DPSDoctors, Patients and Society - Kishu P

Lecture 1: Study designs for healthcare

Asses: Access: Appraise: Act (AAAA): way to keep up to date with new developments and to find appraise and action on research evidence (ex cot deaths)

Types of Studies:

EpidemiologicalDescriptive Analytical Studies

Individual Level Population Observational Intervention

Case report/Case Series

Cross Sectional Studies

Ecological Case Control

Cohort Clinical Trials

Qualitative Studies

Descriptive: how much, how many, where to what extent, disease distribution hypothesis generation (interface between clinical and epidemiology)

Case Report: detailed report of unusual disease in single patient Case Series: detailed report of unusual conditions in several patients ( medical case report journalCross Sectional: information collected in planned way to determin prevalence or survey (eg Health SE, General LifestyleS) Ecological: uses data from population groups to compare disease frequencies, find correlations such as environmental and geographical. Looks at same population at different times or different populations

Analytical: explicit comparison of groups of individuals to test hypotheses 1. Observational: only observes the population. 2. Interventional: allocate exposure

1. Does exposure to a certain factor result in disease (rare disease)

Case control: subjects are split based on whether they have or don’t have a disease. Then measure the exposure retrospectively (cancer = smoking) Multiple risk factors in relation to one disease. (Cheep and fast) What caused the disease Cohort (Longitudinal): Group of patients without a disease who are exposed or not exposed to a particular factor what happens to them. Study of multiple diseases in relation to a single risk factor (Long and expensive) what developed due to exposure. Randomized Control Trials ( clinical trials): randomized into given treatment vs given a control (placebo, no treatment, or another treatment) results are compared benefits and risks

RCT / Cohort / Ecological / Case Control / Case Serise

Qualitative Study: experience of disease and treatment using interviews. Subjective understanding.

Cross Sectional Prevalence or frequency of disease

Case Series & Ecological Hypotheses about causesCase-control & Cohort Testing of hypotheses (exposure)RCTS Benefits/harm of interventionQualitative Experience of disease treatment

Cohort Pros: Multiple outcomes, can be used when RCT not ethical ( harmfull exposure) Cons: Expensive, Can take Long time, Prone to followup loss, can’t be blinded = bias, hard to find comparator group

RCT Pro: comparable group except fro intervention ( lowers bias/ chance), can be blinded and prospective measurement Cons: Expensive, only beneficial exposure, need good hypothesis, run properly

Case-Control Pro: Quick, cheep, multiple risk factors, usefull for hypothesis Cons: poor record keeping, only association, difficult to chose comparator group

Lecture 2: Attachment Behaviour, Parenting and Social Bonding

Parental Relationship is the foundation of other relationships

Attachment: an intense emotional relationship that is specific to two people, that endures over time, and in which prolonged separation from the partner is accompanied by stress and sorrow

Phases of Development

Pre-attachemnt Phase: up to 3 months, afterwards preferred contact with humans = smiling, nustling and gurgling

Indiscriminate Attachment: up to 7 months: even stranger if taking care, starts to discriminate between familiar and unfamiliar people

Discriminate Attachment: develops 7-8 months: tries to stay close to some people ( separation annxietiy). Can differentiate.

- Object permenance: know that the object is there even though you can’t see it. - Fear of Stranger response: fear of strangers, = crying

Multiple Attachment Phase: 9 months + : strong addition ties, fear of strangers weaken.

Theories of Attachment

Lorenz (ethological- animals): nonhumans form strong bonds with first moving object they encounter: chickens! Called imprinting and occurs during brief critical period and irreversible ( show sexual preference for that species. Harlow: rhesus monkey with two surrogates, one with food one with blancket, = need for contact comfort

Psychoanalytic: attached because of ability to satisfy instinctual needsBehavioral: caregivers associated with gratification and learn to approach them to get needs

Bowlby: newborns are genetically programmed to behave towards mother to ensure survival ( crying, smiling, cuddling). Synchrony of action between the two = attachment (36 monts). Infants shows attachment to one adult ( monotropy)

Mirror Neurone: fire when action performed or when other performs action ( language, skills)

Individual Variation

Ganda Study: child’s attachment was significantly correlated with maternal sensitivity and amount of holding by mother

Maternal Deprivation Deprivation: separation from mother Parvation: absence of attachment fig ( no opp for attachment in first place)

Short Term: Distress = protests, despairLong Term: Separation anxiety = aggression, clinging, detachment

Lecture 3: Using information from research on population to help with clinical Decisions

Epidemiology: study of patterns of health and illness and associated factors at the population level. Helps identify risk factors for disease and determining optimal treatment approaches

AAAA: Asses, Access, Appraise, Act

Assess: Define Clinical Question: Population Intervention Comparator Outcome; What’s the best research design? ( RCT)

Access: Search for RCTs that answer the question eg Cochrane Library

Appraise: Check RCTS: ( accuracy, safety, effectiveness, repeatability )

1. Randomization 2. Blinded3. Similar groups at start 4. Follow-up ( minimal dropout)

5. Intention to treat 6. Blind measurement 7. Understanding Results

Act: How might I change my practice as a result of finding this evidence

Validity/ Bias: RCT: randomly allocate new treatment or none since you want two similar groups.

