STUDENT NO:

People, Patients and Populations

Mock Exam Paper: December 2010



This mock exam paper is intended as a self-assessment document. Please complete it prior to the SGT
on 15
th
December 2010, when the answers will be discussed.
STUDENT NO:



Scenario: Siddika Towheed

Siddika Towheed, 40, has made an appointment to see her GP, Dr Stevens. Mrs Towheed has been a
patient at this practice for 19 years, since moving to the UK from Sylhet in Bangladesh following her
marriage.

She put on weight steadily after coming to this country and was diagnosed as a diabetic when she was
30. Her diabetes has been controlled mainly through diet modification. Diabetes runs in the family and
2 of her sisters also have also been diagnosed. Mrs Towheed finds the diet hard to stick to because
the home is above the family business, a balti restaurant, and for convenience the family will often
eat the restaurant food, which can be quite rich. The practice nurse suggested joining the gym, but she
feels she has no one to go with. Several people have given her leaflets in Bengali about diabetes but
she cannot read the language and is reluctant to tell people this.

Recently her diabetes has been getting worse. She has been getting very thirsty, goes to the toilet more
frequently and has had recurrent vaginal thrush. Her feet are often swollen and tender, especially after
an evening helping out in the restaurant kitchen. As a Muslim she has also found fasting for Ramadan
difficult in the winter months. Her optometrist, whose family is also from Sylhet, is concerned about
the state of her eyes and has urged her to consult a GP.

Mrs Towheeds symptoms have been getting so bad that her children have begged her to make an
appointment with Dr Stevens. She is worried about having to explain all this to him. Although she
speaks English reasonably well, she sometimes finds it hard to explain symptoms to a doctor. She has
taken her oldest son along in the past to translate, but feels with the thrush it would be too
embarrassing for him.

Her friend has had to go on injected insulin to manage her diabetes. Mrs Towheed is very anxious that
the GP will suggest this, as she is terrified of needles following bad experiences in the past.

The GP cannot speak Sylheti or Bengali and he is also concerned to see she has not attended for over
six months. Her notes show she is not particularly well controlled. At the time of appointment she
does not attend, which the GP dutifully records in the notes. In truth, Mrs Towheed made it to the front
door of the surgery but was too nervous to continue inside.
STUDENT NO:

SECTION 1 (Sociology)
Medical Sociology (25 marks in total)

1. How is Mrs Towheed representative of the clinical iceberg? (5 marks)

The clinical or symptom iceberg refers to the large proportion of the population in need of
medical care but not consulting their doctors or seeking medical treatment, largest part of
an iceberg is under the water. about her medical problems and is therefore under the water.













2. Mrs Towheed is reluctant to visit the doctor. Can you give 4 reasons why she might be
reluctant? (4 Marks)

thrush. She may also be reluctant to visit because she is poorly compliant with the diet
modification regime imposed because of her diabetes. She may also worry that as English is
not her first language, she may have difficulty in understanding the doctor and in expressing
herself to him. She is also worried about potentially new treatments such as injected insulin.
She may also have possible worries over not having attended the doctors for such a long time.




















CONTINUED.
STUDENT NO:
SECTION 1 (Sociology)
Medical Sociology (25 marks in total)


3. Sociologists have formulated other reasons why people do not consult can you think of 3
other reasons, not included in this case, why people fail to consult GPs?
(3 x 2 marks = 6 marks)

Access to GP practices may be a barrier to consulting if people do not have access to a
car, or the practice location is not served well by public transport for example, or at a
distance from the patient. Rural patients have lower consultation rates than those living in
urban areas.
In urban areas many patients attend A and E departments, especially out of hours rather
than consult a general practitioner.
Those who are homeless and or in temporary accommodation may find it difficult to
register with a general practitioner.
Recent migrants often fail to consult because they do not understand or have little
information on how the NHS works.
Surgeries may be at inconvenient times, during working hours for example or clinics
arranged on the holy days of specific faiths. We know that the unemployed are more likely
to consult than those employed.
The appointments system may provide an insurmountable barrier for many people,
particularly if the only time to make an appointment is in the morning during commuting
or school run times.
Men are also less likely to consult than women.
Some people will be willing to try complementary therapies or traditional medicine before
consulting general practitioners Chinese people have lower consulting rates than other
groups because of this.


