Doctor, Patient, Society

"The conscientious, judicious and explicit use of current best evidence when making decisions about the care of individual patients"

• Collecting the best external evidence

• Applying the best individual expertise

• Acknowledging patient values and expectations

• Dictates whether a procedure is used in healthcare or not.

• only evaluated and useful procedures are used in healthcare

• However unevaluated procedures may be used due to public enthusiasm, political convictions or commercial pressure. This is a problem as it means procedures with a lack of evidence may be used, this can cause harm

Thalidomide

• Marketed as sleeping pill in 1950s, Claimed to be safe in pregnancy

• In the late 50s and early 60s it was also used to combat morning sickness

• In 1961 a connection was made between thalidomide and an epidemic of congenital defects. Early mortality rate was 40% in affected babies. In the UK 5070 babies were affected

This framework is used to scrutinise new knowledge being presented. A doctor should keep up to date.

• Assess - what type of healthcare question, what type of study?

• Access - finding the best evidence in terms of validity and relevance

• Appraise - evaluating the quality of evidence and interpreting the results

• Act - is the evidence relevant to clinical practice. Should it be used to change my practice

These are observational studies - used to answer questions about frequency and patterns of disease e.g how much, time, place, person and distribution.

Data is collected at population level (ecological) or at individual level (cross sec, case report , case series)

• Ecological studies = info is collected from whole population to compare disease frequency. Can be different population and the same time or same population at different times.

• Cross sectional studies = Info is collected in a planned way from individuals in a defined population at one point in time/time period. e.g population / community surveys, health survey for england and census.

• case report = detailed report of unusual condition occurrence in a single patient

• Case series = detailed report of an unusual condition in several patients

Explicit comparison of 2 or more groups of individuals - aims to establish if an exposure causes outcome (cause and effect).

The exposure can be harmful or benefit. Two types: Observational (cohort or case control) and intervention (clincial trials)

• Observational = researcher is an observer of exposure and outcomes. Exposure is not under the control of the researcher due to ethical reasons.

  • Case control - study starts with identification of an outcome e.g. disease. Compares exposure (multiple) in those with the disease (cases) to those without (control). If the level of exposure is higher in cases, the exposure may be a risk factor e.g What causes lung cancer (smoking, asbestose, pollution) (retrospective)

  • Cohort - study starts with identification of one exposure e.g risk factor. Compares those exposed to those not exposed to a factor. Both groups followed over time and the disease development (multiple outcomes) measured and compared. If the incidence is higher in case group, the exposure might be a risk factor. e.g does smoking cause lung cancer (prospective)

• Interventional / experimental = researcher allocates exposure and observes outcome.

  • RCT - Researchers decide whether participants receive the new intervention being tested or receive a control treatment (Rx vs placebo). The trial ? effectiveness of the intevention. Have design feature that can increase validity and reduce bias. E.g does HRT in post menopausal women reduce their risk of IHD / stroke.

Qualitative research - Healthcare questions about patient, carers and professional experiences. e.g

• Why do patients continue to smoke despite evidence of harm and RCT evidence that nicotine replacement therapy is effective

• Why  don't parents immunise children even though the evidence for benefit far outweighs any harms

Qualitative research answer these questions by collecting non-numerical data about people’s subjective understandings of their lives and experiences. These are indepth studies of small no of individual in a specific setting, rather than aiming for generalisability.

Multiple methods are available - direct observation / individual interviews and group interviews.

AAAA

• Assess: what type of healthcare question or study is most appropriate

• Access: finding the 'best' evidence (validity and relevance)

• Appraise: evaluate quality and interpret results

• Act: is the evidence relevant to clinical practice, should it change my practice?

E.g If a patient comes with lower back pain, Dr want to refer him for physio but patient asks for chiropractor. Dr want to know the effectiveness of the chiropractor compared to physio.

• Assess —> define a clinical question, what study desing?

• The clinical Q: is there a beneficial treatment

• Best study design for effectiveness: RCT

• PICO framework can be used to formulate questions

PICO framework - important for efficient searching for evidence in electronic bibiliographic database e.g. pubmed, and for assessing the applicability of the research to the patient

• Population: those who are eligible for treatment with the intervention

• Intervention: new treatment

• Comparator: existing treatment / usual care (no Rx)

• Outcome: mortality, morbidity, physiological measures e.g. blood pressure, blood glucose, pain relief

A 45 year old man consults GP) for treatment for his chronic low back pain. Dr would normally refer him physiotherapy but the patient has requested a referral to a chiropractor. Dr want to know how effective chiropractic treatment is, compared to physiotherapy, for the treatment of low back pain before deciding where to refer him.

• P = Adult with chronic back pain

• I = Chiropractic treatment

• C = Phyiso

• O = outcome Dr want to measure

• The Cochrane Library

• Bibliographic databases such as Medline, PubMed, Embase

• MEDLINE and EMBASE have study design filters (including an RCT filter)

• PUBMED has a clinical query facility

E.g. to know the effectiveness of chiropractor in treating lower back pain in adult:

• Use the component of the clinical question (elements of PICO) - to narrow search results

• Start with the intervention / population of interest. E.g. Chiropractic Rx, adults

• Use alternative terms e.g. manipulation

• Use MESH terms (Medical subject heading)

• Use ‘and / or’

Appraisal questions:

• Does the study address a Q relevant to my clinical problem? e.g. is there a match between PICO and study question / population interested

• Does the study design likley to give valid ans to the Q? e.g for effectiveness did the study use RCT

• Was it done well / trustworthy? e.g steps taken to reduce bias

• If it was done well, what were the results? e.g. direction, size, precision, statistical significance

Bias = Systematic deviation from the normal value (in same direction), can affect validity, usually an over estimate of the effect.

Imprecise = wide variability, less certain (hit or miss), can affect precision

• Random allocation of participants to either New intervention or comparator treatment (or no Rx)

• Having control group helps to compare if pt would get better with existing or no Rx, increases sample size.

• Allocation concealment - hides allocation of participants and those recruiting until they actually start the Rx = reduce selection bias (not same as blinding)

• Blinding - minimise measurement and performance bias

  • If the study population or HCP know which arm of the study pt in, they may have preconceived ideas about the Rx (placebo effect) - it may lead to disappointment and not engage e.g. if in placebo group

• Intention to treat - helps minimise attribution bias

• If we allow manufacturer of a drug to allocate - they may deliberately choose patient who has milder form of the disease who will get better with or without treatment > which may over estimate the effectiveness of the new drug and not true respresentation of the true population

• If we allow participant or clinician to choose - they are likely to choose people who has chronic issue, resisitant to previous treatment.

• So random allocation minimise selection bias

4 groups of people involved in RCT are: Participants, clinicians delivering the Rx, researcher measuring outcomes and staticians analysing. The more blinding possible, the better

• Single blind - only one group is blinded

• Double blind - 2 groups are blinded

• Triple blind - 3 groups are blinded

• Patients may be lost to follow-up at different points in a trial

• They may be available for outcome measurement but not adhere to trial protocol (not taking the new / allocated Rx)

• Patients drop out for a reason from either arm e.g side effect from new Rx or ineffectiveness of new Rx.

  • also patient from control group is likely to drop out as they are not receiving Rx

• Intention to treat analysis helps to minimise it - analysis includes all the original participants regardless of adherance to protocol.

e.g In a RCT of new analgesia (intervention) compared to ibuprofen (comparator) for back pain. Some participants allowcated for new Rx did not take it, instead buys OT ibuprofen. What can be done to these pt to ensure validity?

• They should still be analysed with the group who took the new drug. This is due to intention to treat analysis.

