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					 Year 2 MB ChB




Community Course


   Tutor Guide




                   August 2011

        1
This tutor pack contains updated tutor notes developed during the spring of 2011 to reflect
changes to the MB ChB curriculum introduced in 2009. They also reflect changes to
Tomorrows Doctors guidance from the GMC in 2009. This tutor pack covers year 2
tutorials only.

You will notice the order of tutorials 6 and 7 has been reversed. This reflects the new
course text book:
Cleland JA, Cotton P. Health, Behaviour and Society: Clinical Medicine in Context.
Learning Matters, London 2011
The tutorial reviews were carried out by:

       Dr Brett Finlayson
       Dr Ken Lawton
       Dr Fiona Lopez
       Dr John McKeown
       Dr Walter Mouat
       Dr Rebecca Riddell



The tutorial plans for each topic are:

       Topic 1: Illness in the community

       Topic 2: Communication in the community; emphasis on patient visits

       Topic 3: Problem solving and chronic disease

       Topic 4: The Practice and its team

       Topic 5: Activity Limitation (Disability)

       Topic 6: Epidemiology

       Topic 7: Prevention and Health Promotion

       Topic 8: Environment: Illness in context – Hazards to health (Encompassing
               Occupational Health)


Each session starts with an attendance register. Any absences should be notified
to Dr Hazel Sinclair as soon as possible (h.sinclair@abdn.ac.uk) Tel 437246


               The reading lists are given in the course workbook.




                                                   2
                      Topic 1: Illness in the Community
                                                                            Dr Brett Finlayson
Learning Objectives

Topic objectives

Students should be able to:

      Appreciate health and illness as a spectrum rather than a dichotomy.

      List several factors which may influence an individual’s desire to seek medical
       attention.

      Describe the sick role and its significance for patients and doctors specifically and
       society in general.

      Explain which non medical factors have an influence on illness and the perception
       of and/or attitude towards that influence.

      Explain the main features of the doctor patient- relationship and their effects.



Tutorial objectives

Students should gain an understanding of:

      The definitions of illness.

      Perceptions of illness by professionals and the general public.

      When do people seek help and why?

      The role of the GP and other members of the primary health care team.




Welcome back, introduction of any new students.

Collect contact details (mobiles, emails).

Recap group rules, confidentiality.

Discuss feedback on Year 1 Poster.

Discuss 1st Year of Community Course, leading in to aims/objectives of 2 nd Year.

Outline Assessment – refer students to workbook and online version of workbook.




                                              3
Is Illness normal?

         Straw poll of symptoms in last 2 weeks



         “Iceberg of Illness” - 3% under hospital care

                             19% attending GP

                             55% have symptoms and taking action

                             18% have symptoms and taking no action

                             3% no symptoms

Refer back to Year 1 – normality

As few as 1 in 40 symptoms ever reach medical attention



Define

Disease – symptoms, signs – diagnosis. Bio-medical perspective

Illness – ideas, concerns, expectations – experience. Patients perspective

Problems when the is discrepancy between the 2

Ask students for examples of disease with no illness. How can this cause problems when
treating? Eg medications for hypertension.

Up to 50% GP appts – no disease




Exercise 1

Brainstorm determinants of health.

As students give answers build up Figure 1.3 page 11 Textbook.



Pre-patient Pathways

         Concept of Lay Referral – “Granny knows best”, helpful?

         Sources of info – Peers, family, internet TV, health pages of newspaper or women’s
         mag, “What should I do? Booklet, SHOW website, Practice leaflet or website


                                               4
Exercise 2

Community Pharmacist

             Could ask pharmacist to attend tutorial or students visit local pharmacy in
             small groups or tutor conduct telephone survey prior to tutorial and get
             students to guess the answers:

                       most commonly sold OTC preparations?

                       most commonly prescribed medications?

                       most common presenting symptoms?



      Discuss expanding role – OTC contraception, statins, health checks, smoking
      cessation, Minor Ailments Service




Exercise 3

Brainstorm factors affecting the uptake of medical care “triggers”

Medical factors - new symptoms, visible symptoms, increasing severity, duration etc
Non medical factors – crisis, peer pressure “wife sent me”, patient beliefs, expectations,
social class, economic, psychological, environmental, cultural, ethnic, age, gender, media
etc




Exercise 4   Family misfortunes!

2 teams – top 10 conditions seen by GP. Alternate answers. 1st team to guess wrong 3
times loses!




                                              5
N.B. Could use more up to date data but the list isn’t so specific




                                              6
http://www.isdscotland.scot.nhs.uk/Health-Topics/General-Practice/Publications/2011-02-
22/PTI_Feb11_Fig6_top10Conditions.xls



Estimated contacts in Scotland 2009-10

 Digestive/abdominal S&S                                          970,554

 General abnormal S&S NEC (6)                                     944,014

 Circulatory and respiratory S&S                                  909,767

 Diseases of the skin & subcutaneous tissue (7)                   909,115

 Psychological S&S                                                698,518

 Neurological/musculoskeletal S&S                                 677,088

 Soft tissue disorders                                            629,331

 Acute upper respiratory infections (9)                           597,053

 Back & neck disorders                                            567,071

 Infectious diseases (8)                                          538,222




Definitions of Illness – examples of acute, chronic, self-limiting



Age/Gender contact rates http://www.isdscotland.scot.nhs.uk/Health-Topics/General-
Practice/Publications/2011-02-22/PTI_Feb11_Fig3_Chart_SexAge.xls

              -



Consider possible “benefits” of illness – social, familial, psychological, financial,
medications, responsibilities.

Introduce concept of The Sick Role.




                                                7
8
Topic 2: Communication with patients in the community with
emphasis on patient visits
                                                                      Dr Rebecca Riddell

Learning Objectives

Topic objectives

Students should be able to:

      Appreciate the basic differences between general practice and hospital medicine.

      Describe the role of the GP at the primary care interface.

      Appreciate the clinical content and range of illness presented at the level of general
       practice.

      Appreciate the role of communication and interpersonal skills within the
       consultation.



Tutorial objectives

Students should gain an understanding of:

      The role of the GP.

      How primary care and hospital medicine differ.

      The role of communication in the consultation.

      Preparing for the patient visit




                                              9
Exercise 1

Split into 2 groups to brainstorm similarities and differences between primary and
secondary care.

Come back together to discuss and compare the similarities and differences.



Exercise 2

Explore the difference between patient and doctors agendas

Start by using a flip chart to illustrate possible differences

Bringing in a patient e.g. recent hospital in-patient, if possible is useful to demonstrate this
and also allows for preparation for the patient visit as it may draw out the differences
between communication styles between primary and secondary care. If making your own
video of a patient consultation you must have appropriate consent.

If this is not possible they could split into groups of 2 or 3 to consider patients they have
met on the wards.



Exercise 3

The students will have been introduced to the basic Calgary – Cambridge framework in
first year teaching.

Use whole group or smaller groups to discuss this in terms of general practice.

What different approaches are used for a 10 minute consultation?

What difference does it make when you have known the patient for years?

How do we balance the biomedical aspects with the psycho –social influences for the
benefit of patients?

Link this to patient visit preparation to be covered in second part of tutorial.




Coffee Break




                                                10
Patient Visit Preparation

Outline the purpose of the 2 visits and the presentation to group in later tutorials.



Cover practicalities of names/addresses/transport/directions etc.

Check they have patient visit guidelines information.



Recap from the year 1 family visit: the communication aspects of a home visit

      how to introduce themselves at the door

      good behaviour asking where they should sit etc

      thanking the person as they arrive and when they leave etc



It might be useful to ask them to consider the advantages and disadvantages of home
visits from the point of view of the doctor/health care professional (e.g. seeing the patient’s
home environment can be really useful – number of stairs, damp, cramped) versus the
time it takes to do a visit.



Split the students into pairs who will be visiting together to plan some questions for
patients – it may help to give them some ideas such as patients issues, disease issues,
current and future multidisciplinary primary care and other agency involvement.



Finish with opportunity to address any final questions prior to patient visit session.



Resources:

BJGP paper – Voiced but unheard agendas

BMJ paper – Why clinicians are natural Bayesians

Both on Y2 toolbox CD




                                              11
               Topic 3: Problem Solving and Chronic Disease
                                                                              Dr John McKeown

Learning Objectives

Topic Objectives
• List several methods of clinical problem solving.
• Describe the concept of probability in differential diagnosis.
• To understand the meaning of definitions describing illness and disability.
• To understand the variable severity and course of disease.
• To understand the multiple factors influencing symptoms, chronicity and disability.
• To appreciate the variety of individuals’ responses to chronic disease and the reasons for
these.



Tutorial Objectives
Aim: to learn about clinical problem solving
Objectives:



               The common processes of clinical problem-solving and how these differ.

               How these are applied to common presentations.

               To practice hypothesis testing and communication skills
           a) with a volunteer/simulated patient
           b) with patients

               To raise student awareness of the broad impact on the patient of having a
                chronic disease.



NB: PowerPoint presentation below is on the Year 2 toolbox CD


Content

Personally I start the tutorial with the chronic disease topic, and then move on to problem
solving after a break to touch on the family visits. I think it flows better from tutorial 2 this
way.




                                                12
CHRONIC DISEASE: When an illness cannot be cured




These bullet points lead on to a discussion re the following points.


      Discuss treatments available in the past versus current treatments.
      Discuss why chronic conditions have become more prevalent
      Discuss the burden of disease on the healthcare system
      Possibly tie in with later in the course by mentioning that treatments by and large
       used to be palliative, now are preventative.
      I personally use the example of my diabetic clinic for prevalence and incidence.



