- Worry about pain
- Worry about family
- Guilt:
- Not able to provide for family any more
- Guilt that earlier behaviours have affected health e.g. lack of exercise, XS alcohol intake
- Distress:
- Patient unable to cope with news and shows acute anxiety
- Tearfulness
Identify 5 aspects in Michael’s Hx which indicate he is a suitable candidate for supportive and palliative care.
- Not expected to be alive in next 6-12 months
- Breathless at rest/minimal exertion
- FEV1<30%
- Spends more than 50% of day in bed or chair
- Long term O2 therapy
- 3 hospital admissions with acute exacerbations in last 6 months
Anticipatory care planning aims to proactive rather than reactive.
List 10 examples of proactive care resulting from an ACP.
- Patient on GP palliative care register and discussed at team meetings
- Information on social and financial support give to patients and their carers with referrals to relevant team members to facilitate the provision of this
- Usual GP and district nurse support visits and phone calls
- Assessment of symptoms and partnership with specialists to customise care to patient and carer needs
- Overall care assessed, including respite and psychosocial needs
- Preferred place of care noted and organised
- Care plan and medication issued for home
- End of life pathway/LCP used
- Dies in preferred place, family, bereavement support
- Staff reflect - SEA, audit, gaps in care identified, improve care
What is the definition of sustainability?
The ability to be able to continue over of a period of time
List 16 positive factors that might contribute to a sustainable medical carreer
- Work life balance
- Autonomy
- Flexibility of role
- Job satisfaction
- Team working and development of team
- Good relationship with colleagues
- Manageable workload
- Ability to develop knowledge and diversify interests
- Intellectual stimulation
- Maximal use of personal abilities and skills
- Outside interests for example hobbies - these may promote resilience
- Professional respect form colleagues and patients
- Reasonable occupation health provision
- Potential for educational role
- Job security
- Financial security/reasonable remuneration
- Stable terms and conditions