• Analysis includes all participants in groups they were originally assigned regardless of: compliance, withdrawal or protocol deviation

• This helps to preserve randomisation - mimics real world scenarios (if a pt is poor compliant in a trial, they are likley to be in real world) and avoids over estimating the treatment effect.

RR is the risk in exposed group / risk in unexposed group - measures the strength of association.

• RR = 1: no difference between the treatment group and the comparator group (null value)

• RR > 1: more outcomes in the treatment group than comparator. e.g Chiro (Rx) vs physio (control)

  • RR 1.35 = pt in chiro group is 35% more likely to be pain free than physio)

• RR < 1: less outcomes in treatment group than comparator

RD = risk in exposed group - risk in unexposed. Measures absolute effect. E.g comparing physio vs chiro

• RD = 0: no difference between treatment and comparator groups. Both physio + chiro same effect (null value)

• RD > 0: (+ve) more risk of outcome in treatment group than comparator group. Chiro is more effective than physio

  • If RD is +0.22 = 22% = 22/100 more pt in the chiro group felt better compared to physio

• RD < 0: (-ve)less risk of outcome in treatment group than comparator group. Chiro is less effective than physio

This is the no of patients who needed to be treated with the treatment compared to control group to achieve one more patient with an outcome = 1/RD

• e.g physio/chiro study with NNT +4.5 —> extra 5 patient (always round up the number) would need to be treated to achieve one more patient with no pain in the chiro group.

• So higher the no of patient needed to treat = lower the effectiveness of the drug

• Chance and precision —> outcome of a study shoud be cheked to see if the results are statistically significant or due to chance alone.

• This is done through hypothesis (statistical) testing using P values.

• P value of 0.05 = there is a 5% probability that the observed result is due to chance

• Smaller the P value, the higher the chance that the results are true and not by chance.

• Sometimes the evidence found may be valid but not relevant to the patient population.

• If no evidence found that the intervention is better than the original Rx, then the patient should continue the existing Rx

• Check to see if the study considered all outcomes (including harms), is the trial setting mimics the Dr’s setting, cost of the new intervention, what other Rx available and their cost, finally if the workforce is skilled enough to offer the Rx.

CI – range of values likely containing the true effective size.

95%CI – if study repeated 100x, 95/100 intervals contain true value. So a wide CI means estimate or more uncertainty, a narrow CI means more precise

e.g if RR of a study is 2.1, the CI can range between 1.29 to 3.41.

Review of all literature on one particular question using scientific methods

• Chance

• differences in people, intervention / comparator

• Differences in care, way Rx effects measured, follow-up

• Reporting of available evidence and selection from available evidence

Occurs when the publication of research results depends on their nature and direction. Either be:

• +ve result bias = authors are more likely to submit or editors accept positive than negative or inconclusive results

• outcome reporting bias = Several outcomes within a trial is measured but are reported selectively depending on the strength and direction of those results

Research method used to synthesis multiple pieces of research evidence on effectiveness of a treatment.

• Review of all literature on one specific topic using scientific methods to answer a specific question

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1. Define a Qustion - Use PICO

   E.g The effect of aerobic exercise (intervention) compared to lifestyle modification (comparator) to reduce cardiovascular risk (outcome) in obese men (population)

2. Write a protocol - Description of methods

3. Search for studies - using biniliographic databases like Medline, EMBASE.

4. Select relevant studies - Unbiased manner by using more than one reviewer to independently select relevent studies using pre-defined selection criteria based on PICO

5. Appraise studies - unbiases assessment of quality of each study by 2 or more independent reviewers using CASP checklist to draw strength / weakness of selected studies

6. Analyse & summarise data - statistical techniques to combine quantitative results from several studies (meta analysis)

7. Interpret results - unbiased interpretation

8. Discussion and conclusion - provide summary of the findings, considers the implication of the findings in the context of current practice and knowledge and outlines future research.

It is a statistical technique used to combine the quantitative results of various studies.

• combines data from RCT for the same intervention, compared to the same comparator in the same population for the same outcomes. 

• It combines this data to produce a summary effect for intervention vs control/comparator for that outcome. 

• This gives a stronger and more precise measure of effect of intervention vs comparator.

Meta analysis column components:

• 1st Name of the studies used

• 2nd / 3rd is data from intervention / comparator

• Forest plot

• last column - relative risk and confidence intervals

• Vertical line = line of no difference between intervention and comparator. (this equals to RD of 1 or mean value of 0)

• If the diamonf lies entirely to one side of the line of no difference, the results are statistically significant (+ve or -ve)

• Best source of evidence on effects and effectiveness of interventions

• Assimilation of large amount of research evidence which is better than single study

• Provide reliable, unbiased estimates of effect

• increase precision of effects

• Provide information on generalisability and consistency

• Identifies missing information for future studies

• Useful for making decision

Critical appraisal is the systematic identification of strengths and weakness of pieces of information and application of that info within identified limits.

·     Internal validity: Degree to which the effect observed is attributable to the evidence, rather than any other cause (such as bias and other methodological problems of the review).

·     External Validity: Degree to which the review's conclusion applies to other persons in other places at other times (Only considered if internal validity is strong).

CASP checklist is a tool designed to evaluate the quality and validity of research studies across various methods. Focus in 3 main sections:

1. Validity of the study

   • is the review trustworthy (internal validity)

   • Did it ask clear focus question (PICO)

   • Did it include right type of study?

2. Results of the study

   • Did they identify all relevant studies

   • was it reasonable to do meta-analysis

   • Heterogeneity - ?disimilarity in combined studies

   • Presentation of the results - RD, mean, differences, precision (CI)

3. Applicability / relevance (external validity)

   • Can the results be applied to local population?

   • risk vs benefit vs cost of changing the practice as a result of the finding in the study

The WHO defines self-care as ”the ability of individuals, families and communities to promote own health, prevent disease, maintain health, and cope with illness and disability with or without support from a health worker”.

• recognise individual as active agents in managing their own health.

Self-care interventions are evidence-based tools such as

• Quality drugs

• devices

• diagnostics or digital products

  that support individuals in managing their own health, with or without professional support.

The users are individuals and caregiver who might choose these interventions for positive reasons, or those who dont have acccess to healthcare.

Examples of quality / cost effective interventions include:

• pregnancy tests

• HPV + STI self-test, HIV self-tests

• self-monitoring of blood pressure / blood glucose

• over-the-counter contraceptives.

Positive reasons:

• Convenience, cost-effectiveness, empowerment, and better fit with lifestyle or personal values.

To avoid the healthcare system

• lack of quality healthcare or lack access

Keeping fit and healthy while understanding when and how to seek help from a pharmacist, GP or other professional, and managing long-term conditions effectively.

• Its about understanding the condition and how to live with it

• Restorative: to alleviate illness.

  • E.g. going to GP with symptoms and being told what they must do

• Reactive: to alleviate symptoms.

  • E.g. taking medication from a pharmacy

• Preventative: to prevent disease.

  • E.g. Recognising you are at risk of a particular condition (FH or risk of lung cancer if you smoke)

• Regulatory: to regulate body processes.

  • E.g. Looking after your health

Preventative self-care aims to prevent disease, while reactive self-care aims to relieve symptoms after they occur.

• Self-care maintenance

  • Behaviours performed to improve well-being, preserve health, or to maintain physical and emotional stability

• Self-care monitoring

  • A process of routine, vigilant body monitoring, surveillance or “body listening”

• Self-care management

  • Evaluation to determine if action is needed, treatment implementation and treatment evaluation

• Symptom management

• Definitions of health and illness changing

• Healthism/consumerism

• Body maintenance

• Changing beliefs about medical power and expertise

• Internet use

• Technology (e.g. self-testing kits)

• Over-the-counter medication/on-line pharmacy

• Increase in number of people with chronic disease

• Expert patients

• Patient choice/empowerment

• Need to reduce NHS costs

The presence of two or more long-term health conditions in one person. Include physical, mental and infectious diseases

Because conditions may be treated separately rather than holistically, leading to poorly coordinated and inefficient care > poor patient experience.

