Skin

18.5.06

Skin disease is a major and disabling problem for many people all over the world.

Skin
• Largest organ of the body.
• Many different functions:
-Thermoregulations.
-Protection.
-Metabolic functions.
-Sensation.

2 main regions
• Epidermis.
• Dermis.
• Each provides distinct role in overall function.
• Dermis attached to underlying hypodermis (also called subcutaneous connective tissue).
• Superficial fascia of gross anatomy.
• Stores adipose tissue.

Epidermis
• Most superficial layer of skin.
• Provides 1st barrier of protection from invasion of foreign substances into body.
• Principal cell: keratinocyte.
• Subdivided into 5 strata.
• In stratum corneum, keratinocytes migrate to surface and are sloughed off - desquamation.

Stratum germinativum
• Single layer of cuboidal cells - relatively large nuclei - basophilic cytoplasm.
• Only layer where cell division normally occurs.
• Provides germinal cells necessary for regeneration of layers of epidermis.
• Basal cells disivide asymmetrically - 1 daughter cell remain attached to basement membrane.

Stratum spinosum
• Cell in Stratum germinativum accumulate - many desmosomes on outer surface.
• Provide characteristic "prickles" of stratum spinosum ("intercellular bridges").
• Often called prickle-cell layer.

Stratum granulosum
• Keratinisation - accumulation of keratin by progressive maturation of keratinocytes.
• Cekks accumulate dense basopohilic keratohyalin granules.
• Contains lipids.
• Cytoplasm significantly more prominent.
• Nucleus elongated.

Stratum lucidum
• Normally only well-seen in thick epidermis.
• Represents transition from Stratum granulosum to stratum corneum.

Stratum corneum
• As cell accumulates keratohyalin granules - rupture of lysosomal membranes - release lysosomal enzymes - causes cell death.

Dermis
• 2 areas:
-Reticular dermis.
-Papillary dermis.
• Papillary dermis projects as round pegs into overlying epidermis.

Functions of dermis
• Thermoregulation.
• Support of vascular network to supply avascular epidermis with nutrients.
• Consists mostly of fibroblasts.
• Secrete:
-Collagen.
-Elastin.
-Ground substance.
• Gives support and elasticity to skin.
• Immune cells provide defence against foreign particles etc. passing through epidermis.

Papillary dermis
• Contains free sensory nerve endings.
• Meissner's corpuscles in highly sensitive areas.
• Composed of Type III collagen.
• Increase/decrease in blood flow, heat can either be conserved/dissipated.

Reticular dermis
• Consists of dense, irregular tissue.
• Gives skin overall strength and elasticity.
• Includes glands and hair follicles.
• Composed of Type I collagen.

Inflammation and wound healing
Vascular response
• Initial vasoconstriction as direct response to trauma.
• Exposed subendothelial tissue activates coagulation and complement cascades.
• Platelet adhesion and aggregation causes clot formation.
• Degranulation of platelets releases growth factors and chemotactin factors.
• Inflammatory response due to histamine and 5HT release.

Cellular response
• Migration fo neutrophils, macrophages and lyphocytes.
• Macrophages produce growth factors, leading to migration of fibroblast and epithelial cells.

Wound healing
• Epithelial barrier important - prevents infection - maintains fluid balance.
• Achived by both migration and proliferation of epithelia cells.
• Maximum collagen production occurs at 20 days.
• Maximum wound strength at 3-6 months.
• Initial collagen production disorganised.
• Remodelling lines it up with stresses in skin.
• Reduced vascularity and strength.

Scars
• Become red and thickened during healing.
• Takes several months for flattening of wound.
• Excess collagen formation may occur.

Images - Their Clinical Value Post-The Year 1 Assessment

16.5.06

Types of image
• Plain films.
• Barium and contrast studies.
• Computed tomography (CT).
• Magnetic resonance imaging (MRI).
• Positron emission tomography (PET).
• Ultrasound.
• Nuclear medicine.

Chest radiographs
Lateral chest X-ray - superseded by CT scans.
Abdomen plain image - psoas major muscle - gluteal muscles.

Contrast studies.
• Injection of suitable medium, into vein.
• IVP - renal excretion.
• T-tube cholangiogram - bile ducts, gall bladder, biliary tree.

Liver - associated blood vessels, porta hepatis.

Contrast studies of bowel.
CTs of abdomen.

Portal system - branches that create portal vein.
Porta-caval system.
Mesenteric vessels.
Mesenteric angiogram.