                                             13
I illustrate these bullet points by drawing the example of cigarette smoke, COPD
and susceptibility.




                                        14
Development of chronic disease



Vulnerability




Useful to remind students re Year 1 tutorials on homeostasis.



Nature and Impact of Chronic Disease




The two case histories can be found in the workbook. Personally I have two patient
files that I go back to, illustrating the difficult nature of chronic symptoms, and also
contain a significant amount of somatisation and iatrogenic issues.

                                            15
I ask the students to come up with examples of each as we go from point to point.



Natural history of Chronic Disease or Illness




Useful to break here and talk about the patient’s journey, for example a patient
presenting with pr bleeding. (See next page)




Discuss referral process and delays due to correspondence and waiting for scans,
results. Discuss diagnosis, treatment and relapse. Include brief chat re palliative
section of care.


                                                16
I map this on the board as a flowchart.



The one below is a mobile (ie poor quality) shot of a similar discussion from the
death and dying tutorial, but it gives an idea as to how complex the patient journey
can be when each event is analysed and mapped.




                                          17
Management of Chronic Disease




I discuss this in the context of osteoarthritis, or perhaps cancer with no histological
diagnosis or chronic fatigue.




Short break to discuss Family/Patient Visits




                                               18
CLINICAL PROBLEM SOLVING

I really don’t have anything to add to the illustrations here as I think they are self -
explanatory.

I think the key issues here are getting the students to grasp the different ways that
we can tackle issues and also to ensure that time is given at the end to brainstorm
some clinical scenarios. It would be useful to have mock patients available for that
section, or to ask members of staff to come in.

Pattern recognition




Hypothetico-deductive reasoning




                                           19
Inductive reasoning




                      20
Caveats




Examples of the hypothetico-deductive process




                                          21
                      Topic 4: The Practice and its Team

                                                                     Dr Rebecca Stevenson
                                                                         Dr John McKeown

Learning objectives

Topic Objectives

             To understand the organization of community medicine and the primary care
              team.

             To understand the differing roles of different members of the primary health
              care team.

             To recognise the mutual support available to each other through
              multidisciplinary teams and colleagues.

             To be introduced to basic methods of assessing disability.

             To further understand the multiple factors influencing symptoms, chronicity
              and disability.

             To further appreciate the variety of individuals’ responses to chronic disease
              and the reasons for these.


Tutorial Objectives


Aim: to be aware of the impact of chronic diseases on individuals, families and social units,
on community healthcare and society. Including using expertise and knowledge gained
from patient visits.

      To raise awareness of the roles of different healthcare professionals in the
       community through discussion.

      To review the experience of the patient visits, with reference to the content of
       Tutorial 3.

      To introduce the students to common tools for assessing disability.

      To illustrate how and why individuals differ in their responses to chronic disease.




                                             22
Start the session with:
“How did you get on with your chronic visits?”                                 (light discussion)



EXERCISE 1

Reflection of patient visits.
       Ask to reflect on chronic patient visits (either in large group or smaller groups).

How do you think the chronic illness this individual has affects:-
          Individual
          Family
          Job/social setting
          NHS
          Society.

How is the care they need different from purely medical care?

Which members of the PHCT were involved with your patient?
      What roles did they carry out?

Pairs of students take it in turn to briefly present (not formal)/discuss the above with the
rest of their group.


Exercise 2

Ask group as a whole to formulate a list of PHCT members who could help with the needs
of an individual with chronic illness eg using a whiteboard or flipchart.

I use either a patient with cancer (bit clichéd), or John or Mary from the next tutorial
(introduces a theme). If a patient could attend then fine, but I think that’s a bit much if the
health care team are arriving later also.


Exercise 3

Quick review of terminology from the workbook.

         Split the students into two groups and get them to ask each other (as groups so not
         too much pressure) to define the terminology on P 33. (Still page 33 as of 2011)


Coffee


Invite any students with knowledge of foreign health care systems to describe how they
work. (optional/informal).

(With relation to PHCT as foreign systems of care are covered elsewhere)

                                               23
Exercise 4

Meeting members of the PHCT

Organise for as many different specialists as possible to come and either briefly speak to
the students about their role (eg 10-15 mins) or to be interviewed by pairs of students at a
time. PN, DN, HV, OT, physiotherapist, CPN are usually available (others might include:
midwife, care manager, care assistant, voluntary services).

Review of Overall Health Care Team – using diagram aid enclosed.

Any queries/questions from the students regarding PHCT and what they have learned by
speaking to professionals.



Probably now would be appropriate to include a discussion about the centralisation of the
district nursing teams in Aberdeen and the consequences for patient care, continuity and
interaction with the practice team.

       Discussion of
              Merits of assessing disability and scales of assessment which can be
                used + drawbacks in relation to scales.
              Variety of individual’s responses to chronic disease and the reasons for
                these.
              Variable severity and course of disease.
              Multiple factors which can influence symptoms, chronicity and disability.

Personally I would suggest that this is difficult to formally include in this tutorial and I tend
to cover this in tutorial 5. I think I pretty much cover these areas in discussions in tutorials
3 and 5 and in the discussion in exercise 2.


Reflection & wrap up – any questions/issues?

Any preparation needed prior to next tutorial?



Resources:

Health Care Team diagram (see below)

Inter-professional teaching (University of Aberdeen and The Robert Gordon University)
has a useful handout on Professional Roles (see below)

Interprofessional Education (IPE) in the undergraduate MBChB curriculum – on Year 2 toolbox
CD

Primary Health Care Team PowerPoint presentation: this contains video clips of the various
members of the PHCT talking about their work – provided on CD (not the Y2 toolbox CD)

                                                24
Professional Roles           University of Aberdeen and The Robert Gordon University

Further information on many of the roles listed here can be found at www.nhscareers.nhs.uk

CLINICAL PSYCHOLOGISTS
 Clinical Psychologists work to improve the interpersonal, social and occupational functioning of a
range of individuals. They work with people with mental health problems, personality disorders,
learning disabilities, neurological damage (e.g., post-stroke or health injury), physical health
problems with a psychological component/overlay, etc., to establish the precise nature of the
problem, formulate and administer a treatment plan and work with the patient to facilitate change.
They use evidence-based models of counselling and therapy (e.g., cognitive behavioural therapy)
to help people avoid, overcome or control their problems.

Clinical psychologists work in different ways. They may work with primary care health teams.
They may specialise in particular types of patients, for example, children, the elderly, adults, or
they may work in specific areas (e.g., Neuropsychology, Liaison Psychiatry, Eating Disorders, and
Forensic).

Whatever their area of expertise, clinical psychologists are likely to be involved in delivering
treatment for psychological problems, attending meetings and case conferences, and writing up
reports and letters on patients, to ensure patients receive appropriate psychological care.

Clinical Psychologists teach junior psychologists and may teach other healthcare professions e.g.,
occupational therapy, medical students. They are highly trained in research methodology and
contribute to many NHS research projects, particularly those looking at changing the behaviour of
patients (e.g., improving compliance with medication) and staff (e.g., training staff in patient-
centred communication or counselling skills).

Clinical psychologists have an undergraduate honours degree in psychology then go through a
number of years of post-graduate specialist training, including a Doctorate in Clinical Psychology,
before they can be registered and accredited to work as a Chartered Clinical Psychologist within
the NHS.

DIAGNOSTIC RADIOGRAPHERS
 The diagnostic radiographer uses X-rays and other imaging modalities such as ultrasound and
Magnetic Resonance Imaging (MRI) to diagnose the patient’s illness or to monitor the
management of a disease process. This means that the diagnostic radiographer has contact with
patients and with other health care professionals but at the same time is involved with the use of
sophisticated high tech machinery.

In the case of someone recovering from a hip fracture Diagnostic Radiographers would use X-rays
as required to ensure that healing of the fracture was progressing as expected. Particular areas of
note would be any evidence that the pin was unstable, that there was infection present at the
fracture site or that the pin had been inserted through the articular cartilage of the femoral head.

Occasionally it may be necessary to radiograph the pelvis – to look for pelvic tilt or the lumbar
spine to check the possibility of referred pain. If the hip pain was thought to be of spinal origin an
MRI scan may be considered. See also www.sor.org.uk

DIETICIANS
 A dietician is defined as a person with a legally recognised qualification who applies the science of
nutrition to the feeding & education of groups of people and individuals in health & disease.
Registered Dieticians (RDs) are uniquely qualified to translate scientific information about food into
practical dietary advice. They provide impartial advice about nutrition and health and advise on
food related problems as well as using dietary treatments in many disease states and disorders.
They advise on food policies, set nutritional standards and advise on hospital/ school catering and
menus. Many dieticians work in the NHS and may work in one or more specialist areas e.g.
                                                   25
clinical nutrition, research, diabetes, renal, paediatrics & children's health, oncology, mental health,
learning disabilities, care of the older adult, whilst others may work in the Primary Health Care
Team with people in the community, provide nutrition education to groups, visit patients in their
homes or advise/ audit standards in residential/ nursing homes. They also work in health
improvement and community development. Dieticians are a key part of the healthcare team.
Dietetic Assistants facilitate the work of the dietician and are trained and supervised by the
dietician and can work in the community as well as the hospital setting. The professional
association is the British Dietetic Association. For further information see also www.bda.uk.com

DISTRICT NURSING TEAM
District nurses (DNs) are registered nurses with an additional qualification that enables them to
practice as specialist practitioners including the role of nurse prescribing. They work closely with
other members of the primary health care team to assess and meet the nursing needs of patients
within the community that includes people in their own homes, residential care settings and in the
independent sector. Within Grampian DNs work in teams, with staff nurses and auxiliaries to
support them, and are aligned to GP practices. They work across social and health care
boundaries and they are often considered to be the co-ordinators of patient care.

