Module 1.5: Cold Feet

Session 2012-2013 Year 1 Semester 1

INDICATIVE LEARNING OBJECTIVES

STRUCTURE & FUNCTION  Outline the gross anatomy and microscopic structure of the heart and circulatory system, including the major arteries and veins, and key features of cardiac muscle  Outline the cardiac cycle in terms of cardiac output, and relate it to the normal electrical conductivity of the heart and normal electrocardiogram (ECG) patterns  Define the term blood pressure and discuss its regulation (receptors, hormones)  Describe how tissues are perfused  Explain how cardiac pain is perceived and the role of nitrates in relieving angina pectoris  List the components of blood (and their main functions), and how they are formed and removed from the circulation (spleen role)  Define atheroma and atherosclerosis, and relate these to lipid metabolism and the key features of the coagulation cascade  Describe the key features of how aspirin works, and its effect on coagulation cascade

POPULATION PERSPECTIVE  Illustrate unfair or unjust differences (‘inequalities’) in health determinants or outcomes in populations and implications for health promotion strategies  Outline the hierarchy of evidence from epidemiological study designs (for critical appraisal), outlining the key features of a randomized controlled trial related to the classification of descriptive, observational/analytical, intervention studies and types of bias  Define:- case-fatality rate; cause; relative risk and absolute risk (e.g. incidence) and relate risk to probability; health protection, health education, and primary disease prevention (as elements of health promotion); the Bradford-Hill criteria for assessing causal association

INDIVIDUALS, GROUPS & SOCIETY  Define and explain types of personality in relation to lifestyle  Consider issues of compliance with healthy lifestyle advice and the concept of lay epidemiology

PROFESSIONAL & PERSONAL DEVELOPMENT  List relevant articles for informed consent from the Human Rights Act 1998, and their implications for health care workers and the public’s health  Outline the relevant ‘Duties of a Doctor’ from the General Medical Council’s (GMC’s) guidelines  Discuss the impact of professional attitudes on life-style-related diseases, and professional attitudes to patients who fail to follow professional advice  From a historical perspective, discuss how anatomical knowledge (and in particular of the circulatory system) has been acquired (Harvey, Vesalius, Anatomy Acts, etc.)  From a historical perspective, discuss 19th century ideas of hospitals as a gateway to death

Session 2012-2013 Year 1 Semester 1

SCENARIO – Module 5: Cold Feet

Mr Jim Todd, 47, is an unemployed dock worker. His wife, Laura Todd, reads a magazine article about how to avoid heart disease, mentioning medical evidence associating it with ‘stress’, eating fatty foods, smoking, and lack of exercise. Mrs Todd thinks, “Jim has a lot of these risk factors”, and shouts, “Jimmmmm! If you stopped smoking, it might prevent a heart attack”. After many rows with his wife, Mr Todd reluctantly agrees to see Dr Vini Patel for advice about his feet. Having obtained informed and voluntary consent, Dr Patel examines his chest, measures his pulses and blood pressure, and orders an ECG and blood tests, including a lipid profile. He notes the painful right foot to be colder and paler, and the pulse difficult to feel. Tissue perfusion appears poor. He tells Mr Todd about atheroma, and suggests he stops smoking and loses weight. A month later, the receptionist, Mrs Shah, tells Dr Patel that he has yet to return for his results. Dr Patel wants to prescribe him aspirin. He knows that doctors must ensure their behaviours comply with the 1998 Human Rights Act (incorporating into UK law rights enshrined in the European Convention, including Article 8, the right to respect for family and private life). It is therefore up to Mr Todd whether he attends the urgent vascular referral appointment arranged for him.

The Todds have another row about Mr Todd missing the GP and hospital appointments, but Mr Todd maintains, “How do they ‘know’ smoking causes heart disease and what’s my foot got to do with my heart? Auntie Hettie smoked twenty cigarettes a day and died at 78 crossing the street!” Mrs Todd shouts, “You haven’t even tried to follow the diet or stop smoking. Maybe you need one of those sprays under the tongue for your chest pain. Maybe that’s your circulation too. You must go and tell them - you can hardly walk! You won’t die just because you go to hospital.”

Dr Patel and his partner Dr Vincent Lee think it is highly probable that Mr Todd will “have an MI before he is 50, as he’s unlikely to follow our advice”. They discuss the case-fatality rate, and theorize about his non-compliance and the odds of “patients like him having a serious cardiovascular episode compared with the stressed business executive-types in our practice population”. They also discuss a recent ‘analytical study’ about smoking cessation, and consider the robustness of the evidence-base. Dr Lee recalls Bradford-Hill criteria for assessing causality of associations in clinico-epidemiological research. “Aren’t RCTs a ‘gold standard’ - robust under the ‘study design’ criterion, but then not always right for the research question or

Session 2012-2013 Year 1 Semester 1 situation? Anyway, epidemiology knowledge is not like anatomy is it?” “...but without Harvey, the circulation might have been a mystery for 400 years”, replies Dr Patel.

Mr Todd worries about not telling Dr Patel of his chest pain (fearing it will stop his return to work).

Session 2012-2013 Year 1 Semester 1