CT chest.
CT - mediastinal windows.
CT - bony windows.

Lateral skull X-ray.
PA skull X-ray - paranasal sinuses - orbits.

Dentition and eruption dates.

Sagittal T1W MRI brain scan.
Coronal T1W MRI brain scan - ventricles, CSF.
CT of skull.

MRI of abdomen.

Sagittal T1W MRI knee scan.

STIs

15.5.06

• Major public health problem on its own, and linking with HIV.
• 75% of curable STIs - developing countries.
• Major causes of morbidity, mortality and health costs - sequelae eg. infertility, CA, AIDS.
• Social and economic upheaval in societies.

What is happening?
• Chlamydia did not exist as bacterial STI until 1960s.
• Improved diagnostic methods.
• Active screening problems.
• People mobility.
• Enhanced surveillance of infectious syphilis was introduced in London in 2001.

Sexual history
• Important competent sexual history and assess risks.
• Non-genitourinary signs.
• Social history.
• Sexual history.
• Contraception.

Common symptoms
• Discharge.
• Rash.
• Lumps.
• Pain.

CHLAMYDIA
• Obligate intracellular small gram negative bacteria.
• Two forms:
-Elementary - infectious.
-Reticulate.

Risk factors
• Age <25 years.
• New sexual partner/more than one sexual partner in recent years.
• Lack of barrier contraception.
• Use of oral contraceptive pill.
• Women undergoing termination of pregnancy.

Asymptomatic in 80% of women and 50% of men.

Treatment of uncomplicated infection
Recommended regimens
• Doxycycline 100mg qd for 7 days.
• Azithromycin 1g orally in single dose.

Alternate regimens
• Erythromycin 500mg qd for 7 days
or Erythromycin 500mg bd for 14 days.
• Or, Ofloxacin 200mg bd or 400mg od for 7 days.
• Or, Tetracycline 500mg qd for 7 days.

Pregnancy and breastfeeding
• Doxycycline and Ofloxacin contraindicated in pregnancy.
• Safety of Azithromycin not fully assessed.
• Erythromycin has significant side-effect profile and <95% effective.
• Amoxycillin 500mg td for 7 days.

GONORRHOEA
• Clinical disease resulting from gram negative diplococcus Neisseria gonorrhoeae.

Recommended treatments - uncomplicated infection
• Ceftriaxone 250mg im.
• Ciproflloxacin 500mg orally as single dose.
• Or, Ofloxacin 400mg orally as single dose.
• Or, Amipicillin 2g/3g plus Probenecid 1g orally as single dose, where regional prevalence of Penicillin-resistant N. gonorrhoeae <5%.
• Or, Cefotaxine 500mg im as single dose.
• Or, Spectromycin 2g im as single dose.

SYPHILIS
Congenital or acquired.

Acquired syphilis:
• Early syphilis:
-Primary.
-Secondary.
-Early latent, <2 years.
• Late syphilis:
-Late latent, >2 years.
-Tertiary gummatous cardiovascular neurosyphilis.

Treatable and curable.

Economics Of Alcohol

11.5.06

National burden
• 1 in 20 adults addicted to alcohol.
• 1 in 3 Northern men drink at harmful levels.
• 16-24-year-olds are most likely to be drinking at harmful levels.
• 41% of men and 22% of women in this age group drink above sensible levels.

Local burden
• 1952 patients.
-12.4% attendances to Accident and Emergency.
-9% under age of 18 years.
• Most common reasons for attendance:
-Falls/intoxication.
-Head injury.
-Assault/fight.

Cost to the Trust
• ITU reported to cost 20% of hospital annual operating cost.
• 20% medical admissions related to alcohol.
• Consistent framework for costing yet to be developed.

OTHER COSTS: CASE STUDIES
Case 1: 12-year-old female
• Brought to Accident and Emergency by known prostitute.
• Reported drinking 1 bottle whiskey per day.
• Mother teacher, father accountant, attends good school.
• Resulting harm:
-Medical emergency (choking).
-Child Protection Register.
-STD.

Case 2: 21-year-old female
• 1 bottle whiskey per day since aged 9.
• Sexual abuse by father aged 7.
• Date rape 4 months ago.
• Resulting harm:
-Medical emergency (alcohol withdrawal symptoms).
-Rape.
-STD.
-Homeless.
-?HIV.
-Deliberate self-harm.