Intent To treat Analysis: Patients sometimes don’t get treatment they are allocated. To prevent Bias, analyze group according to original random allocation

if you kick them out, possible that only good, or only bad people moved = uneven groups.

Relative Risk= [a/a+b] / [c/c+d] 1 then there is no difference. >1 then better than normal tmt group<1 means its worse than normal tmt group

Risk Difference: [a/a+b] - [c/c+d]0 no difference between tmt and normal >0 more risk of outcome in tmt ( good) < 0 less risk of outcome in tmt group (bad)

NNT: 1/RD number of patients you’d need to treat to obtain one additional outcome

In this case

Risk Difference: 22% greater chance of getting better in chiro compared to physio Relative Risk: risk of being pain free in chiro is 35% more then that of physioNNT: would need to treat an extra 4.5 patients with chiro rather than physio to achieve one more patient with no pain at three months

Could this be Chance? P Values less than 0.05 is very good ( probability of observing a result like this when there actually isn’t a difference is less than 5 %)

Precision? Confidence Intervals ( 95% good)

Lecture 4: Childhood Development And Adolescence

Paiget EriksonDevelopmental biologist who wanted to understand how the brain and behavior grow.Series of fixed Stages

Psychosocial rather than sexual stages of development, with each stage having a crisis that leads to the next stage. Based on observation

Cognitive SocialBirth – 2 Years: Sensorimotor

Learn by sensory experience and motor activity change from reflexes to goal oriented

2- 7 Years : Preoperational

0-1 years: Trust Vs Mistrust : 1o interaction with mother

1-2 years: Autonomy Vs Shame and Doubt: toilet training, holding on and letting go, start of autonomy

3-5 years: Initiative vs Guilt : start of oedipal

development of locomotion, can’t conceptualize internal parts of body, magical thinking. Confuse psychological and physiological causes of illness. Develop language, don’t understand death!

7 – 12 Years: Concrete operations

Can only understand real phenomenon not hypothetical, self aware

12+ (earliest ) Formal Operations

Think hypothetically, fills gaps with generalizations, differentiates self

More important!

feelings: unconsciously holding hands/ kissing, identifies gender

6- Puberty: Industry vs Inferiority: outside home, enjoys same sex peers, learns from parents, peers and role models

Adolescence: Identity Vs Role Confusion: who am I, consolidation into coherent sense of self . Orient towards present rather than future, initial sexual intimacy and self exploration

Early Adulthood: Intimacy Vs Isolation: primary intimate relations.

Middle Age: Generatively Vs Stagnation: concer is estab and guiding future gen

Old Age: Integrity vs Despair: reflective, I am what survives me.

Problems! : individual differences, environmental, developmental or congenital disorders

Up to 24 months- loss of skill/ language- no bable or gesture by 12 months- no word by 18 monts- by 24 months no two words

By 2 & 3 years onwards- comm problems( lack of socialness)- lack of eye contact ADD- extr Emotional reaction & egression

ADD- over/under sensitivity ( Autism)

Child Protection Plan: to protect children from abuse

Physical/ Emotional: injuries (shaped), disagre in explanation, obv neglect, fearful - home, aggressionSexual Abuse: can’t sit/walk, stained underwear, pain, redness, bruises, wetting bed, withdrawal

*Children’s understanding of Illness ( pre-operational upto 7 year Paiget stages)

1. Immanent justice: sick because naught and being punished ( don’t know why)2. Phenomenoism: cause is external which is spatially and temporally remote 3. Contagion: cause is located in objects or people, Magical

Concrete operation explanations 7-12 years

1. Contamination: cause is thing external to child (physical touching!) 2. Internalisation: illness located inside while cause is external. Understand death

Formal Operations : 12 + years

1. Physiological: cause may be triggered by external, but cause lies in specific physical structures. Malfunction of internal organs of process. Death is permanent

2. Psychophysiological: malfunctioning of organs but understand alternative causes.

Children in Hospitals : in general children don’t like being separated from family and therefore are scared. You can help them by teaching them before the visit, and on admission reduce their fear by distracting them. Problems are caused by: new experience, strange smells, illness etc.

Children staying in hospital could revert to earlier stage of development (wet the bed/suck thumb) refuse to eat, speech, tantrums, cry, anxious, withdrawn

Overall need to understand what the child is thinking so that the consultation can go well!

Adolescence, Development and Health

WHO: 10 years, marked by puberty and signs of maturity. massive hormonal, physical & psychological changes. Increased independence + sexual curiosity

Puberty: Biological even: growth spurt ( muscles, fat) which starts earlier in girls. Some signs are periods & first ejaculation

- Boys: early is generally beneficial, they start to sleep more.

- Girls: start earlier. ( fat stores trigger sex hormones to start puberty – victorian times there was less fat and that meant that girls had their periods later. Early Pubertyy increase breast cancer risk, people who develop later get taller and thinner (models)

Precocious Puberty: happens to early: hypothalamus signals the pituitary to release hormones

This can induce early bone maturation & reduce eventual adult height, emotional and social consequent, develop sex drive inappropriate for age. This can be stopped if found early enough !