• this can occur when an individual’s conditions are non-synergistic (not related in a way they can be treated together e.g. arthritis and HTN)

Conditions that are related and can be treated together, such as hypertension and heart failure.

A dominant social identity that overrides other social roles and defines a person in most situations.

• It is the primary identifying characteristic of an individul.

• Whether ascribed or achieved, it overshadows all other social positions.

• E.g. Upon qualifying, being a “doctor” would be master status (non medically) or medically - “patient with HTN”

  • In healthcare, master status (HTN) determines the priority assigned to particular condition e.g BP management is most important to avoid stroke

Acute illness is usually short-term and curable, whereas chronic illness is long-term and often incurable; professional knowledge dominates in acute illness, while patients often develop greater illness knowledge in chronic conditions.

To equip patients with chronic illnesses with the knowledge, confidence and skills to manage their own condition and work in partnership with health professionals (diet, exercise, setting goals, dealing with difficulties). Focuses on people with chronic illness (e.g. COPD, DM, MS, HIV) due to:

• Ageing population & new concept of ageing

• Co-morbidity

• health service demand

Recognising & responding to symptoms,

medication management

maintaining nutrition / diet

engaging in exercise

Not smoking

managing stress

communicating with healthcare providers

Seeking info and using community resources

Through the development of self-testing kits, digital health tools - smart watch, internet access to information, and online pharmacies.

It provides shared experience, emotional support and practical advice to help individuals manage mental and physical health conditions.

Psychology is the scientific study of the mind and how it influences behaviour, health, emotions, thoughts, and illness outcomes.

Psychological factors can affect disease progression, treatment outcomes, and health behaviours such as smoking or medication adherence.

• strong link between the both - an ill patient suffers both mentally and physically.

Sociology examines how health, illness, and behaviours are shaped by social and cultural contexts.

It argues that traditional medicine focuses too heavily on biological and individual factors while ignoring wider social forces such as poverty and inequality.

• Social determinants of health show disadvantage start before birth and accumulates throughout life.

• Sociology helps to shift the perspective to wider social norm rather than individualism e.g complex social, economical and environmental factors.

The social determinants of health are the conditions in which people are born, grow, live, work, and age that influence health outcomes and are responsible for health inequities > unfair & avoidable differences in healt status between countries.

• These circumstances are shaped by distribution of money, power, global/national/local resources

Economic stability, education, neighbourhood/environment, healthcare access, and community context.

The biomedical model defines health as the absence of disease and focuses on biological causes of illness.

It focuses on specific biological causes (germs, radiation, toxins, genetics), excludes psychological and social factors, relies on technology, and treats the body mechanistically.

• Mind-body dualism (mind and body treated as separate entities).

• Mechanistic (body is regarded as a machine that can be fixed)

• Reductionist (Driven by germ theory, focusing on biological changes that cause disease only)

• Ignoring social, cultural, biographical, and environmental explanations.

• Over reliance on technology

The approach of explaining disease purely in terms of biological processes, ignoring social and psychological influences.

It refers to individuals reporting good health and quality of life even while living with chronic illness.

Health as absence of disease, health as functional ability, health as psycho-social wellbeing, health as physical fitness, health as energy and vitality.

Migration can increase stress, social isolation, and exposure to discrimination, which are linked to higher rates of mental illness such as psychosis.

Cultural stigma may create shame or fear around mental illness, discouraging individuals from seeking professional help.

An explanatory model is a patient’s personal understanding of their illness, including its cause, symtoms, and expected outcome.

• E.g patient with back pain, when HCP asks what they think is causing the pain, they say likely lifting heavy object at work or being stressed lately.

Because beliefs about illness are influenced by culture, religion, social background, and personal experience.

A person may simultaneously hold medical and religious explanations for illness, both shaping their understanding.

• e.g pt says DM caused by genetics and witch

Humanism is a philosophy that prioritises human value, dignity, wellbeing, and evidence-based approaches to reducing suffering.

All individuals have equal worth and should be respected

Human happiness should be optimised while suffering is reduced.

• in humanism, worth is not related to social status, a wealthy person is same as poor, as everyone has same inherent value

• Human rights are derived from humanism - it not only addresses basic human rights but also their needs

The NHS is based on principles of universal care, equal worth, and healthcare as a human right.

Derived from humanist ideology:

An ethical approach focused on meeting individuals’ needs through caring, respectful relationships.

Communicating ill experience is how humans cope with disease allowing then to receive acknowledgement and validation of illmess.

• Listening improves diagnostic accuracy, strengthens therapeutic relationships, validates patient experiences, and improves outcomes.

Not being heard activates stress pathways such as the sympatho-adreno-medullary axis and the hypothalamic-pituitary-adrenal axis.

Listening helps patients feel validated and in control, increasing their ability to make informed decisions about their health.

It refers to ensuring all patients are equally listened to and respected, regardless of gender, ethnicity, or social class.

• e.g. women with pain are perceived as emotional or somatic. Ethnic minorties generally feel more dissatisfied with communication from GP esp older age. Style of dressing, tattoo, being in lower socio-economic status can all impact equality.

Hierarchy can reduce patient autonomy and participation, limiting their sense of control in consultations.

• pt at bottom of social hierarchy have less autonomy / control over their lives / social participation.

Agency is the ability to act independently and make informed decisions about one’s health.

• Dr seen as higher in the hierarchy in Dr-pt relationship > reduce agency in pt as they are powerless

  
  

Intersectionality refers to overlapping social disadvantages (e.g., gender and ethnicity) that compound inequalities in how patients are heard and treated.

Health is considered a fundamental human right that should be enjoyed without discrimination based on race, religion, political belief, or social condition.

A refugee is a person forced to leave their country of citizenship to escape war, persecution (race, religion, politics), or natural disaster.

An asylum seeker is a person who left their country of origin and applied for asylum in another country but whose claim has not yet been decided.

• legally not allowed to work, benefit entitlement of £49.18/week.

An undocumented migrant is someone living in a country without valid immigration documentation, including overstayers or trafficked individuals.

A refused asylum seeker is someone whose asylum claim has been rejected and who has no ongoing protection claim.

All humans have equal worth, and everyone has a right to the highest attainable standard of health regardless of status.

Humanism supports universal healthcare by asserting equal moral worth and the reduction of suffering for all individuals.

Concerns about terrorism, increased demand on services, and crime.

• Gov primary responsibility is to their own citizens.

Migration from war-torn countries are associated with increased attacks, but overall influence is limited and varies by context.

PTSD (31%), depression (31%), anxiety disorders (11%), psychosis (1.5%), as well as grief and distress.

• These can increase the demands on already stretched existing services. Meeting complex needs > significant investment and planning.

Limited opportunities, unmet social needs, and lack of social or familial support can increase vulnerability to criminal activity.

The process of trying to determine whether something is right or wrong. A helpful skill for ethical decision making.

Stage 1: Authority/punishment

• Act is done to avoid punishment e.g. if i don’t let immigrant in, UN will punish me

Stage 2: Egoistic exchange

• getting a favour in return e.g refugees give back more than they get (contribute to economy)

Stage 3: Interpersonal conformity

• Being good - right thing to do

Stage 4: Societal maintenance

• to keep global system running (trade and development)

Stage 5: Greatest good (utilitarianism)

• What brings good to most people. e.g. accepting refuge > reduce suffering at tiny cost to accepting nation.

Stage 6: Commitment to ethical principles (justice).

• Right thing to do because it satisfies demands of justice

Justice and the development of increasingly abstract principles of moral reasoning.