District nurses care for the chronic sick and terminally ill, in addition to providing nursing care to
those who are acutely ill requiring specialist care. The majority of the district nurses’ caseloads
consist of elderly people. However as the number of hospital beds has decreased and earlier
hospital discharge has been facilitated, the number of patients who are highly dependent and have
multiple complex needs has increased. Within their teams the DN works to:

Assess, plan implement and evaluate nursing care to patients in their own homes.
Support and assist relatives and informal carers in caring for the sick, disabled and elderly in their
own home.
Manage the caseload, involving delegation, staff support and supervision.
Liaise and collaborate with other members of the Primary Health Care Team, voluntary and
statutory services.
Be aware of equipment and aids available to enable patients to obtain optimum comfort and
independence.
Maintain accurate records and reports.
Maintain and update professional knowledge.
Maintain stock and resources within available budgets.
Teaching of staff, patients, students and other agencies.
Provide specialist nursing advice to private nursing homes.

GENERAL PRACTITIONERS
General Practitioners work to improve the health of individuals and populations by treating illness,
preventing disease and by acting as a gatekeeper to other healthcare services. GPs view the
individual as a “whole person” within a community or society, whether ill or well. Hospital-based
medical specialities, in contrast, deal mainly with the ill in society. GPs, as well as dealing with
physical illness, see a large number of physically normal people whose main problems are rooted
in psychological or environmental causes. GPs in the NHS work in Primary Health Care Teams
that involve many different healthcare professionals. GPs will thus receive information about the
progress of their patients’ disorders from many such professionals and often develop an overview
of the services thus provided. Most GPs work in practices of about 5 or 6 doctors with about 1800
people per doctor (rather less in Scotland and in rural areas generally). This means that the
practice covers a defined subset of the population, whether they are well or ill. There is increasing
emphasis on health promotion for GPs.

HOSPITAL DOCTORS
Hospital doctors work with ill patients, to establish a diagnosis, formulate and help administer a
treatment plan and subsequently monitor the patient’s progress, either within hospital, or as an out-
patient.

                                                  26
Hospital doctors go through a number of years of post graduate specialist training, sitting a variety
of exams along the way. Ultimately they specialise in areas involving treatment of a particular
group of illnesses e.g. Gastroenterology (digestive tract disorders), Cardiology (heart & circulation)
patients of a particular age range e.g. Paediatrics (children), Medicine for the Elderly areas
requiring development of skills e.g. Surgery, Anaesthetics techniques for diagnosis involving
complex skills and equipment e.g. Radiology (diagnostic images) areas of laboratory investigation
e.g. Bacteriology (infecting micro-organisms), Biochemistry (body chemistry).

The senior doctors i.e. Consultants or Specialists, are very experienced in treating patients and are
experts in their field and advise other doctors about patient problems. Each patient admitted to
hospital is assigned to a consultant, who has ultimate responsibility for that patient’s management.
The consultant is the leader of a team of junior doctors-in-training to whom they give guidance and
whom they teach. These doctors also teach medical students. Junior hospital doctors are training
to be specialists. They need to gain much experience over several years. Junior doctors may also
teach medical students.

All hospital doctors thus liaise with each other, as well as with other Health Care Professionals, to
ensure patients receive appropriate care and attention.

NUTRITIONISTS
Nutrition is a science in which knowledge from various disciplines is integrated to enhance the
impact of food on the health and well being of animals and people. Nutritionists study the factors
affecting food choice, the effects of nutrients in food, how nutrients are used by the body, and the
relationship between diet, health and disease. Graduate Nutritionists who have undertaken
creditable undergraduate or post graduate studies can register with their professional association,
The Nutrition Society, as either a Registered Nutritionist or a Registered Public Health Nutritionist.
They must demonstrate a high standard of competence in nutritional science. Nutritionists are
employed by Government agencies, food manufacturers and retailers, and in research, education
and health care. Their role in the NHS has increased due to new funding, the rapid expansion of
public health improvement strategies, and a shortage of Registered Dieticians. For example, the
Scottish Executive’s recent health initiatives and the national service frameworks (Department of
Health) require specialist nutritional advice, guidance, and implementation. Nutritionists can work
at a strategic level in public health and health improvement, in NHS divisions or as community
Nutritionists in primary care trusts in areas of community development and health improvement
together with Dieticians in NHS departments of dietetics and nutrition.
For further information; www.nutritionsociety.org

OCCUPATIONAL THERAPISTS
 The primary function of occupational therapy is the development of adaptive skills and
performance capacity, its focus is the factors which promote, influence or enhance performance as
well as those that serve as barriers to the individual’s ability to function within their daily life.
Occupational therapy provides services to those individuals whose abilities to cope with tasks of
living are threatened or impaired by developmental deficits, the ageing process, poverty and
cultural differences, physical injury, illness or psychological and social disability.

Occupational therapy uses meaningful occupations to promote and restore the health of people
whose ability to engage in meaningful tasks, roles and routines has been reduced. The
occupational therapist works with the individual to enhance his/her ability to perform the daily life
tasks he/she wants or needs to perform and to increase an individual’s ability to fulfil his/her roles
competently and meaningfully.

The occupational therapist may suggest changes in an individual’s environment that allows him/her
to be more independent in daily occupations or may also engage an individual in a daily occupation
in order to rebuild the skills needed to perform that task or role.




                                                  27
PHARMACISTS
 Pharmacists work in three main areas, pharmaceutical industry, hospital pharmacy and
community pharmacy. However it is in the hospital and community sectors that they are primarily
involved in the direct provision of healthcare to patients. Hospital pharmacists` roles are many and
varied. The clinical services pharmacist works on the wards as part of the clinical team and
provides information and advice ensuring that patients receive the most appropriate medication,
taking into account risk factors such as the disease state, potential drug interactions, side effects
and the cost effectiveness of the treatment. They also provide patients with information about
their medication ensuring that when they are discharged from hospital they have a full
understanding of what drugs they should be taking and how. Pharmacists are also employed in
the hospital sector in the provision of a drug information and advice service, are involved in the
manufacture and dispensing of radio-pharmaceuticals and in the production of sterile products
such as intravenous infusions. They also oversee the dispensing and provision of drugs to all
wards in the hospital.

In the community, the pharmacist dispenses prescriptions, checks for adverse drug reactions and
advises patients on the correct use of their medicines. In addition, because they are readily
accessible to the public for consultation, they provide advice and counselling on minor ailments,
and may prescribe from a wide range of over- the- counter medicines which can treat or provide
symptom relief for a large number of short term, self-limiting conditions. They also act as a filter in
terms of directing the more chronic or serious conditions to the GP. See also www.rpsgb.org.uk

PHYSIOTHERAPISTS
 Physiotherapy is a health care profession concerned with human function and movement and
maximising potential:
it uses physical approaches to promote, maintain and restore physical, psychological and social
well-being, taking account of variations in health status
it is science-based, committed to extending, applying, evaluating and reviewing the evidence that
underpins and informs its practice and delivery
the exercise of clinical judgement and informed interpretation is at its core.

 Physiotherapists work in a wide variety of health settings such as intensive care, mental illness,
stroke recovery, occupational health, and care of the elderly.

REGISTERED NURSES
Nursing encompasses the promotion of health, the prevention of illness, and the care of physically
ill, mentally ill, and disabled people of all ages and across all settings. Nurses in hospitals work
across all the specialities within the multidisciplinary team. The nurse is an autonomous
practitioner whose responsibilities are governed by the Nursing and Midwifery Council. This
requires that nurses are accountable for their actions.

Nursing practice is based on the nursing process which involves:
Assessment of client need.
Planning of care that is related to the identified needs.
Implementation of the plan of care.
Evaluation of the effects of care in relation to the expected outcomes.

SOCIAL WORKERS
Social Workers work with Children and Families, Offenders, People with Learning Disabilities,
Physical Disabilities, Mental Health Problems, Addiction Problems, and Older People. They work
with individuals in their homes as well as in hospitals, residential and day care centres. Most social
workers are employed by Local Authority Social Work Departments and Voluntary Organisations.

The direct work with people in all the following categories is likely to combine therapeutic work to
enhance social functioning, advice giving and the provision of practical help.


                                                  28
See also:
Scottish Social Services Council
Social Care Institute for Excellence


CHILDREN AND FAMILIES
Working with families who are experiencing relationship/parenting difficulties. Physical and sexual
abuse. Fostering and Adoption. Residential Child Care. Providing a service to the Children’s
Hearing System.

 OFFENDERS
Supervising offenders (including paedophiles) in the community with the view of preventing re-
offending. Providing a service to Court, preparing assessment and background reports to assist
Judges to make decisions.

LEARNING DISABILITY/PHYSICAL DISABILITY
Helping individuals who have learning or physical disabilities live as independently as possible.
Facilitating the transition from hospital to independent living. Working in residential and day care
centres.

 MENTAL HEALTH
As a member of hospital or community based mental health teams providing support to individuals
who are experiencing mental health problems. Contributing to the compulsory admission of
individuals into psychiatric hospitals. Working in residential and day care centres.

 ADDICTIONS
Either as a member of a local authority specialist addiction team or working for a voluntary
organisation, providing assessment and help to individuals and families experiencing problems
associated with addiction.

OLDER PEOPLE
Providing support and services to older people living in their own homes. Working in residential
and day care centres.