Signs: pubic hair/ genital enlargement in boys before 9.5 or 8 in females + breast before 7 years and menstruation before 10 years.

Lecture 5: Using information from research on populations to help with decision about diagnosis

What is the accuracy of this test?

Do a search! Is X (INDEX TEST) better than the reference standard Y?

Study Design: special cross sectional Sensitivity and specificity*

Assess: PICO + R ( reference standard test best available test) Must answer a clear question.

Population: Pregnant women (both cephalic and noncephalic) Intervention : abdominal palpationComparator : none Outcome : Test Accuracy * Reference Standard Test: Abdominal ultrasound

MeSH ( Medical Subject Headings) : Will include all medical term for the search joined by “AND” and “OR”

Access: search for and retrieve research from medline (sensitivity & specificity) Appraise: For test accuracy, overall is it a good test? Was it done well? Validity ? Was it

blinded? Randomized? Double blind?

Understanding

True Positive: Said Has it, Has it False Negative: Said Didn’t have it, Has it

False Positive : Said Has it, Doesn’t Have it True Negative: Said Didn’t have it, dosen’t

have it

Sensitivity = True Positives / Total Actual Positives

Specificity = True Negatives/ Total Actual Negatives

To interpret these: The close these number are to 1 ( 100%) the better they are. The number -1 = The rate of getting it wrong!

False negative rate: 1- Sensitivity False positive rate: 1- Specificity

Likelihood Ratio = 1 is useless test these numbers are useable to calculate post test probability of predicting the right outcome

LR + = sensitivity/ (1-specificity) : how good is a positive result at raising the probability of having disease

LR- = (1-Sensitivity)/ specificity : how good is a negative test result at lowering the probability of having disease

Systematic Review: all studies VS Meta Analysis: pick specific studies ( criteria)

Forrest plot If the circle touches the line of no effect = no effect

Larger circles = > populationLine = Confidance interval Up to <10% lost to follow up considered reasonable

Lecture 6: Development through the lifespan

Menopause: Endo of reproductive years, caued by decline in estrogen ( & possibly endorphins) instability in thermoregulation ( hot flushes and night sweats large cultural variation) ( vaginal dryness, depression, fatigue) More of a problem in western women

* Why do we age?

- Wear and tear - Cellular

o Type 1: Hayflick Limit: limit to number of times cells can divide o Type 2: Cross Linking: proteins in cells interact to produce molecules- makes body

stifferer o Type 3: Free Radicals: interact with molecules & cause cellular damage and shut

organs down, reduced by antioxidantso Type 4: DNA – unable to replicate itself when cells divide/dna repair system

- Rate of Living – born with limited amount of physiological capacity - Programmed Cell Death

Physiological Changes:

Brain: age related structural changes in neurons, axons, dendrites, tangled (neurotic plaque which aggregate and interrupt protein function!) Cardiovascular System: accumulation of fat, stiffening of arteries

Respiratory System: rib cage & air passageways become stiffer Appearance and Mouvement: skin, muscle tissue decline, internal bone mass decline Senses: transmissivness – cataracts : rate at which light passesImmune function: Changes in immune cells

Psychological & cognitive changes:

Information processing, attention, psychomotor speed, mental and psycho-social health, orgamic metal disorders

* Dementia: family of diseases with a high prevalence in older people characterized by a relentless progressive cognitive decline (permanent ) Eg Alzheimer’s

Show microscopic changes involving neurons: neurofibrillary tangles and neurotic plaques

* Characteristics:

- communication difficulties - memory loss- spatial and temporal disorientation - change in personality- aberrant behavior - depression and paranoia- incontinence and inappropriate toilet

behavior- diminished self care

- family stress and burden - inappropriate sexual behaviors- - Wandering

Proton emission tomography: show that much more activity and less organized

Prevention : Use it or Lose it! Most active showed 20% lower risk of cognitive impairment than loest active gp.

Lecture 07: Social Cognition & Attributions

Social cognition is an important determinant of behavior and provides an understanding of how people thing and behave, which can help us influence how people think and behave

Attribution: casual explanation for behavior and events

* Kelly’s Covariation Theory (why we do what we do):

Dispositional Attribution (internal): due to person factors Situational Attribution (external): due to environmental factors

Three Factors: 1. Consensus: do other people to the same in this situation 2. Consistency: does the behavior occur reliably in this situation 3. Distinctiveness: does the behavior only occur in this situation

Example: jim isn’t here today

Dispositional (internal) : Consensus: everyone else is here ; Consistency: he’s always abs ; Distinctiveness; generally unreliable - its jim’s fault !

Situational (external) : Consensus: lots of other absent ; Consistency; he’s rarely absent ; Distinctiveness ; he’s a reliable guy It’s not Jim’s fault,

Locus of Control (Julian Rotter’s Personality Theory)

- Dispositional causes: Controllable ( internal LOC) my fault - Situational causes: Uncontrollable (external LOC) not my fault

Ex: get good marks: ILOC: I studied hard ELOC: I was lucky the markers were easy

Internal health LOC: individual is prime determinant of health External Health LOC: luck fate chance determine health and powerful others determine it.