4. Please outline psychological and sociological factors that impact on Mrs Towheeds diabetes
and its poor control. (10 marks)

Mrs












wrong. Cultural and religious reasons, such as fasting for Ramadan, may mean that her
control becomes poorer during that period of the year.




SECTION MARKS: 1=25
STUDENT NO:
SECTION 2

Scenario: David Crouch

David Crouch is a 55-year-old plumber from Stirchley in Birmingham. For the last five years or so he
has had painful twinges in the top right of his groin, particularly when he coughs or lifts heavy
equipment. He usually has adapted his behaviour by avoiding heavy lifting at work and at home. He
has sometimes noticed a bulge where the pain is, but this tends to go away and he would rather not
think about it.

He dislikes going to the GP in general and uses over-the-counter medication when he feels ill. He
smokes 20 cigarettes a day and knows he will get it in the neck if he makes an appointment. He also
likes a few drinks in the local pub but wouldnt class himself a drinker. He doesnt know whether he is
over the recommended number of units a week or not. His wife usually makes appointments for him
and tries to get him to go to the doctors more often. He has been nagged into several check-ups with
the Practice Nurse over the years, which usually end up with banter about his smoking but he has not
told her about his twinges, partly because he doesnt want a woman examining his groin area.

His wife attends the GP frequently and has mentioned her worries over her husbands condition. The
GP advised her to tell him to make an appointment but Mr Crouch has always refused to do so until
now. Unfortunately his plumbers mate broke his leg and forced Mr Crouch to carry heavy equipment
on his own. This caused tremendous pain that got so bad he needed a few days off work. As Mr
Crouch is self-employed this meant a loss of earnings. He eventually decided to call the surgery, When
he finally sees the GP, she urgently refers him for hernia repair and is surprised he has never consulted
about this before. He is in fact rather relieved, as he half suspected the lump might be a tumour.
STUDENT NO:
SECTION 2 (Sociology)
Medical Sociology (25 marks in total)


1. What is the lay referral system? (4 marks)

The lay referral system refers to the social mechanism where a potential patient discusses
troubles with neighbours, friends, and fellow workers in a casual way and explores alternative
explanations for the way she is feeling. She may seek advice from others as to whether she
should seek medical care and from whom.













2. How does the lay referral system work with Mr Crouch? (4 marks)

Mr Crouchs wife is his prime source of lay advice and to the extent that she makes his
appointments with the doctor for him. The advice she gives him on consulting is informed by
her own conversations with the GP about her husbands health.


























CONTINUED..

STUDENT NO:
SECTION 2 (Sociology)
Medical Sociology (25 marks in total)


3. How do sociological and psychological factors impact on Mr Crouchs health regarding the
pain in his groin and his consulting behaviour? (8 marks)

Like many men, Mr Crouch is reluctant to see a doctor. Mr Crouch has modified his
behaviour so that the pain will not affect his job and therefore not lifting heavy equipment has
become a coping strategy for him. The pain is also in the potentially embarrassing area of the
groin and he may not wish to be examined there, particularly by a woman. If he knows he is
likely to see a female GP he may therefore be less likely to consult. Mr Crouch has also put off
going to the doctor for several other reasons: he dislikes being told off about his smoking and
drinking behaviour by the practice nice and may expect another lecture from the GP about
this; his worry over a tumour manifests itself in issue avoidance; he prefers the convenience of
OTC (over the counter) medications.














4. Zola mentions 5 factors, which trigger patients to consult. Which of Zolas triggers would be
most appropriate in Mr Crouchs case? Please provide context from the case. (4 marks)
Zolas 5 triggers are: perceived interference with vocational/physical symptoms and
sanctioning.
In Mr Crouchs case it seems that the pain interferes with a physical activity to such an extent
that he can no longer carry out his job effectively which had led to loss of income. The
temporary loss of his co-worker has meant his coping strategy of not lifting heavy equipment
is not viable.