CARE MANAGEMENT
Most care managers are social workers and work for Local Authority Social Work Departments.
Care managers work with a wide range of individuals. Care management provides a
comprehensive assessment of individual need and co-ordinates the provision of services.

 HOSPITAL SOCIAL WORK
Social Workers belong to multi-disciplinary ward teams in general on psychiatric hospitals. They
provide emotional and practical support to patients and their relatives. Hospital based social
workers liaise with support services in the community before discharge.



 University of Aberdeen and The Robert Gordon University




                                                  29
30
             TOPIC 5: ACTIVITY LIMITATION (DISABILITY)
                                                                         Dr Ken Lawton

Learning Objectives

Topic Objectives

Students should be able to:

      Explain the WHO framework of body structure and function impairment, activity
       limitation, and participation restrictions and relate this to day to day clinical practice.

      Define the elements of the social and medical models of activity limitation

      Give specific examples of measures to prevent activity limitation in children and
       adults.

      Broadly define the epidemiology of activity limitation in adults and children.

      Demonstrate an understanding of the multidisciplinary and multi-agency resources
       available to deal with common forms of activity limitation

      Give examples where attitudes towards activity limitation can affect integration and
       rehabilitation for affected individuals.



Tutorial objectives

Aim: to be aware of the impact of chronic disease on individuals, families and social units,
on community healthcare and society.

      To give and discuss examples of the psychological, social and familial impact of
       activity limitation in adults and children.

      To reflect on the multiple needs of an individual with activity limitation and the range
       of health and social care which may be required

      To raised awareness of the ethics of screening through discussion

      To raise awareness of the conditions for and against screening.




                                               31
Tutorial format

First hour looking at the theoretical background

      Body and structure impairment NOT impairment
       Activity limitation NOT disability
       Participation restrictions NOT handicap
       Draw out what they mean; why the new language; why is it preferred?


      Who do students know with activity limitation? Use patient visit if no examples.


      What about impairment you cannot see, mental health problems?


      Hierarchy of impact PATIENT/INDIVIDUAL
                             FAMILY/CARERS
                             HEALTHCARE
                             SOCIETY


      May wish to look at benefits available to individuals with activity limitations.
       Issues of secondary gain


      Do individuals “overcome” activity limitation or just learn to live with it?


      Is chronic illness different from congenital problem e.g. Down’s syndrome or
       acquired problem e.g. traumatic paraplegia?


      How is activity limitation perceived in society?


      How is it represented in the media? Positive Eddie Kidd completing London
       marathon; Private Joharry VC Dancing on Ice i.e. individuals who have overcome
       their impairment.
       Negative carers killing disabled children and adults because they cannot cope;
       Panorama abuse scandal; Heather Mills!?; Benefits cheats.


      New group of activity-limited war veterans. Surviving horrific injuries. Loss of
       several limbs and other body parts




                                               32
Patients crucial to this session it is what we have to offer.

Guide dog owner always goes down well (don’t forget the dog biscuits)

Wheelchair user

Deaf patient

Patient with Down’s syndrome

Could use a carer


Mobile activity

Look at surgery from the view point of someone who has a specific activity limitation.
       Outside
       Front desk
       Telephones
       Access
       Waiting room
       Surgery
       Toilets etc.


Final discussion

Screening for activity limitation, Down’s, spina bifida, antenatal USS, is being female being
disabled in the context?

Why screen?

Ethics of this. Is it eugenics?

Right to life v right to die.

Legislation to protect Disability Discrimination Act etc


Resources

Oliver Sacks any book any case

Bauby “Diving Bell and the Butterfly” very short but insightful book on locked in syndrome

RCGP Tips cards – on Year 2 toolbox CD

DLA form


                                              33
                           TOPIC 6: EPIDEMIOLOGY
                                                                      Dr Fiona Lopez

Learning Objectives

Topic Objectives

      To develop an understanding of the relevance and practice of epidemiology
      To be able to define incidence and prevalence, risk / relative risk
      To be able to understand different measures of disease occurrence
      To be aware of some of the available sources of data that give and epidemiological
       picture of UK society
      To know about general practice and hospital perspectives on epidemiological data
      To understand some of the basic concepts which are relevant to epidemiology e.g.
       study design, bias, confounding factors


Tutorial objectives

      To develop and understanding of the relevance and practice of epidemiology
      To use examples from community medicine to illustrate the use of all aspects of
       epidemiology in daily clinical practice
      To introduce students to evidence based guidelines
      To introduce and illustrate audit (how to know if you are doing your best for patients
       with a particular condition).
      To help students consider the best study design to use to assess the causes of a
       condition.
      To help students reflect on study design and how this impacts on how useful the
       findings of the study may be
      To discuss setting up a screening programme for a condition at practice and
       national level.




Lots of information in student workbook – Appendix 5: Epidemiology, or
Populations, Health and Disease.



Start with individual cases and follow through to the practice level, to Grampian, then to
UK population data.




                                             34
Exercise 1

What is epidemiology and why is it important?

      Aim of epidemiology (workbook)

      Classic Epidemiological Studies

             John Snow & Broadstreet Pump (Cholera outbreak London, 1854)

             Framingham Study

             Doll & Hill (British Doctors Study)

      Use recent examples e.g.

              Cholera epidemic in Haiti 2011

                     www.cdc.gov/eid/content/17/7/pdfs/11-0059.pdf

                     www.cholerahaiti.com




Exercise 2

Define incidence and prevalence

Put in context of daily practice

       “Common things are common”

Define absolute risk / relative risk

Put in context of daily practice

             Implanon Scare 2011 www.guardian.co.uk/lifeandstyle/2011/jan/05/pregnant-
              contraceptive-implant-implanon

             Risks of DVT with Oral Contraceptive Pill (see handout).

             Vaccination and complication i.e MMR scare

             Drug companies can manipulate data www.nofreelunch.org




                                              35
Exercise 3

Tutor-led interview with a patient or presentation of a case study (Bring in a patient
e.g. with asthma or diabetes, bring in their medication)

   1. Obtain information
          a. History presenting complaint
          b. Past medical history & medication
          c. Social history
          d. Family history
   2. Differential diagnosis

          a. Evidence based guidelines e.g. BTS, UKPDS, SIGN

Suggestions for discussion:

      Use of QOF data to illustrate relevance and practice of epidemiology
      SIGN guidelines / NICE / Local
      Study design
      Screening programmes



Exercise 4

You are a GP and want to know if your practice is doing it’s best for patients with
this condition (Audit)

   1. What do you wish to assess?

   2. How could you do this?

   3. How would you compare your figures with neighbouring practices?

   4. How would you compare your figures with regional and national figures?

   5. List possible suggestions for disparities between figures.



Exercise 5

Examples of different types of study design (descriptive, Cross-sectional, case-control,
cohort, RCTs)

Get students to look at abstracts to help them understand terminology (See handout)

Use examples of retrospective and prospective studies


                                             36
Exercise 6

Get students to design their own study (frequently asked for in the exam!)

Bring in BMJ / BJGP to look at as examples



Homework:

Epidemiology exercise (see handout below)


Topic Checklist - for end of tutorial (see handout below)


Examples of Different Study Design

      The following seven abstracts are examples of different types of study design.
      Choose from:

                    Observational survey
                    Cross sectional study
                    Case-control study
                    Single blind RCT
                    Double blind RCT
                    Individual patient data meta-analysis
                    Nested cohort study


      Abstract                             Study design

          1

          2

          3

          4

          5

          6

          7




                                             37
Answers:

     Abstract                           Study design

           1    Cross sectional study

           2    Single blind RCT

           3    Nested cohort study

           4    Double blind RCT

           5    Observational survey

           6    Case-control study

           7    Individual patient data meta-analysis




                                          38
                                                     Abstract 1

Background     Varicose veins occur commonly in the general population but the aetiology is not well established.
               Varicosities are associated frequently with reflux of blood in the leg veins due to valvular
               incompetence. Our aim was to determine in the general population which lifestyle factors were related
               to reflux and thus implicated in the aetiology of varicose veins.
Methods        In the Edinburgh vein study, 1566 men and women aged 18-64 years were sampled randomly from the
               general population in the city of Edinburgh, Scotland, and had duplex scans to measure reflux in eight
               venous segments in each leg. A self-administered questionnaire enquired about occupation, mobility
               at work, smoking, obstetric history, dietary fibre intake and bowel habit. A bowel record form was
               completed subsequently.
Results        In women, venous reflux was associated with decreased sitting at work (odds ratio [OR] = 0.76, 95%
               CI : 0.61-0.94), previous pregnancy (OR = 1.20, 95% CI : 0.93-1.54). and a lower prior use of oral
               contraceptives (OR = 0.84, 95% CI : 0.66-1.06). mean body mass index was greater in women with
                                                                             2                                      2
               superficial reflux compared to those with no reflux: 26.2 kg/m (95% CI : 25.5-27.0) versus 25.2 kg/m
               (95% CI : 24.8-25.6). On age adjustment, sitting at work remained related to reflux (OR = 0.78, 95%
               CI : 0.63-0.98) and prior use of oral contraceptives to superficial reflux (OR = 0.71, 95% CI : 0.50-
               1.01). In age-adjusted analyses in men, height was related to reflux (OR = 1.13, 95% CI : 1.02-
               1.26)and straining at stool was related to superficial reflux (OR =1.94, 95% CI : 1.12-3.35). No
               associations were found in either sex between reflux and social class, lifetime cigarette consumption,
               dietary fibre intake and intestinal transit time.
Conclusions    This population study did not identify strong and consistent lifestyle risk factors for venous reflux
               although previous pregnancy, lower use of oral contraceptives, obesity and mobility at work in women
               and height and straining at stool in men may be implicated.
Keywords       Venous disease, legs, duplex ultrasound, diet, obesity, bowel habit, pregnancy, oral contraceptive
Accepted       8 December 2000