Attribution Bias/ Errors

Fundamental Attribution error: tendency to overestimate the importance of personality relative to environmental influences in explaining other’s behaviors say their wrong ( my friend is weak willed)

Actor- Observer Bias: tendency to overestimate the importance of environmental influences relative to personality in explaining our own behavior say the environment is wrong ( my friends still smoke)

False Consensus: tendency to believe that our own views are widely shared and consensual

Self Serving Bias: tendency for individuals to make dispositional attritions for their success and situational attributions for their failures (opposite in depression) ( pass cuz I studied, failed because of test)

Belief in a just World: tendency to believe that people get what they deserve in life ( ex: unemployed, rape, hiv) associated with wealth and high social status

Use this to predict and influence patients behavior !

Attributions about Symptoms: Hedonically attributions: make attribution to make most people happy, don’t want to deal with it defensive avoidance delayed consulting

Attributions about Cause: most people make up own causes (they want to know) and want it to be an outside agent. Eg stress, drugs, genetics, diet Affect patient’s decisions about controllability and affect coping and adaptation

Attributions about responsibility for illness management: internal vs external attributions have very different outcomes depending on illness Diabetes: internal management att leads to better metabolic controlObesity: external management attribution leads to better adherence to diet

Pessimistic Attributional Style: internal, stable, global ( Beck’s Cognitive triad ) which is a characteristic of depression

Self Management training: helps patients to gain control over illness, and increases self efficacy- helps in arthirits

Lecture 08: Attitudes, Prejudice & Behavior

Attitude: learned evaluative response, directed at specific objects,which is relatively enduring and influences and motivates our behavior towards this objects OR a psychological tendency that is expressed by evaluation of a particular entity or object . 3 Components of attitude

*1. Cognitive: beliefs and expectations about the object ( how you think) 2. Affective: fellings or emotions aroused by the object ( what’s our response) 3. Behavioral: action towards the object (how we respond)

What are attitudes for?

- Control out view of the world- Be socially accepted - Make yourself feel better (superior) - Integrity + better than people

How are they Formed?

- Operant Conditioning :reward and punishment – dogs - Social learning: copy role models - Experience of critical events : death

They are measured using self report scales ( probs, observer effects response)

Thurstone Scale: agree/disagree with a range of statements Likert Scale: agree/disagree on 5 point scale ( go towards neutral, avoid extremes) Semantic differentials: visual analogue scale with 2 polarized objectives

Attitude behavior relationship: Lapierre: travelling with chinese couple weren’t discriminated in hotels, but 91% said they would refuse to serve them later therefore, behavior not really predicted by attitude. Depends on strength, accessibility and exposure

Changing attitude & Behaviour: Persuasive communications depends on many factors such as the source of the omm, the message (emotional lvl), the revipient ( lvl of educat) and the situation or context (informal or formal)

Can also use: Fear and Persuasion may fail and cause denial, or Subliminal Advertising (unethical)

Prejudice: A hostile or negative attitude towards a distinguishable group based on generalizations derived from faulty of incomplete information. It is also and EXTREME example of attitude. Discrimination is a behavioral component of prejudice Formed By:

Frustration-Aggression Hypothesis: prevented from being angry towards frustration, make a scapegoat! Relative Deprivation Theory: discrepancy between expectation and actual attainment = frustrationConflict theories: intergroup conflict arises when interest conflict Conforming to social Norms Social Categorization Theory: see self as favorable and different from the rest of the group, while other alike and bad

Changing Prejudice: basically teaching people and providing more expose and understanding! ( Elliott experiment Brown eyes vs Blue Eyes)

Cognitive dissonance: state of tension that occurs when someone hold 2 cognitions that are opposite: eg smokes cigarettes, but knows that cigarettes kill.

Lecture 09: Stereotyping

Generalisation about specific groups and members of those groups: cognitive shortcuts and rules of thumb. Perception that most member of a group share some attribute: prototype, make them into a group rather than an individual

We do it because it provides cognitive efficiency by categorizing them and oversimplifying people. We learn the stereotypes mostly from first hand exposure and social learning, 2nd parents, mostly early in childhood

Process of Stereotyping:

1. Illusory correlation: overestimate the coincidence of rare events2. Illusion of outgroup Homogeneity: members of outgroup more similar than ingroup3. Relative deprivation hypothesis: Groups often feel more deprived compared to other

groups

3 Factors of Attitude (prejudice an extreme negative attitude): eg mentally ill patients

1. Affect -> hostility 2. Behaviour-> discrimination 3. Cognition - > stereotyping

Prejudice = Social identity Theory : maintain our self image and self esteem: We’re Better than others!

Conformity: Process by which people’s beliefs or behaviours are influenced by others ( line test thing! )

Scapegoating: hold person or group responsible for multitude of problems. Psychological defence mechanism or denial though prejecting responsibility and blame on others. ( eg French pox vs chinese disease)

Robber’s Cave Experiment: Two groups

1. Group formation 2. Introduce 2nd group = hostility

Introduce conflict!3. Worked together to resolve the conflict ( superior directives) found they weren’t that bad

after all Stereotype Threat: threat that stereotyped people will conform to the negative stereotype!

