Year GEP 1 GEP/HSPH: Human Sciences and Public Health

Lecture: Introduction to HSPH

1. Understanding key requirements of the course
2. Participation in PBLs- e-learning tool
3. Link to previous work in communication skills- the doctor's and the patients' agenda

Lecture: The Epidemiological Approach

1. Understand how epidemiology and clinical medicine are related
2. Explain briefly the two main methods of investigation in epidemiology: the cohort study and the case-control study.
3. Describe the complementary roles of nature and nurture.
4. Describe how different methods of prevention and treatment can be combined

Lecture: Interpreting Data

1. Evaluate if this intervention should be adopted.
2. Be aware of the impact of sample size on uncertainty
3. Why is a critical appraisal of a trial performed and why do we ask the questions we do?
4. Perform a critical appraisal on this paper and interpret its results.
5. Define the terms: Randomised, primary outcome, intention to treat analysis, data & safety monitoring committee, hazard ratio, current controlled trials number, ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI), refractory Angina
6. Be able to calculate and interpret risks, odds, rates and their ratios and differences
7. What is a confidence interval and P value?
8. Be able to describe and interpret confidence intervals for relative risks and odds ratios
9. Have practical experience of calculating risks, odds, rates and their ratios
10. Understand the properties of the Gaussian distribution.
11. Understand the difference between standard deviation and standard error.
12. Have practical experience of calculating and interpreting ranges and confidence intervals for data with a Gaussian distribution
13. Understand what p-values are and be able to interpret statistical significance
14. Be aware of the relationship between P values and confidence intervals.

Lecture: Randomised Control Trials

1. Explain why meta-analyses are undertaken.
2. Interpret the results from a clinical trial and assess how applicable they are to a patient you may be treating.
3. Explain the importance of the following features of clinical trials: randomisation, controls, blinding, and placebo.
4. Define intention to treat analysis, loss to follow-up and compliance.
5. Explain why intention to treat analysis is often used.

Lecture: Cohort Studies

1. Distinguish between the terms relative risk, absolute excess risk and attributable proportion.
2. Understand the nature of bias.
3. Explain the Bradford Hill criteria for causality and give examples of each.
4. Interpret unadjusted and adjusted results and be able to explain when each is valid.
5. Explain how confounding occurs.
6. Explain how confounding works.
7. Describe the essential structure of cohort studies
8. Identify potential biases in cohort studies
9. Interpret the results from cohort studies including survival analysis
10. Interpret unadjusted and adjusted results and explain when each is valid.

Lecture: Case Control Studies

1. Describe the essential structure of case-control studies including nested case-control studies.
2. Identify potential biases in case-control studies
3. Interpret results from case-control studies and distinguish between the terms odds ratio, absolute excess risk and attributable proportion.
4. Detail when each of cross-sectional, case-control, cohort and randomised controlled trials are appropriate research studies.

Lecture: Poverty and Nutrition

1. Describe self-management as a model of health care in the management of chronic illness.
2. Understand the patient's role in managing their illness.
3. Review the effectiveness of self-management using behavioural interventions as exmaples.
4. Describe ways clinicians can facilitate self-management.
5. Outline the biopsychosocial model of disease.
6. Describe the relationship between social structure and health.

Lecture: Health Improvements- What is it?

1. Can discuss basic principles of health improvement and promotion in practice, including wider determinants of health, health inequalities, health risks and disease surveillance.
2. Use a framework to critically evaluate evidence based decision making.

Lecture: Social Determinants of Health – Inequalities in Health

1. Understand key concepts like class, relative poverty and social exclusion.
2. Review key explanations for health inequalities.
3. Understand key concepts in health inequality.
4. Describe the relationship between social structure and health.
5. Outline policy and interventions aimed at reducing health inequality.

Lecture: Social Determinants of Health- ACE, Chronic Illness and Evidence Based Practice

1. Describe the prevalence of chronic illness and the impact it has on healthcare.
2. Describe the difference between impairment and disability.
3. Understand responses to being diagnosed with chronic illness including biographical disruption.
4. Outline current health policy regarding chronic illness.
5. Use a framework to critically evaluate evidence based decision making.

Lecture: Medical Decision Making

1. Consider the psychology of clinical decision-making.
2. Understand how expert clinicians differ from students in the ways they make decisions.

