ArabSocIFP Revision Lecture

Senan Alsanjari

Professionalism• ‘Medical professionalism signifies a set of values, behaviours

and relationship that underpins the trust the public has in doctors’

• The report further describes:• That medicine is a vocation in which doctors knowledge, clinical

skills and judgement are put in the service of protecting and restoring human well-being.

Professionalism• Composed of a doctor’s• Relationship with knowledge• Relationship with colleagues• Relationship with patients• Relationship with society• Relationship with self.

Regulation of Professionalism• The GMC has two main functions:• It holds a list of all registered UK doctors• It acts as a professional regulator.

• Why are medical students always threatened when we act like normal students?• Alcohol

Good Medical Practice• Good clinical care• Maintaining Practice• Teaching and Training• Relationship with Patients• Working with colleagues• Probity• Health

Great Minds Think Revising Will Probably Help

Duties of a Health Care Professional

• Moral duty – Respect patient autonomy• Professional duty - GMC• Legal duty - Law

Ethical Practice• What is ethics?• Duty • Utility• Rights• Virtue

• Ethical Principles• Moral Perception• Moral reasoning• Moral action

Ethical Practice• Consent• This is the “volountary, un-coerced decision made by a

sufficiently competent or autonomous person based on adequate information and deliberation, to accept rather than reject a proposed form of action”.

• Validity judged on the Mental Capacity Act.• Mental Capacity Act (2005)• Primary purpose is to provide a legal framework for acting and

making decisions on behalf of adults who lack capacity to make decisions for themselves.

• Which situations do not require consent?

Importance of Consent• Legal duty• Respect for patient autonomy (Ethical principle)• Respect Patient (Professionalism)• Establish relationship of trust with patient• Benefits patient• Co-operate• Jehova’s witness

Ethics in children• Gillick competence• Brief History• “whether or not a child is capable of giving the necessary consent

will depend on the child’s maturity and understanding and nature of consent required.”

• Fraser Guidelines• They refer to the guidelines set out by Lord Fraser in his

judgement of the Gillick case which apply specifically to contraceptive advice on the basis of a number of key principles.

Competence• Four principles• Patient must understand information• Patient must retain information• Patient must weigh-up options• Patients must communicate decision.

Memory and Conditioning• Memory process• Encoding• Storage• Retrieval

• Atkinson-Shiffrin memory model• Sensory information• Short term memory• Long term memory

Atkinson-Shiffrin

Short Term Memory• This is basically what you are thinking about at any given

moment.• Holds limited amount of information for short period of time –

20 to 30 seconds.• Capacity• 7 +/- 2• Increased by chunking

• Break large amount of information into meaningful information

Long Term Memory• Unlimited capacity• Requires consolidation of information in short term memory• Involves long term potentiation• Can improve working memory…how?• Retrieval of information• Cues• Context• Level of processing• Organisation of information when learnt

Types of Memory• Procedural memory • Form of memory that involves a sequence of movements or

actions and enables us to perform various acts or skills.• Declarative memory• Episodic – form of memory that represents our knowledge of

personally experienced events and the order they occurred.• Semantic – form of memory that represents our knowledge of

words, symbols and concepts including meaning and rules for using them.

Question• A patient comes in requiring bilateral removal of parts of the

hippocampus. After the surgery, the patient can remember everything that occurred before the surgery and has a functioning working memory. However, he cannot learn anything new that has happened post-surgery but can still learn procedural skills without realising he has learnt them.

• Which type of memory is affected?• Does this patient have amnesia? If so what type?

Classical Conditioning• The combination of a neutral stimulus with a stimulus which

does elicit a behavioural response.• The conditioned stimulus produces no response at first but

after conditioning it elicits the conditioned response.• Pavlov’s experiment is a good example to use.

Practical example• If you take an Arab and put a shawarma platter (unconditioned

stimulus) in front of them, they will salivate (unconditioned response).

• If you couple the shawarma (unconditioned stimulus) with a picture of LITTLE RAT (conditioned stimulus), over time, repeated exposure will cause the picture of the little rat ALONE to cause salivation.

Operant Conditioning• Form of learning in which an individual’s behaviour is modified

by its consequences.• What is the difference between Operant and Classical

conditioning?• Reinforcement and punishment are the core tools of operant

conditioning, are either positive or negative.• Extinction

Example• The bird in the box gets a seed when it speaks but when it

moves and does not speak, the chute closes.• Therefore, the bird realises that in order to gain a seed it must

speak.• This is positive reinforcement.• Extinction would be no longer giving the seed after the bird

speaks

Clinical Use• Cognitive Behavioural Therapy uses Operant conditioning• Targets emotional response to event and thus modifies

behaviour.• Common exam question.