                                                     Abstract 2
 Background    Well-designed trials are required to assess if complementary and alternative medicine (CAM) is
               effective.
 Aim           This study assessed the effectiveness of spiritual healing for asthma.
 Design of study
 Setting       Aberdeen, Scotland
 Method        Spiritual healing for asthma, comparing the effectiveness of five sessions of spiritual healing with
               placebo (delivered by an actor) and with a control group receiving normal care only. The primary
               outcome measure was the Juniper Asthma Quality of Life Questionnaire (AQLQ). Secondary
               outcomes were forced expiratory flow in one second (FEV1), peak expiratory flow (PEF), HADS
               (Hospital Anxiety Depression Scale), SF-36 and MYMOP (Measure Yourself Medical Outcome Profile).
               Baseline and follow-up data were collected.
 Results       Eighty-eight adult patients receiving pharmacological treatment for asthma participated. AQLQ scores
               improved significantly from baseline and the end of treatment in all groups (spiritual healing P = 0.008;
               ‘sham’ healing P = 0.001 and control P = 0.01) but there was no significant difference between ground
               (P = 0.57). These improvements were maintained at follow-up1 for two of the groups (spiritual healing
               P = 0.016; sham healing P = 0.001 and control P = 0.09) but none of the groups showed an
               improvement at follow-up 2 (spiritual healing P = 0.161; sham healing P = 0.061 and control P = 0.11).
               Similar proportions of patients in each group showed a clinically important improvement in AQLQ
               score. Analysis of AQLQ scores at end of treatment and both follow-up periods indicated no
               significance between group differences. No consistent changes were seen in secondary outcome
               measures, possibly due to the small sample size.
 Conclusion    Spiritual healing does not appear to have any specific affect on patient asthma related quality of life.

 Keywords      asthma; complementary medicine; quality of life; randomised controlled trial




                                                         39
                                                      Abstract 3

Objectives      To investigate the long term risk (mean >20 years) of death from all causes, cardiovascular disease
                and cancer in women who had or had not had a hysterectomy.
Design
Setting         Royal College of General Practitioners’ oral contraception study.
Participants    7410 women (3705 flagged at the NHS central registries for cancer and death who had a hysterectomy
                during the oral contraception study and 3705 who were flagged but did not have the operation).
Main Outcome Mortality from all causes, cardiovascular disease and cancer
Measures
Results         623 (8.4%) women had died by the end of the follow-up (308) in the hysterectomy group and 315 in
                the non-hysterectomy). Older women who had a hysterectomy had a 6% reduced risk of death
                compared with women of a similar age who did not have the operation (adjusted hazard ratio 0.94,
                95% confidence interval 0.75 to 1.18). Compared with young women who did not have a hysterectomy
                those who were younger at hysterectomy had an adjusted hazard ratio for all cause mortality of 0.82
                (95% confidence interval 0.65 to 1.03). Hysterectomy was not associated with a significantly altered
                risk of mortality from cardiovascular disease or cancer regardless of age.
Conclusion      Hysterectomy did not increase the risk of death in the medium to long term.

                         BMJ 2005;330:1482-5




                                                      Abstract 4
Introduction:   An international, multicenter trial was conducted in 331 patients to determine the effect of a large dose
                of flunarizine (a calcium entry blocker) in the treatment of acute ischemic stroke in the territory of the
                Middle cerebral artery.
Methods:        The administration of the trial medication should start within 24 h after the initial symptoms of stroke.
                According to a random schedule, the patients were assigned to a 4-weeks double-blind treatment with
                either flunarizine (n = 166) or placebo (n = 165): one week intravenous administration (50 mg daily),
                followed by 3 week oral treatment (week 2, 21 mg daily; week 3-4, 7 mg daily). All patients had to be
                investigated by computerized tomography (CT) within 7 days after stroke onset; 36 patients were
                secundarily excluded because the CT showed another pathology. During the treatment period, other
                “stroke therapies” were not allowed. Patients were followed up for 24 weeks.


Results:        After the 24 weeks trial period, the percentage of patients who were dead or

                pendent (modified Rankin score 3-5) was similar in both treatment groups
                (flunarizine 67%, placebo 65%). During the trial, the cores for handicap

                severity (modified Rankin scale), neurological status (Orgogozo) and activities of daily living (modified
                Barthel index) strongly improved in both treatment groups, but no differences were found between the
                treatment groups. In this trial, the administration of trial treatment started relatively late after stroke
                onset (flunarizine group: mean time interval 13.5 h; placebo 12.3 h). A subgroup of patients received
                trial medication within 6 h after stroke onset (flunarizine n =31; placebo n = 29). Also in this subgroup,
                no differences were found between the flunarizine and placebo group.


Conclusion:     Flunarizine did not improve neurologic and functional outcome in patients with acute ischemic stroke.




                                                          40
                                                      Abstract 5

Objective:       To determine Scottish community pharmacists’ present involvement with ‘extended’ service provision,
                 as outlined in ‘The right medicine’ policy document, as well as an insight into the attitudes of
                 pharmacists in delivering such service.

Setting:         All community pharmacists working in Scotland.

Method:          A questionnaire was developed, piloted and refined before mailing to all community pharmacists
                 working in Scotland (n = 1621). Two reminders were sent to non-responders. Data on current service
                 provision was analysed using SPSS version 11 windows.

Key findings:    An overall response rate of 56.4% (914/1621) was achieved for pharmacists. The surgery revealed
                 that the majority of respondents either agreed or strongly agreed with the ‘key service areas’ being
                 provided from community pharmacies. Some services were obviously agreed with more than others.
                 In particular repeat dispensing and emergency hormonal contraception (EHC) were rated highly. Least
                 agreement was provided for needle exchange and schemes for supporting carers.

Conclusion:      There appears to be wide variation in current service provision in the ‘key
                 service areas’ considered. The highest involvement included EHC and methadone supervision. The
                 lowest involvement was for needle exchange and schemes for supporting carers. Community
                 pharmacist’s attitudinal ratings were generally positive towards the ‘key service areas’ suggested.




                                                      Abstract 6

Purpose:         The indications for surgical perforator interruption remain undefined. Previous work has demonstrated
                 an association between clinical status and the number of incompetent perforating veins (IPVs). Other
                 studies have demonstrated that correction of IPV physiology results from abolition of saphenous
                 system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and
                 obstruction are particularly associated with IPV.

Patients and Methods: Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with carrying
                grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds
                ratios (Ors) for the presence of IPVs were calculated for different anatomical distribution of main-stem
                venous reflux and obstruction. The base group are those with no main-stem venous disease.

Results:          There were no significant associations between the proportion of limbs demonstrating IPVs and
                 patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as
                 follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short
                 saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range =
                 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR =
                 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated.
                 Combinations of disease produced higher odds for the presence of IPVs than those above, the highest
                 being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI,
                 2.97-15.83; P =.0001).



Conclusions:     Although the presence of IPVs is associated with venous ulceration, the highest Ors for the presence
                 of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many
                 of these may be corrected by saphenous surgery alone.

                 (J Vasc Surg 2001;34:774-8).




                                                          41
                                              Abstract 7

Context:           Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD)
                   and stroke.

Objective:         To assess the relationships of fibrinogen levels with risk of major vascular and with risk of
                   nonvascular outcomes.

Data Sources:      Relevant studies were identified by computer-assisted searches, hand searches of reference
                   lists, and personal communication with relevant investigators.

Study Selection:   All identified prospective studies were included with information available on baseline
                   fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific
                   mortality during at least 1 year of follow-up. Studies were excluded if they recruited
                   participants on the basis of having had a previous history of cardiovascular disease;
                   participants with known pre-existing CHD or stoke were excluded.

Data extraction:   Individual records were provided on each of 154 211 participants in 31 prospective studies.
                   During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial
                   infarctions or stroke events and 13 210 deaths. Cause-specific mortality was generally
                   available. Analyses involved proportional hazards modelling with adjustment for confounding
                   by known cardiovascular risk factors and for regression dilution bias.

Data Synthesis:    Within each age group considered (50-59, 60-69, and >70years), there was an approximately
                   log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other
                   vascular (e.g., non-CHD, nonstroke) mortality, and nonvascular mortality. There was no
                   evidence of a threshold, within the range of usual fibrinogen level studied at any age. The
                   age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was
                   2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other
                   vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-
                   2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further
                   adjustment for measured values of several established vascular risk factors. In a subset of
                   7011 participants with available C-reactive protein values, the findings for CHD were
                   essentially unchanged following additional adjustment for C-reactive protein.            The
                   associations of fibrinogen level with CHD or stroke did not differ substantially according to
                   sex, smoking, blood pressure, blood lipid levels, or several features of study design.

Conclusions:       In this large individual participant meta-analysis, moderately strong associations were found
                   between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality,
                   and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults.
                   Assessment of any casual relevance of elevated fibrinogen levels to disease requires
                   additional research.




                                                  42
Epidemiology Exercise (Homework)



What is a case control study?

A case control study is one of the analytical study designs used in investigating aetiology.
By this is meant that is examines associations between possible (aetiological) risk factors
and disease outcome, using a hypothesis testing approach.
The basic hypothesis is thus:

If <risk factor A> is aetiologically with development of <disease X> then a group of people
with <disease X> [cases] will have a higher proportion of individuals with history of
exposure to <risk factor A> than a group of people without <disease X> [controls].