An ethical framework focused on meeting human needs through caring relationships and contextual understanding.

Justice ethics focuses on rights and abstract principles, whereas care ethics focuses on relationships and meeting human needs in context.

A reductionist response simplifies complex ethical situations by applying abstract principles without considering context.

It argues that the wife’s right to life outweighs the pharmacist’s right to property.

The care response considers long-term relationships and ongoing needs rather than simply applying abstract rights.

• so if he steals the drug he might save the wife’s life but he need to go jail for stealing > if his wife get sick again, he is not there to take care.

Reductionist response is same as justice response - it ignores the complexity of the situation. It is concerned with whats right and not the consequences. It assumes that one individual must win.

The NHS prioritises treatment based on clinical need, reflecting a care-based ethical approach.

• Justice is around human RIGHT but care is around human NEED. (both are humanist)

It would prioritise meeting the needs of refugees rather than focusing solely on legal rights or restrictions.

1. Undocumented migrant

2. Antenatal care, MH care and STI check

3. No, everyone in the UK is entitled to free primary care, regardless of immigration status.

She may need interpreter to see GP, need to be flaged as vulnerable and homeless, may not be able to receive referral letters, may not attend appt. Give guidance on 111, how to access NHS services, medication info

Her wider needs ( food, housing, social isolation)

Refugees and asylum seekers are entitled to free NHS care, including prescriptions, dental care, and eye tests (with exemptions).

• They may have barriers to access healthcare - Proof if ID / adress (there is no regulatory requirement to check and appt should not be withheld because of lack of proof).

Service that are excempt - Immediately necessary and urgent treatment (A&E), including lifesaving and antenatal care, communicable disease.

Some groups (victims of trafficking / slavery / domestic abuse / sexual violence / FGM, or childer under care of local authority and Rx under MH act)

• for 2ndary care services in UK, it is residence-based = must be living in UK lawfully on settled basis to be entitled to free healthcare. > charge applies to undocumented migrants / refused asylum seekers (except those above).

Fear of unaffordable bills and data sharing with the Home Office can deter people from seeking care.

• Bills > £500 and 2 months outstanding > reported to home office > detention / affects future asylum claim.

• NHS somtimes wrongly charges those who should be exempt

It enables clinicians to weigh justice, needs, and societal responsibilities when treating displaced individuals.

Rights-based approaches focus on legal entitlements, while needs-based approaches focus on addressing human suffering and wellbeing.

Because migration history, trauma, language barriers, and social exclusion significantly affect health needs and access to care.

• Legitimate: Formal authority within the organisation.

• Referent: Ability to persuade/influence.

• Expert: Possessing needed skills and experience.

• Reward: Ability to give valued benefits.

• Coercive: Punish/ withhold reward.

Authority derived from a formal position within an organisation, such as a doctor’s recognised role.

Power based on possession of specialised medical knowledge and skills.

The ability to punish or withhold benefits, for example enforcing treatment or sectioning under mental health law.

-> The ability to impose one’s will on others despite resistance (demand medication compliance )

-> Real or perceived ability to bring about significant changes in people’s lives (power to cure - carries risks

-> the power to define illness / deviance and manage those that are ill (Relevant for mental illness via sectioning or legitimising illness.

Patients trust doctors’ expertise and authority, enabling doctors to influence decisions and behaviours.

Through professions and organisation

Institutions of knowledge (medical schools)

Instituitions of practice (hospitals)

Interaction with patients

Gov advisory roles (CMOs)

Wider society (status to doctors)

• Professions as social organisations.

• Social effects in being diagnosed (patient level).

• Learning to behave as a patient.

• Power in the consultation.

• Institutions and medicalisation (mental health).

-> Body of knowledge - theory (EBM) and skills

-> Regulated training overseen by profession

-> Monopoly of practice through registration (RCP)

-> Autonomic and self-regulating but still works through interaction with gov (for funding and resources) and interprofessional care via teamwork (Dr, nurses, HCA)

Social role within the profession

• Having self-interest, dominance and autonomy over other professions. Upholding ethical values (fitness to practive and not abusing power) and sense of belonging

Social role outside the profession

• Embodying wider role of service e.g. nurses. Social status through trust and respect from others.

The authority of the medical profession over other healthcare occupations, patients, and aspects of society.

• power to diagnose

A regulated occupation with specialised knowledge, controlled training, autonomy, and self-regulation.

Providing service to society and holding high social status based on trust and respect.

Access to treatment, sick pay, sympathy

social legitimacy for symptoms

potential insurance benefits

Dx helps coping with illness

Socially acceptable explanation e.g unusual behaviour

Stigma, particularly in mental illness

loss of status ‘person’ > ‘patient’

difficulty obtaining cheaper insurance or employment

Hard to reject medical intervention / drugs (medicalisation)

-> The sick person is exempt from normal responsibilities (work, household roles)

-> Must seek professional advice, and must want to get well.

-> Unable to get better by their own decisions and will

-> Should apply high degree of skill and knowledge

-> Prioritise patient welfare and community over self-interest

-> Remain objective, and follow professional rules.

Sickness is seen as a ‘problem’ in society that needs to be managed by the medical profession.

It positions doctors as authority figures and patients as dependent, reinforcing asymmetry.

Dr are allowed interventions in pts e.g intimate examination

The process by which individuals learn rules, norms, values, and behaviours appropriate to their social group.

• Primary socialisation - occurs in the family

• Secondary socialisation - continues throughout life

• Anticipatory socialisation - rehearsing for future position

• Patient socialisation - learning corret behaviour as a pt

Primary socialisation occurs in early life within the family (gender roles - blue for boys, pink for girls)

Secondary socialisation occurs later through institutions like schools and workplaces.

Rehearsing behaviours expected in a future role, such as acting like a doctor before qualification, applying for med school.

Learning how to behave appropriately as a patient within healthcare systems.

• e.g learning from own experience, family and friends, media, hospital leaflets, other patients

Patient career:

A person may adopt an illness-based identity, such as becoming “a diabetic” rather than simply a person with diabetes.

• Closer links to practice/staff.

• Ongoing prescription, sense of dependency.

• Self-management: Main responsibility falls to the person managing the conditions, but are they equipped for this?

• Change in identity: Now a ‘diabetic’, instead of a person.

• Patient organisations can help provide socialisation and can be powerful.

The unequal distribution of knowledge, authority, and social status between doctor and patient.

• differences in level of access to information between Dr and pt

• Social position of pt in relation to Dr - this difference can lead to some pt being silenced (Waitzkin)

• Repertoire of behaviour (polite, deferential)

• Its easier to interact if experiences are similar e.g holiday

  
  

The knowledge, skills, and behaviours that enable effective interaction with healthcare systems.

• Knowing how to interact with health care system is useful - can be difficult for immigrants

• People who are more affluent and educated are better at interacting with the healthcare system - knows how to ask

Those with greater cultural health capital (often affluent and educated) navigate services more effectively, worsening inequalities. > those who need the service are least likely to receive it.

A framework recognising overlapping forms of disadvantage based on race, gender, class, sexuality and other identities.

• Developed to challenge discrimination

The expectation that patients are polite, compliant, and uncomplaining.

• can lead to issues like medical adherance - may stop taking meds without telling the Dr

• Relationship breakdown ca lead to sanctions

Patients who challenge authority or fail to conform may experience reduced support or strained relationships.

An institution where all aspects of life are controlled under one authority, such as traditional asylums. e.g MH institutions - shut off communication from outside world

They are totalitarian institutions which have complete power over their inmates:

-> Life conducted in one place under one authority;

-> strict schedules of daily life carried out in group with others

-> separation between staff and inmates

-> restricted communication and mobility.

• Physical and psychological reminders to strip a person of their identity.