Stress, Illness and Coping• Understanding the terms stressor, stress response and strain• Three theories• General Adaptation Syndrome• Life Events Model• Transactional model

General Adaptation Syndrome• Alarm stage• Fight/flight reaction

• Resistance stage• Defence / adaptation to stressor

• Exhaustion• Failure to adapt to stressor

The problems with this model?

Life Events Model• This theory states that an accumulation of life events and

continuous adjustments is detrimental to health.• This model measures stress by totalling number of life events

within a period of time e.g. …• Problems?

Transactional model• This model is based cognitive appraisal of the stressor.• The effect of the stressor is influenced by coping strategies• Stress results from an imbalance in demands versus resources• The perceived resources include factors such as personality

traits, family support, experience.

Problem – situations that occur without prior cognitive appraisal

Models of Health and Disability• Biological model of disability• Social model of disability• Bio-psycho-social model of disability

Impairment – loss of normal age-related structure and function of the bodyDisability – result of any social system which does not allow for inclusion of people with an impairment.

Biological model of disability• Disease centred approach• Management of illness revolves around identifying the illness

from a clinical perspective.• Then controlling it by medical intervention to cure the disease.• The biological model advocates an investment of health

resources to cure disabilities with medical intervention.

Problem with a purely biological approach?

Social model of disability• Reaction to the dominant medical model of disability.• This model identifies systemic barriers, negative attitudes and

exclusion by society that means society is the main contributory factor in disabling people.

• Not everyone with an impairment has to be classed as disabled.

• Difference between biological and social model?• Problems?

Bio-Psycho-Social model• Health is best understood in terms of a combination of

biological, psychological and social factors.• This looks at the biological, psychological and social effects.• Complex interaction between all three.

Health Behaviour• Any behaviour which has an effect on health is known as a

health behaviour.• This can be positive (exercise) or negative (smoking).• Three main theories that influence health behaviour• Health Belief Model• Theory of planned behaviour• Cognitive dissonance

Health Belief Model• The model predicts that individuals will act to promote their

health if they believe:• There is a perceived threat • The consequence and susceptibility to the threat is severe• Recommended actions to deal with the problem are beneficial• The benefits of taking action outweigh the barriers. Problem?

Example• Application of the Health Belief Model to prevent the spread

of HIV/AIDS, individuals would be more likely to practice safe sex if they believed:• They are at risk of HIV infection• The consequences of HIV infection are severe• Safe sex practices are effective in reducing the risk of infection• The benefits of safe sex practice outweighs the potential barriers

Theory of Planned Behaviour• Health behaviour depends on:• Attitudes

• Individual evaluation of a behaviour• Subjective norms

• How society or environment contributes to behaviour• Perceived behavioural control

• The extent to which the individual believes he or she can control behaviour

Problem?

Cognitive Dissonance Theory

Reducing dissonance• In order to reduce dissonance:• Change one or more beliefs• Eliminate a cognition • Introduce another cognition

Loss, Bereavement and Grief• Loss – the physical loss of something.• Bereavement – the process we go through after we lose

something to which we were emotionally attached.• Grief – the emotions associated with bereavement.• Mourning – psychological process resulting from loss and

process of recovery.

Emotions associated with grief• Acute Grief – agitation, crying and hallucinations• Long term – sleep disturbance, sleep withdrawal and

depression

Process of Mourning• Denial• Anger • Bargaining• Depression• Acceptance

Pathological grief• Absent – failure to display symptoms of grief but may show

severe signs on occasions• Prolonged – initially is normal grieving, but loss is still central

after 6 months

Morbidity associated with bereavement

• Biological• ACTH / Cortisol levels rise• Lower lymphocyte proliferation• Lower cytotoxic T cells

• Psycho/Social• Alcohol abuse• Neglect symptoms

Common Mental Disorders• Mental illness – abnormal behaviour associated with reports

of distressing experienecs.• Psychosis – an inability to distinguish fantasy from reality and

is associated with delusions and hallucinations• Neurosis – is not a psychotic illness and is associated with

anxiety and low mood.

Biological Model• Dominated psychiatric profession in the last century.• Huge amounts of research has gone into this area of

psychiatry.• Mental dysfunction is the result of a physical / chemical

change in the brain.• This abnormal functioning in the brain should be treated as

any other physiological illness.

Psychodynamic model• Behaviour and feelings as adults are rooted in our childhood

experiences• Relationships (particularly parenting) are of primary

importance in determining how we feel and behave• Our behaviour and feelings are powerfully affected by the

meaning of events to the unconscious mind• The symptoms shown are expression of unconscious thought

and can indicate underlying problem

Behavioural Model• Mental illness is associated with abnormal behaviour.• Behaviour is a result of the environment rather than genetics

and so reject the view that abnormal behaviour has a biological basis.