The basic comparison is really of proportions exposed in the groups (cases and controls),
the null hypothesis being that there is no statistically significant difference in the
proportions “exposed” in the two groups.

The results tend to be presented as 2 x 2 contingency tables and the computed statistic is
the odds ratio.

This is just a statistically sophisticated way of summarising the comparison of proportions
in two groups.

                                     Cases             Controls



                 Exposed               a                   b



            Not exposed                c                   d



Odds ratio = (a/c) / (b/d) = ad/bc

The odds ratio approximates the relative risk.

(Relative risk is a measure of relative incidence, so strictly speaking can only properly be
calculated from the results of prospective studies).

Statistical tests are used to determine whether the odds ratio is statistically significantly
different from 1 (no association).

[I can provided more background on the statistical details if necessary but I think it’s more
important to understand the design principles that to get bogged down in statistics]




                                             43
How would you design a case control study and look at the possible causes of a
condition you are looking at?

How would you choose your control group within the study?

What unreliable elements are there in your study?

How does the latter affect the interpretation of your results?



The steps for designing a case control study are:

1. Decide on the case definition – one that can be realistically applied.

2. Calculate the number of cases and controls which need to be included in sufficient
statistical power to detect an association if one exists (i.e. avoid a “type II” statistical
error). This calculation should be based on the findings of previous work, and should
incorporate some idea of the prevalence in the general population of the risk factor being
studied, and an idea of how much more prevalent it would need in people with the same
disease to be for it to be considered clinically or epidemiologically important (e.g. 5% in
general population vs 10%, 15%, 50% in the “population” of cases) – clearly a matter of
judgement. The bigger the difference being looked for the fewer the subjects need to be
recruited.

3. Identify cases from appropriate source (community, hospital, practice, institution etc).
This depends on the disease being studied, its frequency or rarity, whether data will be
collected from the cases, their families or medical records of some sort (i.e. case control
studies may be entirely records-based and not involve contacting individuals at all). It is
preferable to recruit cases and controls prospectively, i.e. as they occur, if possible.

4. Identify controls from and appropriate source, preferably the same population as the
cases (i.e. if cases are from the community then controls should be from the same
community; if cases are hospital-based, controls should also be hospital-based if
possible).

If possible, ensure controls are free from the disease under study (i.e. are not cases in
disguise!). This minimises the risk of misclassification, which reduces the pose of the
study to identify an association.

When selecting controls from non-community settings (e.g. hospital), consider whether or
not they are representative of the underlying population of “all people” without the disease.
For example, a hospital-based case control study of smoking and lung cancer used as its
cases lung cancer patients in a hospital and as its controls other patients on the
respiratory ward. No association was found between smoking and lung cancer – because
many of the controls also had smoking-related diseases.



                                             44
Controls may be matched or unmatched.

In an unmatched study the sizes of the two groups need not be identical (because of the
key comparison is of proportions). Sometimes more than one control is recruited per case,
to improve the power of the study, but going beyond 3 or 4 controls per case study is
usually not worth the effort for the extra power gained.

Matching on factors such as age, sex, etc may improve of the power of the study to detect
associations, but, by definition, the matched factors will be present in the case and control
groups in the same proportions – so never match on factors which may be of aetiological
interest. A fully matched case control study is analysed on the basis of matched pairs but
the underlying statistical approach is the same as for an unmatched study – the
contingency table just looks slightly different. A fully matched study means that if there are
any cases for whom there are no control data, then they are discarded from the analysis.

5. Decide on the exposure data to be collected – this should be decided on the basis of
the results of descriptive or other studies and depends on where the data are being
collected from (e.g. records or people). Collect data on possible confounding factors if
possible (see below). Bear in mind the need to try to demonstrate that the exposure came
before the disease, and not as a result of it (e.g. tissue levels of some nutrients may be
affected by the development of cancer – showing that these are lower in cancer patients
compared with controls does not prove that a low tissue level is a risk factor for cancer).

6. Collect the data in an unbiased manner. This means, the same data items should be
collected in a systematic way without regard to (and preferably knowledge of) whether the
individual is a case or control. This applies to whether data are being gathered from
people (patients, relatives etc) or from medical records. This minimises the chance of
information bias – seeking items of information more assiduously for one group than for
the other, so increasing the chance of identifying an association when one does not really
exist.

Another form of information bias is recall bias – where cases or their relatives have
“mulled over” the possible reasons for their developing the disease and “improved” their
recollection of possible risk factor. Controls and their relatives have no reason to go
through this process so are more likely to “fail to remember” things than cases. The
implication of this is that researchers must try not to alert cases/controls of the risk factors
being studied (not so easy) and must seek independent corroboration of exposure from
medical records etc whenever possible.

7. Analyse the data using standard statistical techniques. The analysis should take into
account of possible confounding factors, i.e. factors which are independently associated
with both the disease and the exposure under investigation, so distorting the association
between exposure and disease.



                                              45
Example of confounding: social class IV/V “causes” lung cancer?

The relationship is distorted because there is a higher prevalence of smoking in social
classes IV/V than in the other social classes. There are independent associations
between smoking and being in social class IV/V and between smoking and lung cancer.
These need to be taken into account of statistically before the true association between
social class IV/V and lung cancer can be determined.



Social class IV/V          association             Lung cancer




        association                                 association

                                 Smoking


8. Present the results in an understandable manner and interpret their relevance in the
context of other work in the same area.



What type of study would you design to make more reliable assessment of one of
the theories from your case control study?

The logical next step is a prospective, or cohort study. This is another form of analytical
epidemiology, testing for associations between exposure(s) and disease outcome. In a
cohort study, the direction is forward in time, form classifying exposure levels to factors of
interest in disease free individuals and relating them to subsequent development of the
disease.

The basis hypothesis is thus:
If <risk factor A> is aetiologically associated with development of <disease X> then a
group of people with higher levels of exposure to <risk factor A> [“exposed”] will have a
higher proportion of individuals who go on to develop <disease X> than a group of people
with lower levels of exposure to <risk factor A> [“unexpected” or “less expected”].


Cohort studies are expensive in terms of the number of people who have to be recruited
(related to the expected incidence of the disease in exposed and unexposed and the
prevalence of the putative risk factors in the population), the time lag between exposure
and the development of the disease and the difficulty or ease of following them up.
However they are the “gold standard” in terms of estimating relative risk.



                                             46
What’s the next stage, refining your research?

If there is convincing evidence of an association between the risk factor and a disease
outcome, the there is a case for trying to prevent the disease by modifying or eliminating
exposure to the risk factor. How to do this obviously depends on the nature of the risk
factor. The basic study design would be a trial of some sort. If the risk factor could be
modified/eliminated then the incidence of disease in the intervention group should be less
than in the control group.

The challenge is to use the findings of epidemiological studies to design effective
interventions to prevent disease incidence.




                                           47
48
                         EPIDEMIOLOGY AND PREVENTION


                                    Topic Checklist

   Numbers and rates of disease (numerator and denominator)

   Incidence and prevalence rates

   Commonly used rates e.g. Infant Mortality Rates

   Comparing rates between different populations – age standardisation

   Case definitions

   Case ascertainment (sources of health information)

   Descriptive epidemiology (time, place, person)

   Ecological studies (based on groups)

   Sampling from populations

   Validity and Repeatability of measurements

   Bias – random and systematic

   Case Control Studies

   Cohort studies

   Relative risk

   Attributable risk

   Confounding variables

   Criteria for causation

   Primary, secondary, tertiary prevention

   Screening (specificity, sensitivity)

   High risk and population preventive strategies




                                           49
               Topic 7: Prevention and Health Promotion


                                                               Dr Brett Finlayson
Learning Objectives

Topic Objectives

Students should be able to:

      Define the concepts of prevention, particularly immunisation, secondary prevention
   
       and screening.
   
   
       Be able to apply these to the design and evaluation of preventive interventions.
      Consider how knowledge, attitudes and behaviours are formed and how they might
   
       be changed.
   
   
       Define health promotion, health education and health protection.
   
   
       Be aware of the range of approaches to health promotion.
   
   
       Understand why health promotion has become a component of NHS provision.
   
   
       Place health promotion in a UK and global context.
   
   
       Consider health promotion activities in different settings (eg, hospitals and schools).
      Be aware of the challenges inherent in assessing the quality and outcomes of
       health promotion.


Tutorial objectives

Students should:

      Have discussed the best way to achieve high levels of health for the practice and
       society.
   
   
       Reflected on who should be responsible for achieving immunisation.
   
   
       Have explored and discussed the cervical screening programme.
      Brainstormed preventable risk factors and how to tackle these at individual and
   
       practice population levels.
   
   
       Be able to apply this knowledge to specific examples of illness and/or disability.
      Discussed the pros and cons of health promotion with reference to current
       evidence.




                                             50
Get students to define Health Promotion -
Any planned activity designed to enhance health or prevent disease.

Health affected by genetics, access, environment and lifestyle. The last 3 are affected by
health promotion

How to promote health –    Educational approach
                           Socio-economic approach
                           Psychological approach
Education, Legislation, Prevention.



Examples of Health Promotion

Primary care: Planned – Posters, Chronic disease clinics, vaccinations, QOF

               Opportunistic – Advice within surgery, smoking, diet, taking BP



Government: Legislation – Legal age limits, Smoking ban, Health and safety, Clean air
                         act, Highway code

               Economic – Tax on cigarettes and alcohol

               Education – HEBS (ask students to recall adverts they’ve seen)



Exercise 1

Split into 2 groups establishing a health promoting university and student accommodation.