• Information about the individual and institution is controlled.

• Mobility of people is restricted.

• Can lead to institutionalisation, as patients become unable to undertake simple tasks on their own or make decisions.

• Situational withdrawal: No contact with others.

• Intransigent line: Patient refuses to cooperate.

• Colonisation: Hospital is preferable to the alternative e.g being homeless

• Conversion: Becoming a model patient, better relationship with the staff

• Playing it cool: Using a variety of strategies including the above, depending on the situation.

A modern institution where boundaries between inside and outside are less rigid, and patient contact with society is maintained. Evidence of permeability:

• ward membership is temporary

• contact with outside world is maintained

• instituitional identities blurred - people wear their own clothes and called by their names

Reduced institutionalisation risk but increased safety risks for patients and staff.

• if rules are less restrictive and no gender seperation, at risk of sexual abuse or violence

By regulating leave, negotiating permissions, and selectively restricting movement. Limiting unwanted movement

Team-based care, patient empowerment, access to online information, complementary medicine, and increased regulation.

Greater access to medical information reduces knowledge asymmetry and challenges traditional authority.

The need to form a coherent view of the world and the need to gain control over their environment.

Social cognition is the process by which people think about and make sense of themselves, others, and social situations.

It helps clinicians understand how patients interpret symptoms, illness, and treatment, which influences behaviour and decision-making.

Attribution theory explains how people determine the causes of behaviour and events.

• Internal/ dispositional attribution: Any explanation that locates the cause as being internal to the person (personality, mood, effort) - “its my fault”

• External/situational attribution: any explanation that locates the cause as being external to a person (due to circumstances, action of others, nature of situation, social pressures, luck). - “its not my fault”

1. External health locus of control

2. Internal health locus of control

The dimentions of attribution

Internal vs external, stable vs unstable, global vs specific, controllable vs uncontrollable

Stable attributions refer to unchanging causes, while unstable attributions refer to temporary or variable causes.

• The event or behaviour is due to regular non-changing factors (stable).

  • ‘I always have bad luck, hence that's why I got a D’

• The event or behaviour is due to temporary irregular factors. (unstable)

  • ‘I didn't get enough sleep before the exam, that's why I got a D’

Global attributions apply broadly across many areas of life, while specific attributions apply only to a particular situation.

Controllable attributions refer to outcomes believed to be within personal control (e.g. if i revise i’ll pass the exam), while uncontrollable attributions refer to outcomes believed to be outside personal control.

This theory make attribution stating that cause co-varies with the behaviour. 3 types of information is needed to decide if its internal or external:

• Consensus - Do other people do the same in this scenario?

• Consistency - Does the behaviour occur in the same way on different occasions of the same situation?

• Distinctiveness - Does the behaviour occur in the same way in other situations.

The tendency to overestimate internal causes of others’ behaviour while underestimating situational influences.

• Occurs as result of internal (dispositional) attributions.

• Actor-observer bias or self-serving bias

The tendency to attribute others’ behaviour to internal causes while attributing one’s own behaviour to external causes.

• When someone else litters - “people are so inconsiderate”

The tendency to attribute successes to internal factors and failures to external factors.

The tendency to deny responsibilities for failure (situational attribution) but take credit for successes (dispositional attribution).

• When you litter - “there is no distbin”

Mental shortcuts that allow quick, reasonable conclusion and efficient judgments or decisions to complex problems.

Different types:

Representative, Availability, anchoring heuristics and false consensus effect

Judging someone or something based on how closely they match a stereotype.

• Tendency to allocate a set of attribution to someone if they match a given stereotype category

• E.g. walking quickly past someone wearing hoody in a dark alley

Estimating likelihood based on how easily examples come to mind.

• Tendency to judge the frequency or probability of an event

• e.g. Remember seeing you 5 times here so you come all the time

Being overly influenced by an initial piece of information when making decisions.

• Tendency to be biased towards the starting value in making quantitative judgemet

• E.g. preferring the 1st thing you see in the menu

The tendency to assume that others share one’s own beliefs or behaviours.

• Tendency to see my own behaviour as typical and to assume that under same circumstances others would react the same.

• E.G im sure other people would leave the lecture aswell if their dad called

Understanding attributions (cause of health/illness behaviours of patients) helps doctors predict behaviour, tailor communication, and reduce their own cognitive biases.

• Attributions about symptoms

• Attributions about cause of disease

• About responsibility of management

Patients interpret their symptoms by deciding whether they are due to illness or normal variation. This involves:

-> Often engaging in self-diagnosis - unreliable

-> leads to delay in consulting

-> defensive avoidance - due to fear of outcomes

Avoiding medical consultation due to fear of a serious diagnosis.

Attribution about cause of disease —> Because perceived cause influences coping, treatment adherence, and beliefs about recovery.

• Cause of illness is one of the most important info pt want from doctor

• People have hypotheses for cause e.g. biological, emotional, environmental, self-inflicted etc

• The cause affects pt’s decision about controllability, coping and adaptation to disease

• Other people may have different attribution about the cause e.g. obesity is due to genetics instead of diet

If patients believe causes are controllable, they are more likely to engage in health-promoting behaviours.

It refers to whether patients believe disease management is primarily their responsibility (internal) or dependent on professionals (external).

• e.g eating healthy by their own (internal) or following a diet chart from a dr (external)

• High level of internal control can > personal blame if illness is uncontrollable

A tendency to attribute outcomes to internal factors, often associated with a belief in personal control.

• People likely to believe that things are in their control

A tendency to attribute negative events to internal, stable, and global causes.

• This is characteristic of depression and risk factor for physical illness as it may be related to low immune function

It reinforces feelings of helplessness and hopelessness, which are characteristic of depression.

Pessimistic attributional styles are associated with stress, poorer immune function, and increased risk of illness.

Health campaigns aim to shift attributions (e.g., increasing perceived controllability) to encourage healthier behaviours.

• Clinical communication encompasses verbal, non verbal, written

• Occurs between HCPs, HCP-patient, HCP-family

• Fundamental com skills = active listening, ask questions, give info, empathy, rapport, right language, paralinguistics (tone, pitch, pause, speech, facial expression, body language)

Knowledge

• of disease, Rx options, side effects, FH, patient hx etc

Skills

• clinical skills, handling uncertainity, clinical reasonning, MDT, breaking bad news etc

Character

• Respect patient autonomy, value diversity, show integrity, honesty, be non-judgemental, aware of uncounscious bias, make patient feel heard

• Unconscious bias is bias that we are not conscious of, but it still actively influences our interactions with others.

• Mutual attentiveness - being interested and focussing on what the patient is saying

• Positivity - conveying warmth and compassion

• Coordination - listening to the patient and mirroring (subtly mimicking the language, tone and facial expressions of the patient to create a sense of alignment). This leads to increased trust and better communication overall.

Doctor ows patient a duty of confidentiality when pt discloses information to doctor which they regard as secret or confidential.

-> Dr undertakes duty not to reveal this info to anyone who doesnt already possess it.

• Declaration of Geneva - ‘I will respect the secrets that are confided in me, even after the patient has died’

• GMC - ‘Trust is an essential part of the doctor-patient relationship and confidentiality is central to this’.

• BMA - ‘Patients must be able to expect that information about their health which they give in confidence will be kept confidential unless there is a compelling reason that it should not be’.

1. Non-maleficence - Disclosure > potential harm

2. Autonomy - requires security, self-determinatio

3. Beneficence - Its rare that breaching confidentiality would be in their best interest

4. Justice - is it fair? is it acceptable that in order to access healthcare, pt have to divulge personal info to broader society?