Case 3: 76-year-old gentleman
• Drinking 2 bottles sherry per day for many years.
• Evicted from sheltered housing.
• Accused of many petty crimes.
• Resulting harm:
-Chronic unmonitored ill-health.
-Public health risk.
-Probation services.
-Local police.
-Voluntary agencies.

CHALLENGES - Do we have a capsule of despair?

The need to change attitudes
• Whose?
-Society's, as a whole.
• But where do we start?
-Perhaps with our own attitudes and those of our colleagues.

The Alcohol Continuum
Teetotal↔Social↔Hazardous↔Problem↔Dependency

Types of drinker
• Heavy drinker.
• Dependent drinker.
• Problem drinker.

How many units?

Alcohol specialist nurse theory
• Screening for alcohol-related problems.
• Education of doctors/nurses.
• Increase confidence.
• Improve detection rates.

Alcohol specialist nurse practice
• Give support and advice to patients with alcohol-related problems.
• Give support, advice and training to staff caring for patients with alcohol-related problems.
• Advice on medical management of alcohol withdrawal.

Screening and detection of alcohol-related problems
• Prevent consequences of long-term heavy consumption.
• Optimise medical management.

Brief intervention - what are they?
• Limited assessment.
• Advice on changing.
• Materials for self-monitoring and education.
• Setting of goals.
• Motivational interviews for those who are not ready to change.

Factors Influencing Health Of Children And Young People

10.5.06

OVERWEIGHT AND OBESITY
• Reduction in physical activity in children has led to obesity.
• Diet also has huge impact - more fast food - high fat, high sugar, less important nutrients - ADVERTISING.

Children 2-10
• 20% overall UK population obese (BMI >30).
• Similar pattern in children.
• Type II diabetes diagnosed in 11-year-olds.
• Children exceeding maximum recommended adult intake.

Obesity and ill health
• Hypertension.
• CHD and stroke.
• Type II diabetes.
• Some cancers.
• Osteoarthritis.
• Mental ill health.

Diet and health
• Up to a third of deaths from cancer and CHD could be prevented by a better diet.
• Eating at least 5 portions of fruit and vegetables each day.

Five a day
• Average UK consumption is 2.8 portions of fruit and veg per day.
• Consumption significantly lower in lower socio-economic groups.
• 20% children eat no fruit.

Diet and health inequalities
• Shopping not done at market/supermarket costs 25% more.
• Healthy diet costs 50% more than unhealthy diet.
• Fruit and veg account for significant proportion of this.

MENTAL HEALTH
Depression in children
• Children - 2-4%.
• Adolescents - 4-8%.
• May present as:
-Behaviour disorder.
-Withdrawn.
-Irritability.
-Uncooperative.
-Disruptive.

Self harm
• Evidence that 10% children self harm.
• Rates now highest in Europe.
• Numbers increased.
• Female:male ratio = 7:1.
• Why do people self harm?

Drug use in last year in 11-15-year-olds
• Illicit drugs:
-Boys - 15%.
-Girls - 13%.
• Smoking:
-Boys - 9%.
-Girls - 12%.

Alcohol consumption (11-15-year-olds)
• Alcohol in last week:
-Boys - 25%.
-Girls - 23%.
• Average consumption per week:
-Boys - 11.6 units.
-Girls - 9.1 units.

Calculating units
• ABV (%) x Volume consumed/1000.

SEXUAL HEALTH
STIs
• 1980s and early 1990s: gradual decline.
• Since 1995, progressive rise.
• Genital warts.
• Chlamydia.
• Gonorrhoea.
• Herpes.
• HIV.

Teenage pregnancy - failure to decline.

The mother
• Single parenthood.
• Educational failure.
• Poverty.
• Unemployment.
• Ill health.

The child
• Increased stillbirth.
• Increased infant mortality.
• More accidents.
• More hospital admissions.
• More likely to live in poverty, to fail in direction, to become teenage parents themselves.

Teenage pregnancy strategy:
• Prevention.
• Support.

CHILD ABUSE
• Physical eg. hitting, throwing, poisoning etc.
• Emotional eg. telling child they're useless, unwanted etc.
• Sexual - physical or non-physical.
• Neglect - withholding food, shelter, clothing, protection from harm.

Prevalence
• 30,000 children on Child Protection Register.
• 600 added each week.
• 25% of rape victims are children.
• 1 child dies each week due to cruelty.