Cycle of change - New textbook p51 Table 3.3



Primary Prevention
Define Primary Prevention – education

Give up to date vaccination schedule
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/VaccineCoverageAndCOV
ER/VaccinationSchedule/




                                            51
Discuss uptake




   Wakefield study - summary

      12 children referred for GI problems.
      Did to carry out another study to find out if parents blamed MMR had a case – some
       children in both studies.
      Looked initially for a link between Crohn’s disease and MMR, later included autism.
      5 children had same solicitor.
      Not randomly selected.
      ‘Link’ – 8/12 parents said it started after MMR. No actual scientific link.
      Hypothesis: MMR > chronic measles > autoimmune bowel disease > toxins leek >
       brain damage.
      No step ever proved.


How to improve vaccination uptake?

Discussion topic: schools in some states in the U.S. will not accept children who are not
fully vaccinated. This can spark an interesting discussion on whose responsibility it is to
encourage vaccination, parental autonomy, nanny state etc.



                                               52
Secondary Prevention
Define secondary prevention

Brainstorm Wilson’s criteria – Illness – important, natural history understood, pre-
symptomatic stage
                              Test – easy, acceptable, cost effective, sensitive specific
                              Treatment – acceptable, cost effective, better if early

Discuss prostate screening and take a vote, do Wilsons Criteria for prostate, give
information sheet and vote again.

What do we screen for?

Why not screen for everything? eg whole body scans – 100’s of measurements remember
distribution of normal (5% of normals outwith normal range) so very little chance of having
no “abnormalities”

1500 – 87% at least 1 finding, 33% needed extra tests

http://www.mja.com.au/public/issues/181_06_200904/and10325_fm.html Conclusion - no
proven benefit, and indeed possible detriment

Breast Screening pop quiz

   1) Does screening reduce chances of getting cancer ? 68% of public think yes

   2) Does it halve mortality? 62% think yes

   3) Screen 2000 women for 10 years – Ask students for number of how many saved
      75% of public think more than 10

2,000 women screened over a 10 year period. 1 will avoid dying. 10 healthy women
treated (4 mastectomy, 6 breast conserving, most of them 10 received chemotherapy).
One patient per GP in 10 years saved. But if every GP can save one person this can
result in significant saving of lives.

Exercise 2

Get students to write an Invitation letter to attend breast screening - split into 2 groups:

Do they mention risks vs benefits? Informed consent

Other Discussion points:
Benefits vs risks of screening - discuss anxiety/depression in patients with low-grade
abnormal smears.
Recent Aberdeen study on abnormal smears (see final Resource).
N M Gray, L Sharp, S C Cotton, L F Masson, J Little, L G Walker, M Avis, Z Philips,            I
Russell, D Whynes, M Cruickshank and C M Woolley on behalf of the TOMBOLA group
                                              53
Psychological effects of a low-grade abnormal cervical smear test result: anxiety and
associated factors. British Journal of Cancer 2006:94:1253-1262 - on tutor CD.
Tertiary Prevention

Define tertiary prevention

Relate to patient visits, QOF, (remember that secondary prevention of MI etc relates to
tertiary prevention

Patient interview


Resources:
Health Promotion Quiz (see below)
NHS Cancer Research UK. Prostate Cancer Risk Management Programme – an
information pack for primary care.
Atkin WS. Impending or pending? The national bowel cancer screening programme.
BMJ 2006;332:742.
Jørgensen KJ, Gøtzsche PC. Content of invitations for publicly funded screening
mammography. BMJ, Mar 2006; 332: 538-541 – on Year 2 toolbox CD
Very good article on breast screening. Good for:
1) The belief of the women screened that it is much more beneficial than it really is.
2) The lack of knowledge that screening can do harm.
3) Not informed consent because people providing information are the ones who want the
uptake to be high.
4) Gives actual figures of benefits and harm.


Petr Skrabanek and James McCormick. Follies and Fallacies in Medicine. The Tarragon
Press. Glasgow. 1990. Chapter 4 Prevention: - Successful prevention; Screening for
cancer; Screening for breast cancer; Screening for cancer of the uterine cervix; Prevention
parodies. ISBN 1 870781 02 3

Petr Skrabanek. The Death of Humane Medicine and the Rise of Coercive Healthism.
St Edmundsbury Press, Bury St Edmonds. 1994. ISBN 0 907631 59 2

James Wills. The Paradox of Progress. Biddles Ltd, Guildford and King’s Lynn. 1995.

ISBN 1 85775 063 2

Prostate screening information sheet – On Year 2 toolbox CD

Stroke Screening discussion paper – On Year 2 toolbox CD




                                            54
                                 HEALTH PROMOTION QUIZ

       HEALTH PROMOTION: HEALTH EDUCATION: HEALTH PROTECTION



From the following which statement is the true definition?

1.    Health Promotion:
      (a)    Information given by health professionals to help improve patient’s health
      (b)    Distribution of leaflets on health issues
      (c)    Any planned activity which enhances health or prevents disease


2.    Health Education:
      (a)    Communication activity aimed at enhancing positive health and preventing or
             diminishing ill health
      (b)    Legislative measures to improve patients’ health
      (c)    Providing health in the curriculum for primary and secondary school pupils


3.    Primary Prevention is:
      (a)    To completely stop a disease occurring in the whole population
      (b)    Preventing the onset of disease by giving a patient a minute dose of that disease
      (c)    Preventing the onset of disease by altering or removing the predisposing
             aetiological factors


4.    Secondary Prevention is:
      (a)    To reduce symptoms of a disease
      (b)    To detect the disease at an early pre-clinical stage in order to achieve a cure,
             prevent recurrence or reduce complications
      (c)    To find out a patient’s risk factors


5.    Tertiary Prevention is:
      (a)    Long-term monitoring of a patient with established disease to prevent or minimise
             the impact of complications
      (b)    Long-term management of chronic disease to allow social integration
      (c)    Long-term management of disability to assess for help for living independently




                                                    55
6.    Definition of the Tannahill model of health promotion is:
      (a)    It incorporates the dimension of health education with those of health protection and
             prevention to influence the knowledge, beliefs, attitudes and behaviour of the
             community.
      (b)    It is to reinforce the negative aspect of certain beliefs and behaviour on health
      (c)    To legislate against all behaviours considered to be unhealthy


7.    Health Protection is:
      (a)    The services provided by the primary health care team
      (b)    Legal and fiscal measures which aim to prevent ill health and promote positive
             health status
      (c)    Educating on health risks


8.    Health Prevention is:
      (a)    Wearing extra clothes when told
      (b)    Drug therapy administered to achieve better health
      (c)    Measures to tackle the disease process and the incidence of disease


9.    Who has been charged with the lead role in raising awareness among the Scottish
      population for the potential for a healthy lifestyle?
      (a)    The HEA (Health Education Authority)
      (b)    The HEB (Health Education Board)
      (c)    Health Promotion


10.   How many different approaches to health promotion are there?
      (a)    Three
      (b)    Seven
      (c)    Five


11.   Definition of the medical/preventive approach to health promotion is:
      (a)    Immunisation
      (b)    Screening
      (c)    Scientifically based activities to reduce morbidity and premature mortality




                                               56
12.   The educational approach to health promotion is:
      (a)   Health fairs
      (b)   Providing knowledge and information to develop the necessary skills to make
            informed choices
      (c)   The distribution of posters and leaflets


13.   Social approach to health promotion:
      (a)   Socio-economic change to promote positive health status
      (b)   Better housing equals better health
      (c)   More money means you live longer


14.   The behavioural approach to health promotion:
      (a)   Setting targets for health to be achieved in certain time-limits – e.g. reduce smokers
            by 5% in five years
      (b)   Strategies to encourage individuals to adopt healthy behaviours
      (c)   Medical profession to set an example of healthy living


15.   Empowerment approach to health promotion:
      (a)   Decision on health is totally the responsibility of the individual
      (b)   The Government dictates the healthy lifestyle
      (c)   How to gain skills and confidence to identify individuals’ own concerns and make
            changes


16.   Knowledge, beliefs and attitudes:
      Models have been used to explain relationships between having knowledge and behaviour
      change. What is the definition of the health belief model?


17.   What is the definition of the theory of reasoned action?


18.   Name the five stages of behaviour change in the stages of change model:


19.   Define WHO’s global strategy of “health for all” by the year 2000 formulated in 1981
      – a hint is it has three principles:


20.   Can you think up any ways of assessing the quality of health promotion




                                                57
                                HEALTH PROMOTION QUIZ


                                     (Answer Sheet)


1.   Health Promotion:
     (a)    Information given by health professionals to help improve patient’s health
     (b)    Distribution of leaflets on health issues
     (c)    Any planned activity which enhances health or prevents disease        


2.   Health Education:
     (a)    Communication activity aimed at enhancing positive health and preventing or
            diminishing ill health   
     (b)    Legislative measures to improve patients’ health
     (c)    Providing health in the curriculum for primary and secondary school pupils


3.   Primary Prevention is:
     (a)    To completely stop a disease occurring in the whole population
     (b)    Preventing the onset of disease by giving a patient a minute dose of that disease
     (c)    Preventing the onset of disease by altering or removing the predisposing
            aetiological factors         


4.   Secondary Prevention is:
     (a)    To reduce symptoms of a disease
     (b)    To detect the disease at an early pre-clinical stage in order to achieve a cure,
            prevent recurrence or reduce complications 
     (c)    To find out a patient’s risk factors


5.   Tertiary Prevention is:
     (a)    Long-term monitoring of a patient with established disease to prevent or minimise
            the impact of complications            
     (b)    Long-term management of chronic disease to allow social integration
     (c)    Long-term management of disability to assess for help for living independently