“A duty of confidence arises when one person discloses information to another (e.g. patient to clinician) in

circumstances where it is reasonable to expect that the information will be held in confidence. It –

a. is a legal obligation that is derived from case law;

b. is a requirement established within professional codes of conduct; and

c. must be included within NHS employment contracts as a specific requirement linked to disciplinary procedures.”

Note: Utilitarian and virtue ethics also favors confidentiality

“if information is given in circumstances where it is expected that a duty of confidence applies, that information cannot normally be disclosed without the information provider’s consent.

• In practice, this means that all patient/client information, whether held on paper, computer, visually or audio recorded, or held in the memory of the professional, must not normally be disclosed without the consent of the patient/client.”

An indivisual can sue in the civil court for breach of confidentiality. To establish a legal breach:

• The information disclosed must have the quality of confidentiality

• The information must have been gained in confidential circumstances

• The plaintiff must show that there was unauthorized use of the information

Successful suits also show that harm resulted from the breach

The breach does not have to be deliberate

Confidentiality is not absolute, and may be breached (with patient consent) in situations:

• Referrals, research, publications (pictures), teaching and third party request (insurance company)

Can be breached without patient consent:

• Disclosure required by the law, or it is in public interest

• Public health act: Notification of infectious disease *

• Disclosure to court if ordered by judge *

• Abortion regulation - TOP must be notified to cheif medical officer *

• Reporting death, major injuries, accidents needing more than 3 days off work

• Road traffic act - RTA to police ? driver commited traffic offence

• Terrorism act - to prevent act of terrorism *

• NHS Act - NHS counter-fraud investigation

• Medical act - GMC can access patient records when assessing Dr’s fitness to practice

This act covers all healthcare records of living person, brings GDPR to UK law.

Personal data should be: *

• Processed lawfully, fairly, and transparently.

• Collected for explicit specified and legitimate purposes.

• Adequate, relevant, and limited to what is necessary.

• Accurate and, where necessary, kept up to date.

• Kept for no longer than necessary.

• Protected against unauthorised or unlawful processing and accidental loss, destruction or damage.

Some data must be handled extra careful under GDPR rule:

• Data revealing race, ethnic origin, political opinion, religious beliefs, trade union membership.

• Genetic data, biometric data, data concerning health, sex life and sexual orientation

NHS is the owner of medical records, and patients have a right to access their records through a Subject Access Request.

However, this information may be withheld if:

• It is believed that disclosure would likely cause serious physical or mental harm to the individual or another person.

• The records contain information related to a third party.

• unsure of the identity of the person seeking the info

  
  

SARs can only be made for living person, but relatives can also view the records under ‘Access to health record act’

Caldicott Guardians

The caldicott principles:

1. Justify the purposes for using confidential information.

2. Use confidential information only when it is necessary.

3. Use the minimum necessary confidential information.

4. Access to information should be on a need-to-know basis.

5. Those with access should be aware of responsibilities.

6. Comply with the law.

-> An organisation of beliefs, feelings & behavioural tendencies towards significant objects, groups, events or symbols

-> Psychologically, a predisposition to evaluate something in a favourable or unfavourable manner

Developed by Rosenberg & Hovland (ABC)

• Affect: A person's feeling/emotions towards the attitude object. e.g fear of spider

• Behavioural: The way these feelings influence our behaviour. e.g avoid spiders if they see

• Cognition: The person's knowledge or belief about the attitude object. e.g believes spiders are dangerous

Note: Attitude object = things someone makes judgement about or has feeling towards

• Implicit attitude can affect Dx, prescribing & patient communication.

• It bridge gap between internal needs and external environment

• Four main functions - knowledge, value expression, adaptation & ego-defence

Formed through own experiences and can be learned through:

• Biological factors

• Social learning - from family or people around

• conditioning - according to +ve or -ve reinforcement during development

• Direct experience - +ve/-ve

• Social norms - group of people hold same attitude

• Analysis by LaPiere and Wicker concluded that attitude and behaviour are weakly associated = people are less likley to out attitude into action & apply it to their behaviour

• Theory of planned behaviour by Azjen - the stronger a person’s intention to perform a behavior, the more likely they are to execute it, provided they have sufficient control over the behaviour

  • Core compoents: attitude towards behaviour, social norm/pressure and perceived control

  • e.g If student belive studying hard > passing, if his family/society also encourage him and he has the ability & resources to carryout

• When the attitudes are formed through experience.

• When there are fewer potential barriers towards behavioural change.

• Attitude is repeatedly expressed, strong & firmly held.

• When measured in specific settings and contexts.

Patient attitude can influence:

• Adherence to lifestyle advice.

• Concordance with treatment.

• Engagement with non-pharmaceutical interventions.

• Uptake of screening tests.

• Willingness to attend appointments.

Doctor attitude can influence:

• Diagnostic decisions

• Threshold for referral or treatment

• Treatment options offered

Cognitive Dissonace (Festinger)

• feeling of discomfort when holding conflicting beliefs (e.g smoking when knowing its bad) - to reduce discomfort they change the attitude or behaviour > healthier choices

Self-perception (Bem)

• Traditionally - attitude determines behaviour

• Bem - behaviour determines attitude. e.g. goes to gym (change in behaviour) then realise they enjoy it (change in attitude)

Persuasive communication (Hovland)

• Attitude change occurs in stages - attention > comprehension > acceptance > retention > action

• Depends on source of communication, the message & the audience. E.g. Likely to change attitude if a knowledgeable person gives a quality message to the right audience

Social influence

• Compaigns / add

• ASK about smoking - Identify and document tobacco use

• ADVISE to quit smoking - In a clear, strong, and personalised manner.

• ASSESS willingness to quit - Determine if they are ready to attempt to quit.

• ASSIST patients in their attempts to quit - Leaflet, referrals to counselling.

• ARRANGE follow-ups - Schedule a follow up, after quitting.

“A widely shared assumption about the personality, attitude or behaviour of a person based solely on their group membership”- Hogg and Vaughan

• Belief that all/most members of a group share a specific trait.

• Can be positive but usually negative.

• Widespread agreement about the content of the stereotype.

• Usually incorrect and based on sweeping generalisations.

Social group to which a person does / does not psychologically identify as being a member.

• Out-Group Homogeneity effect:

  • People perceive out-group members as the same.

• In-Group Differentiation Effect:

  • People tend to perceive in-group members as distinct.

-> Can be either explicit or implicit

• Implicit stereotypes - unconscious, automatic associations about groups of people. Identified by implicit assoc. test

• Explicit stereotypes - conscious, deliberate beliefs about those groups

-> Implicit association test = speed at which one classify images linked to subconsious thoughts about them are.

• ‘Kernel of truth’ = Stereotypes made by generalisations which may hold tiniest bit of truth.

• Socialisation = receiving info via culture e.g. family, friends, TV, internet, media

• Illusory correlation - assuming a correlation between 2 rare instances .

• ‘Kernel of truth’ 

  • Stereotypes made by sweeping generalisations which may hold the tiniest bit of truth.

• Socialisation:

  • Receiving information via culture, such as: Family, friends, TV, Internet and the media.

• Illusory correlation (Hamilton):

  • Assuming a correlation between two rare instances.

• Reinforced by conformation bias and identifying exceptions.

This model proposes that stereotypes are formed along:

-> Warmth = stranger’s intention to help / harm them

-> Competence = Stranger’s capacity to act on the intention.

This creates 4 types of stereotype:

-> Cognitive function

• It simplifies & systemise information about the world.

• In the absence of info - its more easier to retrieve

• It reduces processing time & increase reaction time

-> Affective function

• may be used as self-esteem booster

-> Social function

• Allows learning wihtout first-hand experience and may justify violence or discrimination towards outgroup ppl.