CONTINUED..
STUDENT NO:
SECTION 2 (Sociology)
Medical Sociology (25 marks in total)


5. Mr Crouchs attitude towards his health is very different from his wifes. What do we know
about the relationship between gender and health? (5 marks)

Men of all ages have higher death rates and are less likely to consult than women, which can
be partly explained by consultations for contraception, maternity care and menopause.
Mainly because of reproductive reasons womens lives have in a way mens lives have not. It
has also been noted that womens magazines are more likely to focus on health issues than
men, and women in general are more at ease discussing health issues in their close social
networks than men are. Women, particularly mothers, play an important role in the lay
referral system and single young men who live at home are more likely to consult than those
who live away.














SECTION MARKS: 2=25
STUDENT NO:
SECTION 3 (Psychology)

Scenario 3

Lisa has been feeling run down for some time and feels very stressed at work and home. Lisa decides
to visit her GP, as she seems to be experiencing a churning sensation in her stomach and is frequently
visiting the toilet. Lisa is also having difficulty sleeping and has lost her appetite.


1. List four key life events that may adversely affect individuals health? (2 marks)

Examples of main life events
Death of spouse or other close relative Divorce
Moving house Pregnancy
Sexual difficulties Jail term
Retirement The sack
Marital reconciliation Personal injury or illness
Change in health of family member

2. How do the biomedical and biopsychosocial models differ? (2 marks)

Biomedical -

conditions (e.g. cultural influences, social support)
Patient is not seen as a passive victim and is encouraged to take responsibility for their health
All physical signs are experienced via psychological processes
Helps to explain variations in health - e.g. "illness or a problem of living

3. According to the General Adaptation Syndrome (Selye, 1976) how are stress and illness
related? (6 marks)

Three phases
Stage 1: Alarm reaction - mobilises resources
Stage 2: Resistance - cope with stressor
Stage 3: Exhaustion - reserves depleted and the bodys resistance to stress can only last so
long before exhaustion sets in.













SECTION MARKS: 3=10


STUDENT NO:
SECTION 4


Scenario 4

J ohn has come to see you, his GP, for advice about his health. J ohn has been drinking and smoking
heavily for several months as he has been feeling under pressure at work. J ohn often goes out to the
pub with his colleagues at lunchtime and after work; he rarely eats healthy food or takes regular
exercise these days.

1. J ohn appears to be drinking heavily throughout the day. Give two other commonly health
impairing behaviours that may damage a persons health. (2 marks)






2. According to the health belief model what factors are important in determining a persons
readiness to take health action. (8 marks)

Main factors:



























SECTION MARKS: 4=10


STUDENT NO:
SECTION 5 (Ethics & Law)


Short Answer Question:

Dr Lowe is the medical director of a NHS nursing home for the elderly. The residents of his home are
unable to care for themselves and many of them suffer from varying degrees of dementia. Dr Lowe
wishes to treat his patients with a new drug that slows down the degenerative process of senile
dementia.

1. Briefly describe each of the four elements of consent, with reference to the above case.
(10 marks)

(i) Information- In order for patients to make an autonomous decision about medical
treatment they need to have the relevant information

Ethically, in order for patients to make a real choice about whether or not to
undergo the proposed treatment, they not only need to know about the suggested
treatment but also information about any alternatives (i.e. to tell the truth).

Legally, the law of battery provides that a patient needs to know about the
proposed treatment in broad and general terms.

(ii) Decision-making. Therefore, patients may need to be reassured that any refusal to
consent to the medical directors suggestions, will not affect their treatment generally in
the nursing home.


(iii) Decision: Yes or No?
Each competent individual would have to make a decision about whether they wished to
receive the new drug or not; acquiescence would not be sufficient.























CONTINUED..


STUDENT NO:
SECTION 5 (Ethics & Law)


Extended Matching Set and Multiple Choice Questions:


2. When is a child Fraser/Gillick competent?

A: A child is Fraser/
A: A child is Fraser/Gillick competent if they are generally mature and intelligent for their age
B: A child is Fraser/ Gillick competent if they have sufficient maturity and intelligence to fully
understand the nature of this particular treatment and make a decision
C: A child is Fraser/Gillick competent if the medical treatment is in their best interests
D: A child is Fraser/Gillick competent if they can make a decision about whether they want the
treatment or not
Answer: B




3. Complete the following statement: A parent of a child who is Fraser/Gillick competent
to make a decision about a medical treatment :