1997 study
• 150,000 children suffer severe physical punishment each year.
• 100,000 each year have potentially harmful sexual abuse.
• 450,000 bullied at school at least once a week.

DOMESTIC VIOLENCE
Definition:
• Physical, psychological, sexual or financial.
• Intimate/family-type relationship.
• Pattern of coercive/controlling behaviour.
• Most victims/survivors women.

Impact on children
• 90% incidents children in same room.
• 25% cases children also subjected to violence.
• 33% children on Child Protection Register have mothers who are victims of domestic violence.

Impact on health
• Immediate result of physical violence.
• Secondary effects of chronic physical and psychological ill health.

Chronic ill health - children
• Frequent appointments.
• Physical injury.
• Vaginal discharge.
• Depression.
• Behaviour problems.
• Sleep problems.
• Enuresis.

NSPCC: 0808 800 5000.
Women's Aid: 08457 023 468.

Society And Lifestyle Choices In Young People

9.5.06

Context
• Recent decades have seen numerous changes affecting lives of young people.
• Teenage years commonly viewed as time of peak physical functioning and as being marked by low incidence of illness.

However…
• Increasing evidence shows adolescent physical and mental health related to family structure, own educational attainment, current economical position and personal disposable income.
• Adolescence is a key time when many experiment with behaviours that if they continue will be detrimental to their health.

Smoking and children
• Very few 11-12 year old children smoke.
• By age of 15, 23% children regular smokers in England.

Sociological explanations
• Structural explanation.
-Refers to structures socially constructed or societal structures eg. social class, family, education, gender.
-Focus upon how individual decisions shaped by structures.
• Agency/individual explanations.
-Lifestyle choices made are (in some way) a reflection of who we are and what ewe have seen and done.

Structure and agency/individual explanations
• If we want to understand teenagers' health-relevant behaviours:
-Study within structural locations that influence person/subjective experiences.
-Explore different routes through which young people make transitions towards adulthood.
-Take into account rapid social and economic change occurring.
• Therefore, must take into account BOTH structural and individual explanations.

Pavis et al 2002
• Sought to focus on young people as they made key decisions in life.

Reasons for drinking:
1. For social facilitation.
2. Because of peer influence/pressure.
3. In order to influence mood.
4. For comfort/solace.

Reasons for smoking:
• Type I: smoked solely with one group of friends on in one social setting.
• Type II: smoked with various friendship groups in different social settings.
• Type III: smoked both with different social groups and alone.

Smoker types I and II most likely to give up, as did not view themselves as genuine smokers.

Water Fluoridation

8.5.06

Methods of fluoride delivery
• Water fluoridation.
• Fluoride tablets and drops.
• Fluoride salt.
• Fluoride milk.
• Fluoride in fruit juice.
• Topical fluoride applications.
• Fluoride toothpaste.

How does fluoride work?
• Topical and systemic effect - topical effect more important.
• Fluoride incorporated into hydroxyapatite crystals in tooth - renders it more resistant to acid attack.
• Presence in saliva promotes remineralisation of tooth.
• Interferes with metabolic pathways of bacteria, thus reducing acid formation.

History
• McKay.
-"Colorado stain" identified (1901).
-Relationship between stain and caries noted (1929).
• Dean.
-Epidemiology of fluoride, enamel stain and caries (1931).
-Demonstrated inverse relationship between fluoride and caries with reduction at 1 ppm (part per million), and only mild stain at this level (1938).
• Trials in USA of artificially-fluoridated water.
• Trial in UK.
• Fluoridation schemes established in UK in 1960s.

Do we need water fluoridation?
• Prevalence of caries falling.
• Individual behavioural modification lowering caries.
• However, still a problem.

Issues associated with implementing water fluoridation
• Likely positive effects:
-Best available evidence suggest fluoridation of drinking water supply DOES reduce dental caries.
• Likely negative effects:
-Cancer.
-Down's syndrome.
-Bone fluorosis - fractures.
-Alzheimer's.
-Allegation that it may make men frisky.
-Fluorosis.
• Safety of fluoridation:
-Question of possible secondary effects caused by fluorides taken in optimal concentrations through life object of thorough medical investigation - shown to have no effect.
• Ethical issues:
-Autonomy - reduction of individual freedom has to be accepted for greater good.
-Beneficence and nonmaleficence - issues must be considered in terms of whole population.
-Justice - reduces inequalities in health.
• Legal issues:
-Enabling/mandatory frameworks.
-UK - enabling legislation - water companies can choose whether to fluoridate water or not.
-Mandatory - water companies obliged to fluoridate water.
-Water (Fluoridation) Act (1985).
-Water Act (2003).
• Environmental issues.
-No evidence of any adverse environmental effects.
-Chemicals used manufactured as co-product of manufacture of phosphate fertilisers.