• Person is categorised as belonging to a group (implicit or explicit) > stereotypes associated with that group is automatically activated

• Can be overridden consciously by the person placing them if motivated

• Can affect our expectation of others & ourselves

• Affect social perception & behaviour > deflection of a responsibility & scapegoating

• Lead to prejudice, stigma & descrimination

• stereotype threat = person feels anxious / concerned that they may confirm a neg stereotype linked to their ingroup > negative impact on performance. But it can boost the performance in some cases.

Via education, the media, counter-stereotypes and ‘Contact hypothesis’ (Allport)

• Equal status, common goals between groups.

• Support each other’s laws and customs.

• Imagined contact/ e-contact.

• Imagining a positive outcome with a group member, will lead to a more beneficial outcome.

Values are beliefs about what is important and how things should be.

• Important determinants of behaviour (esp subconscious)

• Honesty, probity, reliability, and responsibility.

• Respect for others, integrity, and empathy.

GMC best medical practice

-> Care of patient the 1st concern

-> Good standard of care, work with competence

-> Work in partnership with patient

-> Treat collaegues with respect

-> act with honesty and open when things go wrong

• Whole-person care

• Respect for people’s intrinsic value

• Considering others’ perspectives

• Suspending judgement

• Recognizing universality - finding common ground, humility in the face of shared humanity

• Relational focus

They guide decision-making, influence behaviour, and shape interactions with patients.

Professionalism is the adherence to ethical principles, behaviours, and values expected of a doctor.

The hidden curriculum refers to the informal, unspoken values and behaviours learned through the culture of medical practice.

It may promote behaviours such as detachment or hierarchy that contradict values like empathy and respect.

Explicit professionalism

• Fully internalising and consistently applying professional values in behaviour (respect & honesty) -consciously & subconsciously

cognate professionalism

• Being aware of professional values but only applying them when consciously thinking about them.

Tacit professionalism

• Adopting unspoken values from the medical environment rather than formal teachings - “hidden curriculum”

Hidden curriculum - A position of self-interest, with values based around objectivity, detachment & wariness (Coulehan & Wilson).

• loss of idealism and acceptance of hierarchy (Sinclair)

• neutralization of emotions (Hellman)

• detachment and entitlement (Coulehan & Wilson)

It has shifted from a paternalistic model to a patient-centred model.

• ‘Old’ - Where doctors make decisions for patients with little patient input.

• ‘New’ - A model where doctors and patients collaborate, considering patient preferences and values.

High workload, stress, and lack of support can negatively impact professional behaviour.

Stress and pressure reduce capacity for empathy and reflection, increasing likelihood of poor behaviour.

They promote positive values, guide professional development, and shape identity.

They may reinforce negative behaviours from the hidden curriculum.

It promotes detachment and conflict between personal and professional values, leading to stress.

Desirable value or trait lay between 2 undesirable extremes

You become fit to practice by practicing the professional virtues and applying them to everything you see and do

The process by which death is treated as a medical event managed by healthcare professionals rather than a social or cultural process.

• Place of death is now the hospital instead of home.

• Decreasing importance of religious rituals.

• Increased taboo on death as society values youth and health.

-> Biological death = end of the biological organism = the physical end of life

-> Social death is the loss of social identity and relationships before physical death. e.g terminally ill / AIDS

Individuals may be socially withdrawn, excluded, or lose roles and identity before they physically die.

Lawton

·       Retirement - ceasing full participation in active society.

·       Body can no longer be controlled, bed-wetting, soiling.

·       Loss of autonomy - Moving into institutional care.

·       Dying person wishes to say goodbye to family and friends.

He distinguished between biological and social death, showing that death is a multidimensional process.

• describe death as less than a single event, but rather one with multiple dimensions. 

Traditional, modern, and postmodern death.

A personalised approach involving hospice care, diverse practices, and emphasis on individual preferences.

The extent to which patients, staff, and relatives are aware that a person is dying.

• Closed awareness - Only staff is aware

• suspicion awareness - Patient suspects but not been told

• mutual deception - Both know but don’t talk about it

• open awareness- both know & openly talks about it. Relative may or may not know.

It allows honest communication, informed decision-making, and emotional preparation.

People die at different paces; unexpected developments can lead to conflict and distress. ypical illness trajectories:

• Gradual slant: Long, slow decline in health.

• Downward slant: Rapid decline in health

• Descending plateaus: Periods of decline followed by stabilisation, then repeats.

• Peaks and valleys: Remission and relapse, gets better then worse.

Denial, anger, bargaining, depression, and acceptance.

• Denial: Denying that they are dying.

• Anger: Angry that they are dying.

• Bargaining: With God or doctors, ‘if I stop smoking, I may survive’.

• Depression: Feeling helpless and defeated.

• Acceptance: Almost at peace with the struggle

Individuals may move between stages in different orders or revisit stages over time.

• Advantages:

  • Helps those in a supportive role understand how the person is feeling and why they may respond differently, like wanting support or pushing people away.

• Disadvantages:

  • When used prescriptively. There is a rush towards acceptance and moving on.

A death that aligns with the patient’s preferences, dignity, and personalised care needs while they are dying.

Acceptance of death and maintaining dignity and comfort.

Specialised places to provide palliative care focused on comfort, dignity, and quality of life.

Cultural perceptions, lack of awareness, and accessibility issues.

Focus on quality of life, patient autonomy, symptom control, and support for families.

• Dying is acknowledged as part of life.

• Dying people can/ should be enabled to live as well as possible.

• A dying person should have the privilege of autonomy.

• Support of the family/ bereaved is also important.

• Focus is to improve the quality of life, which may be more important than the quantity of life.

• Enabling ‘good deaths’ for patients. 

• Bereavement: A situation of those who have experienced significant loss.

• Grief: The range of emotions felt by the bereaved.

• Mourning: The visible signs of grief or the period in which grief happens. e.g wearing black

Those bereaved can be at a greater risk of many things, such as:

-> Increased risk of depression

-> Social isolation

-> Self-harm

-> Alcohol misuse

Due to social inequality, people from poorer or ethnic backgrounds may be less aware of palliative care services available. This can lead to:

• Financial impact, especially on women, adding to grief and distress.

• Lack of support in interaction with statutory services and bureaucracy (making sure bills stop when a person passes).

• Lack of support from employers, and the ability to take leave.

• Lack of cultural competence by care providers due to less people from ethnic backgrounds accessing services.

Provide a roadmap for navigating grief + find healing.

-> Accepting the loss,

-> working through grief,

-> adjusting to life without the deceased, and

-> maintaining a lasting connection with the deceased.

• Treating, curing, and averting death.

• Breaking bad news

• Symptom control

• Discussing patient wishes

• Completing death certificates.

Sex = refers to biological characteristics such as chromosomes (XX,XY), reproductive anatomy and biological function

gender = refers to the social and cultural interpretation of an individual’s sex

Gender role refers to Behaviours, attitudes, values, and beliefs which society expects and considers appropriate to males and females.

Widely held beliefs about psychological differences between males and females.

The process by which children learn and adopt gender identity and gender-appropriate behaviours.

Sex is a multidimensional variable which correlates:

Chromosomal sex, gonadal sex, hormonal sex, internal reproductive structures, and external genitalia.

Disorder of sex development - A condition where there is inconsistency between biological aspects of sex, making classification difficult.

• May influence an individual’s gender identity and roles, and the effect on sexual orientation is more complex.

Androgen insensitivity syndrome

• Male develops female external appearance due to androgen insensitivity

Androgenital sydrome

• Female develops male external appearance due to prenatal exposure to high levels of androgens

DHT deficiency

• Males develop female external appearance due to deficiency of 5-alpha-reductase.

chromosomal abnormalities

• Turner’s (X) - incomplete pubertal development, infertility

• Klinefelter syndrome (XXY) - small testes, infertility

Males and females are biologically programmed for different roles, supported by evidence for structural and functional differences between respective brains. But this is not supported by some human studies:

• Emphathising-systemising theory

• Femist theory

• Biosocial theories

• Sociobiological theories

• Social learning theories

A theory suggesting individuals differ in their ability to empathise (understand others) and systemise (analysing systems) - can impact their social behaviour and roles.