• Abnormal behaviour result from unhelpful learned responses.

Example• A patient’s fear (phobia) of heights would be explained

through the process of classical conditioning. Some time in the past, she would have learned to associate the emotion of fear with the stimulus of being in a high place through a chance association between the two stimuli. As a result, she would avoid heights, and therefore not have the opportunity to relearn the association in a more adaptive way. Treatment would involve desensitising the fear through conditioning techniques.

Cognitive model• Mental illness is an error in thinking• View of the world is determined by our thinking.• Dysfunctional thinking dysfunctional view of the world.• Therefore treatment targets necessary changes in thinking.

Example• A patient suffering from a depressed mood after failing a

driving test may be having negative thoughts not only about that specific failure but may be generalising those to other areas of her life. She may believe she is a failure in all aspects of her life and will never be successful again. These thoughts are irrational and polarised, and the therapist would strive to teach the patient ways of changing her thoughts. The therapist might also emphasise the importance of increasing positive reinforcements, and suggest ways in which this might be achieved.

Advantages and Disadvantages of Classificaiton of Mental Illness• Advantages• It gives a diagnosis to the individual• It frames the problem and allows goal-directed activity from the

individual to get better.• Disadvantages• People often want to blame something for their illness, who do

you blame?• Labelling and stigma

• Felt • Enacted

Statistics

Standard Deviation• Measure of spread of data• Used in normal distributions• Calculate variance• Standard Deviation is the square root of variance• Don’t need to know how to calculate but need to know what it

means in simple terms…

Normal distribution• If data is normally distributed it will follow a Bell shape curve

What is a 95% Reference range• It is calculated• Mean + (2 x SD)• Mean – (2 x SD)• 95% of the data will lie within these limits if the data is normally

distributed.

ExampleSystolic BP in 1500 middle aged men• Mean BP = 140mmHg• Standard Deviation = 20mmHg• 95% Reference Range• Mean + (2 x 20) = 180mmHg• Mean – (2 x 20) = 100mmH

• Based on this sample, we expect 95% of men to have BP values between 100 and 180mmHg. This can be extended to say that we expect 95% of middle aged men in the population to have BP values between 100 – 180mmHg

Standard Error• Imagine that samples of the same size ‘n’ are repeatedly taken

from a defined population…and the mean BP of each sample is calculated.

• There will still be a spread of the means, even in the absence of bias because of sampling error or random variation.

• Standard error is simply a spread of sample means.• Key features

Standard Error• But instead of doing lots and lots of samples, we can

determine the standard error using one sample.• Standard Error = Standard Deviation / √n• What do you think a small standard error means?

Confidence Intervals for a mean• From: Mean – 2 x SE• To : Mean + 2 x SE

Take the following figuresMean – 140mmHgSE - 0.5

140 – (2 x 0.5) = 139140 + (2 x 0.5) = 141

95% CI = 139-141

Interpreting a Confidence Interval• In the population from which this sample came we estimate

the mean BP to be 140mmHg and we are 95% sure that the true mean BP in the population is within the interval 139mmHg – 141mmHg.

Key Points• If looking at 95% Confidence Intervals from relative risks –

check to see whether the range includes 1.• If looking at 95% Confidence Intervals from differences in

means – check to see whether the range includes 0.

95% Reference range and 95% Confidence Interval• 95% reference range tell us about the spread of data.• Therefore it is the spread of data which contains 95% of the

observations• 95% confidence intervals use standard error and tells us about

the distribution of estimates (such as means)• Therefore it is a measure of the accuracy of sample estimate

Interpreting 95% CI Intervals• Narrow CI Precise estimate• Wide CI Imprecise estimate• When looking at differences between means does 0 lie in the

CI?• When looking at relative risks does 1 lie in the CI?

P values• Defined as “the probability that the result could have arisen by

chance if there is no genuine association at all (null hypothesis)”

Example• A randomized double blind clinical trial of propranolol vs

placebo after a myocardial infarction reported the following results after 1 year of follow-up:-

• Relative risk of cardiac death in propranolol vs. placebo = 0.64• 95%CI from 0.38 to 1.06• P value = 0.12

We get more information from confidence intervals. • The value of the null hypotheses for relative risk is 1• Does the 95% CI contain the null hypotheses value• Yes – it includes the value of 1• Therefore this study cannot conclude that propranalol reduces

the risk of cardiac death compared to placebo• More data is needed.

Things you should go through• Intelligence• Always comes up but you just need to learn the facts

• Lay Health Beliefs• Boring descriptive rubbish, so just read it and try and remember

bits and pieces

Thanks• Questions?