Unfavorable stereotypes for: overdose, alcohol/ drug dependence/ anorexia/ mental illness/ schizophrenia people with negative stereotype about docs are less likely to seek medical help

Change Stereotypes, Contact Hypothesis: contact between groups! Educationa nd insight!

Lecture 10: Stigma & Prejudice

Stigma: a mark of disgrace or infamy! Goffman- An attribute that is deeply discrediting and reduces the bearer from a whole and usual person to a tainted, discounted one. We categorize people as normal or devian and a stigmatized person is less than whole.

Classification of Stigma ( Goffman)

1. Tribal Identities: negative evaluation of people due to association with particular group (medschool restricted entry, religious groups, ethnicities, racial ex jew, muslims)

2. Abominations of the body: physical deformation or deviations from a social norm ( deformations, illness, paralysis – most common in children results in low se, withdrawl, depression, embarass)

3. Blemishes of Character: stigmas associated with a person’s character, identity or simply their particular way of being ( drugs, alcohol, prostitution, convict)

Hate Crime Stats:

Racial bias………………………48.8%Religion bias……………………19.1%Sexual orientation bias……..16.7%Ethnicity bias…………………..14.8%Disability bias…………………..0.6%

Goffman’s Discredited Stigma: stigmatizing condition that can be seen openly and people are forced to deal with it during every interaction unemployment, poverty, isolation, despair, suicide

Disavowal: pretend not to notice condition, person, ignore subject Avowal: acknowledgement as attempt to diffuse stigma

Goffman’s Discreditable Stigma: persons who possess a stigmatizing characteristic that cannot be obviously and immediately discredited. Can be covered ( not choose to tell people)

Felt Stigma: the shame and expectations of discrimination that prevents people from talking about their experience and stops them seeking help: less likely to visity gp, treated unfairly in job interviewsEnacted Stigma: actual experience of being treated differently because of stigma.

Courtesy Stigma: Stigma from being related to or being in close proximity to someone who is stigmatized: HIV/AIDS workers, Parents blamed for autismDiscredited Stigma: blatantly obvious Discreditable Stigma: Can be disguised or hidden Norm: socially enforced rules which are constructed either through cultural, moral, or legal forces. Deviance: in violation of such social normsInvoluntary deviance: refers to deviant behavior that is beyond control of the individual ( ex sick child misses school vs kid who skips school bot result in poor education. Voluntary Deviance: individual makes a conscious decion to adopt a behavior that is deviant

Coping Mechanisms: Physical removal, removal of people (isolation), sympathetic others,

Prejudice (enacted stigma) in healthcare Settings: an unjustified negative attitude towards a group and its individual members eg: racism (drugs vs talking), learning disability 1.5 million IQ<70, 58% more likely to die before 50, homophobia in doctors: don’t tell their gp

Lecture 11: Death and Bereavement

Invisible Death: we don’t like to talk about it or even acknowledge its existence due to movement of death away from home to hospital and the increased atheism which is leading to death rituals

Death can possibly be the cause of religion, as a coping mechanism.

Death Rituals: (hertz)Biological death: end of biological organismSocial Death: death of the person’s social identity occurs through a series of ritualistic ceremonies including the funeral say goodbye, respected, alleviate feelings of guilt, assertion of control over forces of nature.

Medicalization of Death: its being mamaged in a medical setting (65%, 20% home, 7% other com, 6% hospice) , and now you see doctor instead of priest, conflict between natural death and medical intervention, can sorta control it.

Role of doctor: facilitate care, drugs, counseling and therapy, maintaining hope

Death Certificate: medical certificate signed by doctor treating patient if cause of death is known; sealed and addressed to the local registrar of births, death and marriages referred to coroner if cause is unknown. All are sent to an independent medical examiner to be validated

Hospice movement: a halfway between the hospital and the home; providing medical care and pain control in a homely and nonmedicalised environment. Problems are that its perceived as a white, middle class Christian institution, supply less than demand fragile funding.

Bereavement: dying of a broken heart ( at risk for depression, isolation, alcohol, otc drugs, suicide

Worden’s Task of Mourning

1. to accept the loss2. to work through grief3. to adjust to the envi. To which the deceased is missing4. to emotionally relocate the deceased and move on with life

Depression: seen as normal after bereavement, but should follow soon after bereavement and subside after some time.

Isolation: unable or unwilling to interact with others normally

Glaser and Strauss: write books about dying and preparing to die

*Awareness of dying:

- Closed awareness: staff aware of poor prognosis, patient is not aware - Suspicion: patients suspect poor prognosis, but hasn’t been told- Mutual deception: both patients and staff know poor prognosis, but don’t talk about it- Open awareness: both patient and staff know prog is poor and discuss it openly

Trajectories of dying

Simple premis: people die at different paces, ofter different from those predicted by families or healthcare teams. Death vary in form and duration

Gradual Slant- a long slow declineDownward Slant – rapid decline Peaks and Valley – alternating patterns of remission and relapseDescending plateauds – decline, stabilization, decline, stabilization

Kubler Ross: 5 stages of Grief criticized because death industry, predominant approach for counselors, why does it have to be a journey?