Gender is socially constructed and shaped by societal power structures - e.g. dictated and maniplated by men.

The interaction between biological factors and social upbringing determines their gender identity

• Sociobiological theories - Gender evolved to allow adaptation to the environment. (parental investment > increase chance of survival)

• Social learning theories - Behaviour is learned through observation, imitation, and reinforcement.

Freud’s psychoanalytic theory -> Gender identity develops during the phallic (penile) stage through resolution of the Oedipus complex (attachment of child to parent of opposite sex with agression towards parent of same sex) or Electra complex (girl’s psychosexual competition iwht her mother for possession of her father) .

Children’s discovery that they’re male/female causes them to identify with and imitate same sex models:

• Gender labelling (age 3)

• Gender stability (age 4 – 5)

• Gender constancy (age 6 – 7)

A theory suggesting that children develop gender identity and then organise behaviour according to gender-based schemas.

• Gender identity alone can provide a child with sufficient motivation to assume sex-types behaviour.

The idea that gender roles and identities vary across cultures and are socially constructed.

An individual whose gender identity, behaviour or sense of self differs from their sex assigned at birth.

• It used to be listed as psychiaric disorder by WHO

• Transgenders are more likley to be male and there are specialist psych referrals before surgery can take place

Wearing clothes of the opposite sex without identifying as that gender or for sexual arousal.

• Enjoy cross-dressing to gain temporary membership of the opposite sex.

• Not necessarily related to sexual orientation.

A person’s pattern of emotional, romantic, or sexual attraction to others. Factors that influence it are:

• Genetic, hormonal, neurological, psychological, and social factors. - likley to be combination

Love of the beyond / irregular = abnormal sexual preferences - Atypical and intense sexual interests involving unusual objects, situations, or behaviours. They usually begin in adolescence.

• Fetishism - strong gratificaition for an object/activity

  Exhibitionism - sexual gratification from indecent exposure

  Voyeurism - watching others involved in sex act

  Sadomasochism - pleasure from inflicting pain

  Paedophilia - sexual desire towards children

Paraphilias are persistent / recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature.

Paraphilia alone is not classed as disorder, it need one of:

• When it causes distress

• involves non-consenting individuals

• poses risk of harm / death.

Causes - Early conditioning, social learning, possible biological factors, and brain abnormalities.

Management - Psychological therapies (e.g. CBT) and medical treatments such as SSRIs to reduce libido or hormonal therapy.

Desire, arousal, plateau, orgasm, and resolution.

• It is a complicated response consisting different no of stimuli (cognitive & biological)

Problems of desire, arousal, and orgasm.

• Commonly occurs simultaneoulsy & in combination

• Could happend due to medication side effects e.g SSRIs > reduced libido

Hormonal changes and psychological factors such as stress or depression.

• Lack or loss of desire - common, occur due age, hormones, medical/psychiatric disorders, medications, etc

• Sexual aversion (strong dislike) - This is rare and most who experience this have a history of sexual abuse

• Lack of sexual enjoyment

-> In women - tend to result in lact of subjective excitement + lack of adequate physiological response. Occurs due to:

• Psychological - eg anxiety

• Pathological - eg infections

• Oestrogen deficiency - eg postmenopausal

-> Problem in men is common, increase with age.

• Erectile Dysfunction

• Organic and psychological aetiology

• Change in treatment due to viagra

Ejaculation that occurs earlier than desired, often with minimal stimulation.

In men, problem wiht orgasm tends to occur in one of 3 ways:

• Inhibited orgasm

• Ejaculatory pain

• Premature ejaculation

Involuntary contraction of vaginal muscles that makes intercourse painful or difficult.

A framework for managing sexual problems:

• Permission to talk

• Limited Information

• Specific Suggestions

• Intensive Therapy.

A therapy involving couples working together to improve communication and gradually rebuild sexual intimacy through structured exercises.

• Educated on anatomy / physiology of sexual intercourse

It helps identify issues, improves relationships, and supports effective treatment.

Being empathetic, non-judgemental, using clear language, reassuring patients, asking open questions, and avoiding assumptions.

-> Participation in research is potentially altuistic act = it will benefit the society but may not benefit the patient.

-> consent in reseach must be:

• Voluntary: Up to the patient, due to the presence of subtle forms of coercion. E.g., offering enrolment to someone in dire situation.

• Informed: Patients should be fully informed; however, uncertainty of research must be emphasised.

• Capacity: Patients should have the capacity to make these decisions.

-> trust is very important

• Low quality research, duplicate studies, participants suffering the burden of researc with no clear social benefits

Aggression: Behaviour that is intended to either injure a person or to destroy property. Can be physical or verbal. Must be a conscious effort involved in doing the harmful behaviour.

• Hostile aggression: aggressive action is carried with the sole aim of harming another person (excludes self-defence)

• Instrumental aggression: a premeditated aggressive action that is carried out to achieve a specific goal (includes self-defence)

• Proactive aggression: same as instrumental aggression 

• Reactive aggression: reacting aggressively to a perceived threat.

• Relational aggression: aggression that damages someone’s peer relationships or social status (e.g., social exclusion or rumour spreading). 

Nature vs nurture (psychoanalytic theory vs social-learning

theory)

-> Many of the actions are determined by instincts (sexual)

• Eros: Drive for pleasure and reproduction. (Sexual instinct).

• Thenatos: (Death instinct)

-> When expression of said instincts is frustrated or interfered with, an aggressive drive is induced.

-> Aggression is a basic drive like hunger.

-> Allowing catharsis - the process of releasing, and thereby providing relief from, strong or repressed emotions

Freud’s theory equates our personality to three elements:

• Id - Impulsive & unconscious > respond immediately to our desire > shout / swear back

• Ego - rational self > represses the Id’s aggressive impulse > people may sare if i shout > glare instead of shout

• Super Ego - ideal image of oneself > ‘its not right to shout at someone’

• Aggression is always consequence of frustration

• Existence of frustration always lead to some form of aggression

Revised frustration-aggression hypothesis:

• Frustration produces anger rather than aggression.

• Frustration is psychologically painful, and anything that is psychologically or physically painful can lead to aggression.

• For anger/psychological pain to be converted into aggression, cues are needed, such as environmental stimuli.

Weapons effect: Viewing weapons are more likely to cause anger, which becomes aggression.

Ethological perspective - by Lorenz

• Aggression is the fighting instinct in beast / man - directed against the members of same species

• Important in evolutionary development of species as it allows individual to adapt to the environement > survival > reproduce successfully.

Social learning theory - by Bandura

• Assumes that we dont have innate aggressive drive, instead its learned as part of maturation

• Aggressive behaviours are learned through reinforcement and the imitation of aggressive ‘models’.

• They occur through observational learning, rewards / punishments, social & environmental factors .

Suggests that aggression is a result of the personality and interaction of the person in the situation.

• When certain group or anonymous situations > reduction in salience of one’s personal identities and sense of public accountability.

• In doing so > aggressive or unusual behaviour

• Affected by group size or anonymity

-> It's like when you're in a crowd and you feel like no one knows who you are, so you might do things you wouldn't do if you were alone or if people could see you clearly.

Experiments done to test how obedient volunteers were taking orders.

• Teachers tasked with shocking students if they get Q wrong

• It showed that in certain situations, people will obey harmful instructions and may feel obedience when they see its their supervisor’s responsibility and not theirs.