Advantages
• Reaches everyone who might benefit from it.
• Cheap.
• 20-40% reduction in caries over a lifetime.
• Safe, cost-effective, consistent, good population coverage, compliance not needed, low risk of overdose.

Disadvantages
• Mass medication.
• Freedom of choice.
• Requires complex infrastructure at beginning and initial capital outlay.

Current situation
• 400 million people worldwide drink fluoridated water.
• 65% of USA population.
• 10% of UK population.

Conclusion
• Decreased caries.
• Cheap and effective.
• Reaches high-risk populations.
• Dental fluorosis at 1ppm very mild.
• Only effective in areas of high caries prevalence.
• Freedom of choice.

Module 1.11

Sport And Spots.
8.5.06 - 19.5.06.

Nearly there!

Child Development

5.5.06

www.healthforallchildren.com - Parents' page - plot child's growth.

Lines on charts are centiles - based on normal.

50th centile
• 50% of normal children below, 50% above.

2nd centile
• 2% of normal children below, 98% normal.
• Is small child normal or abnormal?

Surveillance about watching (i.e. over time)
• Does child follow centile or cross-centiles?

Sometimes also used as cross-sectional assessment of growth, "screening" separating out those who are probably normal.

Developmental norms are developed empirically.

Regression
• "Given data of a dependent variable y and one or more independent variables x1, x2 etc. Regression analysis involves finding the best mathematical model to describe y as a function of the 'x's."
• Will see it used in many papers.
• Regression used to:
-Describe relationship between variables.
-Predict outcome from set of risk factors.
-"Adjust" for known confounder.
• Interpretation of coefficient depends on model.
• Can be:
-Linear (single or multiple).
-Logistic (probably commonest).
-Proportional hazards.
• Logistic regression estimates odds ratios.
• Will see these terms in papers you read.
• Linear regression different from correlation.

Correlation coefficient: "A measure of association that indicates the degree to which two variables have a linear relationship. This coefficient, represented by the letter 'r', can vary between +1 and -1; when r= +1, there is a perfect positive linear relationship in which one variable varies directly with the other; when r+ -1, there is a perfect negative linear relationship between the variables."

Scenario - notifications?
• Of infectious diseases.
• Commenced end of 19th Century - 1891 in London, 1899 elsewhere.
• List of diseases increased over time - now stands at around 30.
• Originally, head of family or landlord's responsibility to local Proper Officer.
• Now, attending medical practitioner, either in patient's home, surgery or hospital.
• Proper Officer = CCDC.

Purpose of notification
• To detect possible outbreaks of epidemics.
-Accuracy of diagnosis secondary.
• Statistics of collected rationally at Registrar General's office.
• In 1997, responsibility for administering NOIDs system transferred to Communicable Disease Surveillance Centre, now HPA.

Epidemic precipitates investigation, in order to:
• Determine source and mode of transmission.
• Interrupt chain of transmission (control measures).
• Prevent secondary spread.
• Prevent other outbreaks under similar circumstances.

Steps in investigation
1. Confirm diagnosis.
2. Set case definition.
3. Describe case by person, time and place.
4. Formulate and test hypothesis.
5. Undertake any additional methods to control outbreak.
6. Evaluate measures taken.
7. Report on handling of outbreak and its control to various authorities.

Patterns of epidemic
• May start from Common (Point) Source - with all cases exposed at same time to one source of infection.
• In contagious epidemic, disease passed from person to person.
• Slow rise in number of cases.

Prevention paradox?
• Preventive measure bringing large benefit to community, but may offer little to most participating persons.
-Eg. immunisation.
- Why is paradox problem for NHS?
• People motivated by benefit which is visible, early and likely.

Infectious disease epidemiology
• Health promotion.
-Disease prevention.
§Primary - immunisation.
§Secondary - limiting spread.

Gait

4.5.06

Gait control
• Cortex, pyramidal.
• Cortex, extra-pyramidal.
• Cerebellum.
• Reflex arc - can be tested.

Development of walking
• Milestones.
• Development of all structures required.
• Characteristic patterns when impaired.