Defence: it was meant to describe the experience of the interviews with people who were dying

1. Denial: this isn’t happening to me2. Anger: why me?3. Bargaining: just let me do this!4. Depression: the defeated stage 5. Acceptance: this is going to happen

Tasked Based Approaches to aiding the dying Corr

- Physical: satisfy bodily needs and minimize distress - Psychological: maximixe security, autonomy and richness in living, respect- Social: not abandoned or isolated, private time with loved ones - Spirityal: identify or develop sources of spiritual energy and foster home

Lecture 12: Asylum Seekers

Refuee: International law defines a "refugee" as a person who has fled from and/or cannot return to their country due to a well-founded fear of persecution, including war or civil conflict. - This means they have been granted indefinite leave to remain in the UK and have the same rights as a UK citizen ( around 25 k – 30 k) Assylum Seakers: a person who has left their country of origin, has applied for recognition as a refugee in another country, and is awaiting a decision on their application TOP: afganistan, Zimbabwe, iranPeople who don’t meet these criteria may be granted “exceptional leave to remain” for 3 or 4 years, especially children who can stay until they turn 18 ( eg civil war) Top Refugee hosting: Pakistan, Syria, Iran, Germany

Asylum seekers not allowed to work and are allowed only 70% or basic income 37.77 pounds (much more in other place) Refugees are allowed to work, but don’t tend to because of prejudice ! (even though very smart)Both get same healthcare as UK citizen ( failed asylum seekers awaiting removal only entitled to emergency) Its hard to register with GP as well as they can be refusedIssues: most have experienced trauma: an event that surpasses usual human experiences

Lecture 13: Aggression

Stanford Prison Experiment: prisoners and guards

Aggression: behavior that is intended to injure a person or to destroy property ( physical or verbal) Ex: war, fights, bullying, road rage, vandalism, arson

Can effect health in Direct (physiological) and Indirect pathways (behavior such as smoking, sleep, exercise)

There are competing theoretical perspectives upon Aggression

1. Aggression is Innate (psychoanalytical Theory) Freud

Innate disposition arising from natural selection (useful in getting strongest leader and spreading ppl) This makes it like an innate drive and is a form of energy that persists until its goal is satisfied. It is present at birth and is caused by frustrations of instincts steam boiler analogy catharsis (emot release)

2. Aggression is a Leaned Response (Social Learning Theory) Bandura

Agression is learned from social behavior, with no innate aggression drives. Caused by : Past learning, current rewards and punishment, and social and environmental factors. Caused by reinforcement: avoiding pain, winning approval

3. Frustration- Aggression Hypothesis: Too Simplistic Dollard

Frustration is the result of goals being thwarted leads to behavior that injures obstacle. Frustration always = aggression, vice verca.

BOBO Doll Experiment: children can be influenced to be aggressive !

Causes of Aggression (social and environmental)

1. Frustration : leads to aggression, most prominent 2. Direct Provocation: reciprocity3. Exposure to media violence: seems to be important factor ( murders rise after MMA

camp match) 4. Being in a group: mob mentality, deindividualisation leads to anonymity and diffusion of

responsibility 5. Hightened Arousal: stress, vigorous exercise, music, explicit pornography 6. Hot and humid weather : increased aggression shown in studies 7. Pain: more likely to be aggressive ( Berkowitz: lab rats attack any nearby animal if

shocked (brain tumors!)

Individual Differences in AGression

1. Personality: high-strung Type A (more aggressive) and the easy-going Type B2. Gender : males more than females can be due to nature (genetic +) and nurture

(gender rol

Dissocial Personality Disorder ( ICD-10) : intelligent, charming, poor self control, no remorse, sometimes commit very violent acts, reduced activity in prefrontal cortex

Warning Signs (threat gestures) : irritability, fast speech, pacing, shouting, glaring eyes, verbal threats, intrusion into personal space

Dealing with angry patient: avoid being defensive, stay calm and speak fimly, acknowledge anger, do not fuel the fire

Lecture 14: Human Sexuality

Sex ( sexual identity): biologically determined (is also very variable, chromosomes, gonads)

Gender: (gender identity): social interpretation of sex ( the two don’t always correspond) Gender Role: behavior, attitudes, values, beliefs which society expects/ considers appropriate Gender Stereotypes: widely held beliefs about psychological diff between m and f Sex Typing: process by which children acquire sex/gender identity and learn gender appropriate behave.

Hermaphroditism: have both male and female tissues: eg the female runner! ]

Nature or Nurture?