Lecture: Stress psychology and illness

1. Describe the interactions between psychological, developmental, social and physical processes in wellbeing and disease.
2. Describe the role of interaction between environment and genes.
3. The contribution of psychological factors to specific disease groups/states: e.g. cardiovascular disease.
4. Psychoneuroimmunology: the interaction of behavioural, neural, and endocrine factors and the functioning of the immune system

Lecture: Psychological Therapies

1. Review the evidence base for the use of psychological therapies in general medicine and primary care.
2. Describe how psychological therapies may be used to help patients cope with acute and chronic stress.
3. Describe commonly used psychological therapies and how they are used in general medicine.

Lecture: Domestic Violence

1. Critically appraise the research on inequality in health related to race
2. Define the historical antecedents, theory, distribution, cause, prevention, management and evidence base.
3. Know how to define ethnicity, culture, and racism

Lecture: Connecting Human Rights and Health- Gender and Age

1. Age: Define ageism and age discrimination.
2. Age: Discuss the health and health care needs of older people.
3. Understand the relationship between big picture policies and health outcomes e.g. Violence against women, LGBTI rights, Migration history, Age
4. Gender: Be aware of differential patterns of morbidity and mortality related to gender.
5. Age: Describe different experiences of later life.
6. Age: Outline the differences between biological and social ageing.
7. Gender: Consider different causes for these patterns.
8. Gender: Discuss key health concerns for men and women.
9. Age: Describe changes in the demographics of ageing.
10. Gender: Describe the changing relationship between social structure and gender.

Lecture: Medical Advice and Taking Medicine

1. Understand the size of the problem and non-adherence.
2. Differentiate between intentional and non-intentional non-adherence.
3. Describe beliefs related to non-adherence.
4. Describe ways clinicians can improve adherence.

Lecture: Strategic Essentialism- Categories and Social Medicine

1. Know how to define ethnicity, culture and racism.
2. Identify patterns of ill-health in relation to ethnicity.
3. Review and discuss key explanations for ethnic health differences.
4. Describe the principles of culturally competent health care practice.

Lecture: Professional Identity & Uncertainty - bridging the gap between science and practice

1. Consider working in a multi-disciplinary team.
2. Consider how different disciplines contribute to professional identity.
3. Consider the social formation of professional identity- list possible influences.

Lecture: Biopsychosocial Model of Health

1. Describe how understanding a patient's experience illness may aid diagnosis and care- narrative medicine, arts, humanities.
2. Outline the biopsyhosocial model of disease.

Lecture: Ethics and the Law: Declaration of Helsinki. Legal, moral, ethical responsibilities of patient care.

1. Gaining consent- articulate the rights of patients as regards to refusal of medical interventions.
2. Compare the local standard to acceptable standards elsewhere of information that should be offered to patients.

Lecture: Culture of Medical School

1. To understand the role of the doctor in the context of a multidisciplinary team.
2. To understand how the culture of medical school can impact on development as a doctor.

Lecture: Health Beliefs, Behaviours & Moral Injury

1. To be aware of the importance of health beliefs.
2. To be able to describe factors that influence health beliefs.
3. To understand how health beliefs influence behaviour.
4. To have familiarity with common health belief models.

Lecture: Self-Management - Social Support

1. Self-Management: Understand the patient's role in managing their illness.
2. Self Management: Describe self-management as a model of health care in the management of chronic illness.
3. Social Support: The importance of taking a social history addressing familial, occupational, and recreational aspects of the patient's personal life which have the potential to be clinically significant.
4. Self-Management: Review the effectiveness of self-management using behavioural interventions as examples.
5. Self-Management: Describe ways clinicians can facilitate self-management.
6. Social Support: The two dominant hypotheses linking social support and health: the stress buffering hypothesis and the direct effects hypothesis.
7. Social Support: The role of social support as a protective/risk factor for mortality, as well as mental health, cardiovascular, immune, and endocrine end-points (including incidence, course, prognosis, recovery).
8. Social Support: The nature of social support including social isolation, network size, and perceived and received functional support (emotional support, practical support, informational support).
9. Social Support: Potential psychological, physiological, and behavioural mechanisms by which social support might influence physical and mental health.

Seminar: Refugee Health- Doctors of the World: Anna Miller

1. Describe common physical and mental health problems in this patient group.
2. List common barriers to healthcare faced by this group in the UK.
3. Explain why the UK accepts asylum seekers.
4. Define who qualifies as a refugee under the Geneva Refugee Convention.

CAL 1:

1. Understand the properties of the Gaussian distribution.
2. Understand the difference between standard deviation and standard error.
3. Have practical experience of calculating and interpreting ranges and confidence intervals for data with a Gaussian distribution
4. Understand what p-values are and be able to interpret statistical significance
5. Be aware of the relationship between P values and confidence intervals.