A: Will not be able to overrule any decisions that child makes about the medical treatment
B: Will be able to overrule all decisions about the medical treatment that are made by that child
C: Will be able to overrule their child' refusal to medical treatment but not their consent
D: Will be able to overrule their childs consent to medical treatment but not their refusal


B: Will be able to overrule all decisions about the medical treatment that are made by
that child
The GMC advise doctors that they may disclose confidential patient information in 7 circumstances.
The following statements include the 7 correct circumstances identified by the GMC:

A. Disclosure with the patients consent
A. Disclosure with the patients consent
B. Disclosure within health care teams
C. Disclosure with the next of kins consent
D: Disclosure in the patients medical interests
E. Disclosure in the public interest
F. Disclosure after the death of the patient
G: Disclosure in connection with legal proceedings
H. Disclosure in accordance with statutory requirements
I. Disclosure for the purposes of teaching, research or audit.

Disclosure within health care teams
C. Disclosure with the next of kins consent
Select from the list above, the most appropriate justification advocated by the GMC for disclosure of
confidential information, for the following case:


CONTINUED..
STUDENT NO:

SECTION 5 (Ethics & Law)

4. Miss Frost is buying a house and her mortgage company insist on her having life
insurance cover along with her mortgage. Miss Frost, in order to obtain life insurance,
fills in a medical questionnaire. After reading Miss Frosts answers to the medical
questionnaire, the insurance company write to her GP, Dr Soaper, asking for
clarification to a number of questions. Dr Soaper wants to be able to disclose the
information so as to help Miss Frost get her mortgage. (SELECT 1 JUSTIFICATION)



Failure to tell the truth patients can take a number of different formats:

A. Involuntary Deception
B. Voluntary Deception
C. Intentional Deception
D. Unintentional Deception



Choose what type of deception occurs in the following cases, from the list above:



5. Chi Chan attends clinic for the results of a blood test to detect whether his leukaemia has
responded to treatment. Dr Raj tells him that there is a good response, even though the
response is marginal, at best. (SELECT THE MOST APPROPRIATE STATEMENT)

Answer: C


6. Mr Davies overhears a receptionist talking with a doctor about a chest x-ray result. As
Mr Davies has just been to the hospital for a chest x-ray, he assumes it must be his they
are discussing. (SELECT THE MOST APPROPRIATE STATEMENT)












CONTINUED..









STUDENT NO:
SECTION 6 (Public Health)


True/False (6 Marks)

1. Lung cancer has overtaken breast cancer as the most important cancer cause of death in this
country. (T)
2. Hospital episode statistics provide a reliable guide to the number of cases of asthma in the
community (F)
3. Death certificates are a good source of information on the prevalence of diabetes (F)
4. England and Wales use the International Classification of Diseases (ICD) as the basis for
classifying mortality (T)
5. Developed countries tend to have triangular-shaped population pyramids (F)
6. Secondary prevention aims to prevent the onset o disease (F)



Short note question: (16 Marks)

1. What is primary prevention? Please illustrate with an example. (6 marks)

Model answer

Primary prevention aims to prevent the onset of disease, for example encouraging smokers to
quit, encouraging the general population to reduce the saturated fat content of their diet and
to increase their fruit and vegetable consumption.







2. List 4 diseases that physical activity can help to prevent. (4 marks)


Model Answer

Physical activity can help to prevent:

Physical activity intervention that could be implemented by the NHS:













CONTINUED..
STUDENT NO:
SECTION 6 Continued. (Public Health)


3. Describe one intervention to increase physical activity that can be implemented by each of the
following (6 marks)

(i) The NHS

Model Answer

Practice nurses can weigh patients, take an exercise history and encourage them to
increase their physical activity. They might consider finding out what sorts of physical
activity the patient has undertaken in the past, setting goals, making a follow-up
appointment to increase motivation, providing information about group-based
activities such as exercise classes, led walks etc.




(ii) Local Authority

Model Answer

Local authorities can run sports activities for school children after school or in the
holidays. They might subsidise the cost of the classes, located them, or promote them
in disadvantaged communities. Alternatively they might consider improving street
lighting in areas.





(iii) The Government

Model Answer

The Government can legislate to make the cost of driving higher by for example,
increasing the tax on petrol, introducing road pricing, taxing work-based car parking.