Some studies have shown that males and females are biologically programmed fro different roles supported by structural and functional differences in males and female brains, bust some disagree

Feminism: females felt that gender is socially constructed and it keeps them imprisoned

Biosocial theories: Money and Ehrhardt’s Biosocial theories : males who are femaleish Sociobiological theories: gender evolved so we can adapt to environmentSocial Learning Theories: learn behavior through being treated differently/ observation Freud’s Psychoanalytic Theory: rooted in the phallic stage of psychosexual development….. of courseCognitive development theory: Discovery that they’re male/female causes them to identify with and imitate same sex models ( gender labeling as soon as 3) Gender-schematic processing Theory: gender identity alone can provide a child with sufficient motivation to assume sex-types behavior

Cultural Relativism: gender is socially constructed ( some places females more dominant)

Disorders of Gender Identity: - Transsexualism: convinced they are gender ooposite to chromosomal sex, listed as

osychiatric disorder (more common in males) Cross dressing not for sexual arousal- Transvestism: wear clothes of opposite sex but not for sexual excitement no are

transsexuals. Enjoy cross dressing to gain temporary membership of opposite sex ( not related to sexual orientation)

Sexuality: Three components incorporated around time of puberty

1. Gender identity2. Sexual responsiveness and orientation3. Maintenance of emotional relationships

Sexual Orientation: homosexuality unique to humans ( same sex) but there’s a continuum. 30% males, 6% females have had at least one hs experience. Determinants are not known : combo of genes, hormones, neuroanatomy?

1977: WHO: mental disorder 1967 Decriminalised in UK

Paraphilias: love of the beyond or irregular: sexual urges directed to non-human objects, sufferin/ humiliation of oneself or partner, toards others incapable of giving consent

- fetishism, exhibitionism, voyeurism, pedophilia)

Begin in adolescence due to social learning/ conditioning, and to try and manage them through psychotropic medication, recondition techniques – further research needed

Classified as Mental Disorders ICD-10 1992 and part of Mental health Act 1983

Sexual Response Cycle: limbic system ( brainstem/ midbrain)

1. Desire problem: age hormones, lack of enjoyment, meds2. Arousal

Lack of excitement/ physiological response due to anxiety, infections hormone deficiency ( women) In men, erectile dysfunction : lifelong or acquired and common and increase with age: VIAGRA

3. Plateau4. Orgasm Problem

Women: 15% premenopausal and 35% postmenopausal ( physical/ psychological) Men: inhibited orgasm, pain, premature ejaculation (especially in young males)

5. Resolution

You can have sexual disorders if there’s a problem with desire, arousal and orgasm or combo

Management: history and physical assessment to establish cause of problem, simple advice counseling and education, couple therapy, sex therapy, physical treatment

Sex Therapy : Masters and Johnson: - partners treated together, helped to communicate better about sexual relationship and

education about physiology and anatomy of sex. 50-70% of couples report substantial benefits.

Asking about sensitive Subjects: important to know everything. Be empathetic and non-judgmental, reassure its common, start with open questions

Lecture 15: Complex and emotionally demanding Patients

1. Histrionic Patients: dramatic, emotional and overwhelming style of presenting, may be seductive twrd doctor and need to be sexually desierable. = emotional and flirtatious ( danger to doc ;)

2. Dependent Patients : need inordinate amount of attention and don’t feel reassured still. Urgen repeated calls and demand special consideration ( doc gets frustrated)

3. Demanding Patients: demand discomfort and problems, feel entitled and superior to mask their own sense of helplessness and weakness. They can be easily frustrated and can be angry and hostile

4. Narcissistic Patients: self love; they think they’re superior to everyone else including doctor and may be rude, arrogant, hostile and demanding.

5. Suspicious Patients: chronic, deeply ingrained suspicion that other people are unreliable and untrustworthy and only want to hurt them. They misinterpret neutral events

6. Help-Rejecting Patients: only appear to communicate through litany of complaints and disappointments. They often blame other and make people feel guilty for not doing enough or not caring

7. Manipulative Patients: appear to use lying and manipulative acts as a means of communicating. They may also have a history of using violence/self harm

Somatization disorder: physical symptoms inexplicable by medical conditions or symptoms in excess of physical illness. Usually in patients with a psychiatric disorder before 30, and treatment of the psychiatric disorder reduce the physical symptoms tempted to pursue countless costly investigations to get diagnosis, also tempted to do nothing and pass them off.

Conversion disorder: condition that presents as an alteration or loss of physical function suggestive of a physical disorder; Motor symptoms, sensory symptoms, seizure or convulsions that can’t be explained my medical evaluation. Most probably caused by psychological conflict with which patient could not admit. ( eg soldier paralyzed because fearfull of going to front, but can’t admit this to themselves) symptoms = primary gain and secondary gain.

Hypochondriacally Disorder: worry/ anxiety of being sick or getting sick, they get worried very easily. They’re preoccupied with the fear of getting seriously sick based on misinterpretation of bodily symptoms. Last for 6 months

Body dimorphic disorder: preoccupation with an imagined defect in appearance or if a slight physical anomaly is present, the person’s concern is markedly excessive. Results in significant distress or impairment in function. Most common: face, though any part of the body can be involved and the preoccupation may be focused on several body parts.

Factitious Disorder ( Munchausen Syndrome) : patients admitted to hospital with apparently acute illness supported by plausible but dramatic history which is later found to be full of falsifications. Motivation is to assume the sick role, and usually external incentives (financial gain) for the behavior eg. Acute abdominal, neurological, cardiac, resp.