CAL 2:

1. Have practical experience of calculating risks, odds, rates and their ratios.
2. Be able to calculate and interpret risks, odds, rates and their ratios and differences.
3. Be aware of the impact of sample size on uncertainty.
4. Be able to describe and interpret confidence intervals for relative risks and odds ratios.

PBL 1: Critical Appraisal: Randomized Trial of Preventive Angioplasty in Myocardial Infarction

Two cardiologists are trying to decide whether to start performing preventive angioplasty in patients who have just had an MI and have several occluded vessels. Current guidelines recommend infarct-artery-only PCI in patients with multivessel disease, but a recent trial in the NEJM by researchers at Barts and the London suggests that preventive angioplasty should be performed (Randomized Trial of Preventive Angioplasty in Myocardial Infarction. N Engl J Med 2013. DOI: 10.1056/NEJMoa1305520). They wondered how to determine if the trial had been conducted properly. Someone suggests using a critical appraisal tool to assess the paper. 

Abstract

Background

In acute ST-segment elevation myocardial infarction (STEMI), the use of percutaneous coronary intervention (PCI) to treat the artery responsible for the infarct (infarct, or culprit, artery) improves prognosis. The value of PCI in non infarct coronary arteries with major stenoses (preventive PCI) is unknown.

Methods

From 2008 through 2013, at five centers in the United Kingdom, we enrolled 465 patients with acute STEMI (including 3 patients with left bundle-branch block) who were undergoing infarct-artery PCI and randomly assigned them to either preventive PCI (234 patients) or no preventive PCI (231 patients). Subsequent PCI for angina was recommended only for refractory angina with objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. An intention-to-treat analysis was used.

Results

By January 2013, the results were considered conclusive by the data and safety monitoring committee, which recommended that the trial be stopped early. During a mean follow-up of 23 months, the primary outcome occurred in 21 patients assigned to preventive PCI and in 53 patients assigned to no preventive PCI (infarct artery-only PCI), which translated into rates of 9 events per 100 patients and 23 per 100, respectively (hazard ratio in the preventive-PCI group, 0.35; 95% confidence interval [CI], 0.21 to 0.58; P<0.001). Hazard ratios for the three components of the primary outcome were 0.34 (95% CI, 0.11 to 1.08) for death from cardiac causes, 0.32 (95% CI, 0.13 to 0.75) for nonfatal myocardial infarction, and 0.35 (95% CI, 0.18 to 0.69) for refractory angina.

Conclusions

In patients with STEMI and multivessel coronary artery disease undergoing infarct artery PCI, preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery. (Funded by Barts and the London Charity; PRAMI Current Controlled Trials number, ISRCTN73028481.)

The abstract is given above and the full paper and a set of critical appraisal questions are also included in your guide. It is recommended that you concentrate on the information given above in the first PBL and look at the full paper together with the critical appraisal questions when completing your private study.

Link to paper:  Randomized trial of preventive angioplasty in myocardial infarction. NEJM 2013.

Link to critical appraisal questions:  critical appraisal questions

PBL 2: Recreational Drug Use and Testis Cancer Risk

Mr Gordon Pie walks into your upper GI clinic in the Royal London Hospital. Mr Pie is currently a lawyer for a bank in the city, and he specialises in mergers and acquisitions in the biomedical science sector. He is 54 years old, and has a history of poorly controlled reflux. He has been taking omeprazole and Gaviscon intermittently for the last 5 years, and would like to discuss further options. 

You start by talking to him about his history. Mr Pie mentions he has a stressful job, with many late nights, struggles to exercise regularly, eats from restaurants often and admits to drinking alcohol on 4-5 times per week. He has a BMI of 29. You mention that these are risk factors in the development of reflux disease, and he asks what evidence you have for this.

You mention to him that you are running a trial for people with poorly controlled reflux comparing different types of medication. You also mention that he may be suitable for fundoplication, as this might be a better way of controlling his reflux disease as you are unsure of his adherence to omeprazole.

However, Mr Pie is unwilling to undergo surgery as he has read on the internet that there can be significant disturbing side effects. Mr Pie is interested in enrolling for the trial, but has several questions. He wants to know how the trial is regulated, how it is designed, how you know the treatment is safe, how you know the treatment works and how it will affect him.

You explain that the phase 3 double blind crossover RCT is covered by the Declaration of Helsinki/GCP regulations, and has been through successful phase 1/2 trials. You explain how the trial is designed, what the control arm will consist of, and that you are currently at equipoise with this treatment and omeprazole. You give him time to read the PIS and mention you will contact him two weeks later to discuss enrolment.

When you call him, he asks whether not enrolling will have any effect on him, who will be able to access his data, and how he will find out the results. He is thinking of investing in the company if the drug works. 