                                                   58
6.    Definition of the Tannahill model of health promotion is:
      (a)    It incorporates the dimension of health education with those of health protection and
             prevention to influence the knowledge, beliefs, attitudes and behaviour of the
             community.       
      (b)    It is to reinforce the negative aspect of certain beliefs and behaviour on health
      (c)    To legislate against all behaviours considered to be unhealthy


7.    Health Protection is:
      (a)    The services provided by the primary health care team
      (b)    Legal and fiscal measures which aim to prevent ill health and promote positive
             health status 
      (c)    Educating on health risks


8.    Health Prevention is:
      (a)    Wearing extra clothes when told
      (b)    Drug therapy administered to achieve better health
      (c)    Measures to tackle the disease process and the incidence of disease           


9.    Who has been charged with the lead role in raising awareness among the Scottish
      population for the potential for a healthy lifestyle?
      (a)    The HEA (Health Education Authority)
      (b)    The HEB (Health Education Board)       
      (c)    Health Promotion


10.   How many different approaches to health promotion are there?
      (a)    Three
      (b)    Seven
      (c)    Five     


11.   Definition of the medical/preventive approach to health promotion is:
      (a)    Immunisation
      (b)    Screening
      (c)    Scientifically based activities to reduce morbidity and premature mortality   




                                               59
12.   The educational approach to health promotion is:
      (a)   Health fairs
      (b)   Providing knowledge and information to develop the necessary skills to make
            informed choices             
      (c)   The distribution of posters and leaflets


13.   Social approach to health promotion:
      (a)   Socio-economic change to promote positive health status              
      (b)   Better housing equals better health
      (c)   More money means you live longer


14.   The behavioural approach to health promotion:
      (a)   Setting targets for health to be achieved in certain time-limits – e.g. reduce smokers
            by 5% in five years
      (b)   Strategies to encourage individuals to adopt healthy behaviours      
      (c)   Medical profession to set an example of healthy living


15.   Empowerment approach to health promotion:
      (a)   Decision on health is totally the responsibility of the individual
      (b)   The Government dictates the healthy lifestyle
      (c)   How to gain skills and confidence to identify individuals’ own concerns and make
            changes                 


16.   Knowledge, beliefs and attitudes:

      Question:   Models have been used to explain relationships between having
      knowledge and behaviour change. What is the definition of the health belief model?
      Answer:      Change will result from a person’s beliefs.

17.   What is the definition of the theory of reasoned action?
      Answer:      Previous Course Textbook (Taylor, Smith, van Teijlingen), page 124, Box 1.
18.   Name the five stages of behaviour change in the stages of change model:
      Answer:      Contemplation, contemplation, action, maintenance, relapse
19.   Define WHO’s global strategy of “health for all” by the year 2000 formulated in 1981
      – a hint is it has three principles:
      Answer:      Previous Course Textbook (Taylor, Smith, van Teijlingen)
20.   Can you think up any ways of assessing the quality of health promotion
      Answer:      Outcomes



                                                60
Psychological effects of a low-grade abnormal cervical smear test result: anxiety
and associated factors.

A paper published in the British Journal of Cancer by one of the Research Fellows based
in the department (Dr Nicola Gray) has attracted some press coverage. The paper focuses
on the anxiety experienced by women who have received a low-grade (borderline nuclear
abnormality or mild dyskaryosis) cervical smear result. Most previous studies have
focussed on high-grade abnormal smears. The study involved over 3,500 women with
slightly abnormal smear test results taking part in the TOMBOLA trial (Trial Of
Management of Borderline and Other Low-grade Abnormal smears). The women were
screened for clinically significant anxiety using the Hospital Anxiety and Depression Scale
(HADS). Socio-demographic and lifestyle factors, locus of control and factors associated
with the psychosocial impact of the abnormal smear result were also assessed.

The United Kingdom NHS Cervical Screening Programmes (CSPs) have reduced the
incidence of, and mortality from, cervical cancer. However, the screening test has a high
degree of sensitivity, resulting, each year, in over 250,000 cervical smears showing
abnormalities. Assessing the levels and determinants of psychological and psychosocial
consequences of receiving a low-grade abnormal smear result is of considerable public
health importance; low-grade smears account for the majority of cervical smears classed
as abnormal in the UK.

The results of the study suggest that significant numbers of women could be incurring
adverse psychological and psychosocial consequences of screening. There was a high
prevalence of anxiety among women who had a low-grade smear, and the proportion
scoring in the abnormal range was consistent with previous studies of women with high-
grade smear results. When the HADS anxiety scores were analysed, 23 percent of the
women were categorised as ‘probable cases’ (scoring 11 or more) and a further 20
percent as ‘possible cases’ (scoring between 8 and 10). The study further found that those
who were at highest risk of anxiety tended to be younger, have children, be current
smokers, or have higher levels of physical activity. These may represent particularly
vulnerable subgroups of the screening population.

Strategies are needed to minimise the adverse effects of a low-grade smear result on
women. Interventions that focus particularly on women’s understanding of smear results
and pre-cancer, and those that directly address their fears about cancer, treatment and
fertility might provide greatest opportunity to reduce the adverse psychosocial impact of
receiving a low-grade abnormal cervical smear result.

The determinants of anxiety will be further investigated in the analysis of the TOMBOLA
longitudinal data.
N M Gray, L Sharp, S C Cotton, L F Masson, J Little, L G Walker, M Avis, Z Philips,
I Russell, D Whynes, M Cruickshank and C M Woolley on behalf of the TOMBOLA group.
Psychological effects of a low-grade abnormal cervical smear test result: anxiety and
associated factors. British Journal of Cancer (2006) 94, 1253-1262.


Full copy of publication on Year 2 toolbox CD




                                            61
   TOPIC 8: ENVIRONMENT: ILLNESS IN CONTEXT – HAZARDS TO HEALTH
                ENCOMPASSING OCCUPATIONAL HEALTH
                                                                           Dr Walter Mouat

Review to be used in conjunction with PowerPoint presentation which is the format I use
for delivering this tutorial.

See Y2 toolbox CD for copy of Walter Mouat’s PowerPoint presentation
Learning Objectives

Topic Objectives

Students should:

      Understand the concepts of hazard and risk.
      Be able to explain different types of hazard.
      Understand the importance of an environmental and occupational history.
      Be able to take an environmental/occupational history.
      Appreciate the opportunities this provides for disease management and prevention
       at different levels (patient, doctor, employer/regulatory body, Public Health
       Department and legislation)

      Understand the importance of communicating risk to patients including the concepts
       of Number Needed to Treat (NNT) and Number Needed to Harm (NNH)

      Understand Fit Notes

Tutorial Objectives

      To demonstrate the concepts of hazards and risks with examples.

      To generate examples of everyday hazards that may be encountered by the
       student, in the practice/workplace and elsewhere.

      Discuss what of the above are the greatest risks to health and what opportunities
       exist for disease management and prevention.

      Interview a patient with an occupational illness (or a dangerous job) or indeed an
       illness caused by his/her environment (e.g. smoking).

      To conduct a tour of a GP surgery asking students to note examples of hazards or
       examples of risk reduction. Alternatively, arrange a tour of a local workplace.

      Demonstrate Fit Notes

Content


                                             62
   Aims of the tutorial
   Hazard and Risk definitions and examples of hazards
          A Hazard is anything with the potential to cause harm.
          Risk is a measure of the likelihood of harm occurring.
   Exposure, Dose and Susceptibility

    Exposure should be measured in terms of its level and duration

    e.g. concentration of carbon monoxide in the air we breathe and for how many
    minutes that this was inhaled.

    Susceptibility. This influences the likelihood that something will cause harm.

    e.g. a-1-antitrypsin deficiency makes a sufferer more likely to develop COPD from
    cigarette smoking. Babies are more likely to be affected by cold temperature.

    Exposure to Pollutants can be by:

    •   Inhalation e.g. Carbon monoxide
    •   Ingestion e.g. food poisoning organisms
    •   Direct Skin Contact e.g. acids

    Influencing the above are our Accommodation, our Occupations and our
    Lifestyles.

   Communication of Risk to Patient, NNT/NNH

    Provide Copy of BHF Factfile (April 2005)

    Number Needed to Treat (or Number Needed to Harm) - fairer, easier to
    understand means of describing the impact of a treatment.
    Use website thennt.com using excellent Youtube tutorial.

   Introduction to Occupational Health & Occupational/Environmental history taking

    A discipline in its own right

    A sideline for many GPs

    We ALL need to be occupational Health Physicians to some extent.




                                          63
       Taking an Occupational/Environmental History

       •   It is often necessary to delve into the occupation of a patient presenting with
           symptoms consistent with occupational exposure to something toxic.
       •   This is not just a “What’s your job?” question but also “How do you spend your
           working day?” or “ Does your job involve exposure to chemicals or anything else
           irritant?”



      Case histories (PowerPoint resource on Y2 toolbox CD)



      Invite Patient with an occupational illness (or a dangerous job) or indeed an illness
       caused by his/her environment (e.g. smoking).



      Surgery/workplace tour and discussion




Further Reading

Communicating Risk to Patients. British Heart Foundation Fact file. April 2005 - on Y2
toolbox CD



Resources:

Fitnotes – healthyworkinglives.com (Search for ‘fit notes’)

Paling Pallete1Downs – on Y2 toolbox CD

BMJ paper – Cancer science and the communication of risk – on Y2 toolbox CD



See Y2 toolbox CD for resource PowerPoint presentation




                                                 64

				
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