By Proxy (to let someone else) : physical or psychological symptoms intentionally produced or invented by a parent or caregiver, which they deny. Symptoms diminish when the child is separated from the perpetrator.

Malingering: Consciously motivated, intentional production or signs and symptoms: Clear external incentives: avoid jail/ military, obtain drugs

Identifying with patients: treating other healthcare personal/ people with similar disease to us = potential lack of appropriate detachment

Sex and the doctor: don’t do it.

Patient’s We don’t like: deal with it in a professional manner?

Lecture 16: Medical Power

5 Bases of Power ( French & Raven)

1. Legitimate2. Referent3. Expert4. Reward

5. Coercive

Some examples of the operation of power within medicine

1. Medicalisation: assigning medical terms to otherwise normal events eg ADHD caused by Ritalin

2. Sick Role ( Parson’s): the role that the sick patient is expected to take. Can put power in the hands of the doctor, or can put power in the sick person’s hands eg demand treatment.

3. Professional Role: Doctor: the role that the doctor will take in treating the patient

Socialization: life long process of inheriting and disseminating norms, customs and ideologies

Primary: child learns the attitudes, values and actions appropriate to individuals as members of a particular culture. It is mainly influenced by the immediate family and friends.

Secondary: process of learning what is the appropriate behavior as a member of a smaller group within the larger society. takes place outside the home, it is where children and adults learn how to act in a way that is appropriate for the situations that they are in.

Total Institutions: Those institution whose inmates are separated from social intercourse with the outside world (mental illness Goffman)

- all aspects of life are conducted in the same place and under a single authority - batch living: daily life carried out in a group with other under a schedule - Distinction between managers and the managed

Physical and psychological reminders of a person’s identity are striped by removing personal possessions and restricing privacy and individual responsibility

The effects: stress, anxiety, depersonalization, parents become apathetic

Modes of adaptation: 5 modes of adaptation: Goffman

1. Situational withdrawlal2. Intransigent line3. Colonization4. Conversion5. Playing it cool

Permeable institution: ward membership is temporary, outside contact maintained, instutional identities are blurred. This reduces the risk of institutionalization but increases the risk to staff and patients

Example of threats to medical power:

- shifting intra-professional division of labour- complementary and alternative healthcare- technological developments- availability/ accessibility of information - patient empowerment - erosion of autonomy

Lecture 17: Negligence

Negligence: being careless: usually not deliberately and as a result can be sued by the patient ( compensation) or condemed by the GMC (suspend licence). Health care negligence are the same as other types of negligence. Negligence comes under Common law jurisdiction and therefore it is Judges that define it legally and determines liability.

The patient (family) will try to sue the doctor of the hospital and prove that they were negligent. The patient has 3 years from the date of discovery and competence ( eg wait until 18 y.o. to start count) That why we keep record till 21

3 Elements of the Tort of Negligence :

1. The defendant: the doctor/HCP must owe the claimant patient a DUTY OF CARE ( if not duty, doesn’t count)

2. The doctor/HCP must be in BREACH of that duty ( He she must be careless/Negligent) 3. This breach must CAUSE the patient’s Harm

1. Duty of care: in cases where the positive acts of a private individual cause physical damage, the existence of such a duty of care can be assumed ( Neighbour principle: you owe a duty of care to your neughbour which automatically exist)

Doctor’s Duty of care: activated automatically by doctor patient relationship. Doc owes DOC to paitents on list and hospital and entire staff owe a duty to patients admitted for tmt

- reasonable care and skill in diagnosis, treatment and advice

2. Breach of Duty of Care: civil negligence consists of falling below the standard of care required in the circumstance to protect others from the reasonable risk of harm ( they must be your patient and you must fall below the standard care: the reasonable doctor/HCP

Standard of Care; Bolam Test/defence: A doctor/HCP will not be negligent if they act in accordance with a practice accepted as a proper by a responsible body of medical/professional opinion in that situation

ordinary skilled and experienced doc, pharmacist, nurse- not the best. Inexperience or lack of skill is not an acceptable excuse Refer to supervisor!

unless it was someones fault, you don’t get paid

Bolitho: medical practice is subject to a reasonableness and responsibility test, which means that the court can review common practice to ensure that it is reasonable and responsible

3. Causation: the claimant must prove that the defendant’s acts or omissions were responsible ( CAUSED) for their loss

But for test: but for doctor’s negligence they would not have suffered harm ( claimant must prove that their version is most probable true vs criminals where they must prove that their version is true beyond any doubt

Negligence: 2 types:

Treatment or Diagnosis: poor clinical practice

Consent : not enough information given about the side effects of the treatment and therefore if the patient had known all the information they would not have consented to the treatment ( at that time) and would not have suffered the risks or side effects

3 Elements of the crime of Gross Negligence Manslaughter:

1. Owe a duty of care 2. HCP must fall so far below the STANDARD OF CARE to warrant criminal and moral

culpability3. This breach must cause the patient’s DEATH