Milestones
• Sits at 6 months.
• Crawls at 9 months.
• Stands and walks aided at 15 months.
• Walks unaided at 15 months.
• Runs at 18 months.
• Adult pattern by 3 years.
• Fully mature pattern only by 6 years.

Infant gait pattern
• Jerky, unsteady, wide-based.
• Arms abducted and extended.
• Foot-strike flat and knee flexed.
• Longer double stance phase.
• Rapid steps, but low velocity.

What can go wrong?
• Brain.
• Spinal cord.
• Nerves.
• Muscles.
• Joints.
• Bones.

Brain
• Cortex and internal capsule.
-Stroke - usually one-sided.
• Extrapyramidal system.
-Parkinson's.
• Cerebellum - important in coordination of gait.
-Ataxias.

Spinal cord
• Injuries.
• Tumours.
• Degeneration.

Upper and lower motor neurones
• Upper motor neurone lesion.
-Increased tone and reflexes.
-Spastic paralysis.
• Lower motor neurone lesion (anterior grey horn).
-Decreased tone and reflexes.
-Flaccid paralysis.

Nerves and muscles
• Injuries.
-Laceration, traction.
• Pressure.
-Carpal tunnel syndrome.
• Degeneration.
-Polio, motor neurone disease, myopathies.

Bones and joints
• Injuries.
-Fractures, ligament ruptures.
• Degenerations.
-Osteoarthritis.

Gait analysis
Normal gait
• Gait cycle.
• Stance phase.
• Swing phase.
• Double stance.
• Double swing.

Some abnormal gaits:
• Painful gait (antalgic) - short stance phase.
• Drop foot gait - rupture of tibialis anterior, L5 root problem.
• Parkinsonian.
• Cerebellar.
• Stiff leg gait - joint abnormalities.
• Athetoid - wild, abnormal movements.
• Back-knee gait.
• Tabetic - heavy walk - no sensory input from feet - syphilitic loss of proprioception.
• Spastic diplagic - scissor gait.
• Stroke (paraplagic).
• Lurching (rolling) gait - hip pathology.
• Trendellenburg.
• Slapping gait - less pronounced version

Appropriate And Inappropriate Attitudes In Healthcare

3.5.06

What are morally inappropriate attitudes?
• Attitudes aimed at (in)appropriate objects.
• Attitudes aimed at appropriate objects, but had to (dis)proportionate degree.
• Attitudes expressing (in)appropriate attitudes.

Examples of appropriate attitudes:
• Empathy.
• Sympathy.
• Appropriate/proportionate feelings of anger.
• Degree of modesty/humility.
• Appropriate sense of fun?

Examples of inappropriate attitudes:
• Callousness.
• Racist, sexist, ageist and other prejudicial attitudes.
• Senseless/disproportionate anger.
• Pleasure felt at another person's displeasure/suffering.
• Inappropriate amusement.
• Excessive anxiety.

Two types of cases in which in which inappropriate attitudes may raise fitness to practice concerns
1. Where attitude threatens to negatively impact on behaviour/practice:
(i) By causing distorted/inadequate understanding of features of clinical situation.
(ii) By affecting motivation.
2. Where attitude itself is source of harm - where this may be a result of:
(i) The offence caused by the showing of that attitude.
(ii) The negative effect that attitude has on the patient-doctor relationship, and thereby the quality of car the patient is likely to receive.

Points of consideration:
1. Potential harm threatened by possession of attitude should be sufficiently severe in order to cast doubt on practitioner's fitness to practice.
2. Mitigating circumstances exist in which having of the attitude not to be taken as good indication of practitioner's overall fitness to practice.
3. How might we go about cultivating the right attitudes in ourselves and others?
-Are attitudes things that we can simply change at will?
-Might not be clear.
-May have some direct control over behaviours that will eventually impact on attitudes we have.
4. Issue of responsibility.
-Attitudes involuntary, therefore, should not be held responsible for them.
-May have some control over whether we cultivate certain attitudes in ourselves.
-Therefore, sometimes indirectly responsible for attitudes.
-People who feel wrong attitudes should not always be reproached for those attitudes.

Questions
1. In what ways do you think attitudes may impact on behaviour?
2. How do you think we can cultivate better attitudes in ourselves?
3. Do you think we should ever be punished/reproached for having certain attitudes?

Further reading
• "Tomorrow's Doctors" - GMC (2003).
• "Learning Outcomes For Attitudes, Ethical Understanding And Legal Responsibilities" - Scottish Doctor.