PBL 3: The Ticking Time Bomb

In this PBL you will be asked to participate in an e-learning tool (The link is posted on the HSPH QMplus page under ‘E-learning Tool’) by imagining that you are a patient who has been diagnosed with Cystic Fibrosis, cardiovascular disease – congenital cardiomyopathy, right sided heart failure and cor pulmonale, bronchiectasis and co-morbidities of diabetes, and chronic pain from in your joints. Current symptoms include breathlessness, heart pain and productive of sputum thick, coloured, tenacious. You are 19 years old.

The e-learning tool will last for three days and take you through the daily routines and dilemmas of being a young patient with Cystic Fibrosis. Your participation and engagement with the e-learning tool will count the same as your attendance at PBL sessions. In Week 2, starting Monday 11th March, PBL 3 Intro will be devoted to introducing this e-learning tool. PBL 3 Debrief will be for discussing how the events within the e-learning tool impacted upon you and the value of running an e-learning tool for students to explore HSPH. The main queries will be around whether students found the e-learning tool fit for purpose, whether the e-learning tool enhanced the student learning experience in HSPH, and how achievable was the work-life balance in the scenario.

The e-learning tool will probably take less time to complete than the usual preparation for a PBL depending on how much you write and engage. You will be guided through each step of the way and each step will be self-explanatory. The material will apply to the learning objectives covered in lectures. You will also have opportunities during the lectures to ask any questions about the requirements for this part of the HSPH module. The link will be on this QMplus page which you can access by scrolling through the page from here.

Any queries with the use of the e-learning tool, please do not hesitate to contact the e-learning fellow Dr Saj Ranmuthu on smd-elearning-fellows@qmul.ac.uk

PBL 4: Don’t Mention the F-word!

Shahid and Craig are both on an IT diploma course at Dagenham FE College.  They have known each other since school and play football as part of a local Sunday league team.  Craig has an asthma attack one Sunday morning during a home game and ends up being taken to Homerton Hospital A&E.  He is admitted to hospital and has to stay in, missing two days of his course.  

Shahid is surprised that Craig has asthma.   He does too but neither of them has mentioned it to each other.  He visits Craig in hospital and they start talking about it.  Craig then mentions that he’s been admitted to hospital several times but hadn’t mentioned it as ‘it’s just asthma’ and he finds it embarrassing to say he’s got it.  Both say they don’t really see asthma as a problem as they hold the belief ‘no symptoms no asthma’ and because of this they don’t take their preventive medications as prescribed but do use their salbutamol inhalers. 

Shahid sees his GP each year for an asthma review and has been referred to a self-management course but he does not feel he needs it so didn’t turn up.   Craig’s GP has not seemed particularly interested in his asthma despite his admissions to hospital.    Both of them just take their salbutamol when they feel a bit breathless and feel that’s fine.  Craig does say that he seems to have had to get new salbutamol inhalers a lot over the last six months. 

Shahid mentions about how his Mum is worried about his sister, Salma, who has been admitted to hospital twice in the last year with asthma attacks.  She read an article about people from non-White backgrounds being more likely to be admitted to hospital with asthma and wondered why. 

PBL 5: Coping With Stress

Marysia is a 23 year old woman has had a knee injury and has been in severe pain over the last three months. In December 2017, Marysia slipped on ice on her way back from work and has been virtually housebound since. In 2010 Marysia was diagnosed with bipolar affective disorder and an eating disorder. She manages this with medication, therapy, journaling and regular visits to her GP. Being housebound does not help the isolation she feels.

Her GP referred her on to an orthopaedic surgeon for further investigations on her knee. Radiographic evidence showed a tear in her cartilage with a chip of bone floating in the synovial space. In March 2018, during her appointment with the consultant, she was advised that she would need to lose weight before being considered for surgery.

Marysia took offense at this, saying that she felt discriminated against because she was overweight and vowed never to return to the orthopaedic surgeon. She states emphatically that it was the slip that caused her knee injury, not being overweight.

Marysia managed to lose some weight, bringing her BMI down to 26 with the use of a Monk’s diet, approved by her GP. She cannot afford to join a gym so her GP has prescribed exercise for her which she can access for free although she has not yet attended because she is afraid of how people will look at her. Marysia tends to stay on her own for fear of stigma relating to mental health conditions. Her GP did ask if she was interested in enlisting in a social prescribing scheme.

Small Group Seminars – Observational Studies

1. Appreciate how observational studies are designed
2. Appreciate their limitations

Workshop: Evidence Based Decision Making

1. Explore a framework to critically evaluate evidence based decision making