Abstract
Women in medicine
The Royal College of Physicians (RCP) has produced a report ‘Women and Medicine: the future’. A short summary (or the full version) can be downloaded free from the RCP website. The proportion of medical school entrants has stabilized at 57–58%; there has been an overall steep rise in the number of medical students and there is no evidence that women are more likely than men to leave medicine. The Royal College of General Practitioners (RCGP) has a large number of women in senior council and officer positions including the next president, the current vice chair and the present and future honorary secretaries. This is quite different from some of the other specialties.
The British Medical Journal also published two studies in June 2009 that looked at career progression in the National Health Service (NHS) and at the proportion of UK medical graduates that goes on to practise in the NHS.
The key factor determining career progression is working pattern; working part-time delays progression. Specialty destinations of women who have always worked part-time differ from women who work full time and from men. Over-representation of women in general practice is strongly associated with part-time working.
I do not find it surprising that the study found that women tend to favour ‘people orientated specialties with more plannable workloads’. What surprises me is that both genders do not opt for plannable workloads.
Taylor, A., Lambert, T., Goldacre, M. Career progression and destinations, comparing men and women in the NHS: postal questionnaire surveys. British Medical Journal (2009) 338: p. 1429.
Goldacre, M., Davidson, J., Lambert, T. Retention in the British National Health Service of medical graduates trained in Britain: cohort studies. British Medical Journal (2009) 338: p. 1430.
Patient groups
Does your surgery have a Patient Partnership Group (PPG)? In June 2009, a campaign to encourage the use of PPGs was launched by the RCGP, in partnership with NHS Alliance, the British Medical Association and the National Association for Patient Participation (NAPP). About 40% of GP practices in the UK now have PPGs. The NAPP website(www.napp.org.uk) hassomeshortdocuments giving examples of possible PPG activities and also advice about setting up a group.
If you are interested, you could use some self-directed learning time to go to one of your PPG meetings. At our surgery, we have only recently had an active group but we have already found it very useful for example in giving us feedback on our Patient Satisfaction Survey. Both partners and registrars are welcome at the group meetings and one of my registrars recently attended the NAPP annual conference. I expect that you would find your own PPG equally welcoming.
Trainee survey
The annual Postgraduate Medical Education and Training Board survey has shown wide differences in the amount of support offered to trainees for study leave and training courses.
As a London-based trainer, I worry about the lower satisfaction rates reported by London trainees. Trainers and Programme Directors on our scheme plan to ask our registrars if there are aspects that could be improved. I wonder what action this report has triggered in your own area?
My other worry is that fewer than 10% of trainees are getting experience of working at night. I am not sure whether this is important. In a world with few partnerships, I think some of you will take on out-of-hour posts and that it might be helpful to have had varied experience of out of hours while being trained. You cannot learn everything that you need to know as a GP registrar but I do think that it is important that we offer you a range of experience so that you have a general grounding on which to build once you become independent GPs. I know that there are some registrars who are sure that they will never do out-of-hour sessions, as there may be some who are sure that they will never perform cervical smears or a baby's 6-week check. What do you think we should offer in training? I would be happy to hear your views.
Test of treatment or therapeutic challenge?
The GP surgery is all about managing risk and probability of disease in patients. We sometimes inadvertently (and often subconsciously) use what is called test of treatment to confirm or exclude diagnoses. For example, a patient with symptoms suggestive of oesophageal reflux is trialled with proton pump inhibitors for a period and reviewed. Improvement in symptoms suggests confirmation of diagnosis of reflux. Or does it?
Test of treatment is often most useful when a single diagnosis is highly probable but not certain, when an available treatment works for most patients if the diagnosis is correct and when there is a measurable short-term outcome. But as for every diagnostic test, the test of treatment can have both false-negative and false-positive results. This can easily lead to inappropriate diagnosis simply because of chance or evaluation bias. False negatives can arise because of insufficient dose or duration of treatment or if the patient is resistant to that particular treatment. So in the above example of oesophageal reflux, the average sensitivity of this test is 78% and a specificity of only 58%. In order to reduce the influence of chance fluctuations and bias, the authors recommend using multiple measurements over different treatment periods with objective/blinded measurements thereby improving the accuracy of tests of treatments.
Glasziou P., et al. Diagnosis using “test of treatment”. British Medical Journal (2009) 338: p. 1270–1.
Dosage errors in children
Do you always weigh children in primary care before deciding on the dosage of a certain medication? Often, we base our calculations on the age or clinical condition of the child. The UK patient safety watchdog (National Patient Safety Agency) has raised concerns about the high rates of dosage errors in the paediatric population, particularly for children younger than 4 years. Giving an incorrect dose or strength of drug was the highest reported type of drug incident. Sometimes, the complexities of dose calculations involving decimal points have been considered a factor in the occurrence of dosing errors. The full report can be found at www.npsa.nhs.uk/nrls/improvingpatientsafety/children-and-young-people/.
Many of the drugs we use are not licensed for use in children. Until recently, there was no separate British National Formulary for Children (BNFC). Launched in 2005, the formulary provides practical information on the use of medicines in children of all ages from birth to adolescence. The information in the BNFC is based on emerging evidence, best-practice guidelines and advice from clinical experts. If you have not used it before, have a look at your practice copy.
Whooping cough
I was interested to read the article about whooping cough (Harnden 2009) in a recent British Medical Journal.
I saw two children with whooping cough last winter. The first was an 18 month old who had not been immunized (despite discussions with myself, our health visitor and the local paediatricians). She coughed until she vomited many times a day for about 8 weeks but never exhibited the classic ‘whoop’. The second child was a 2 year old with a similar history but a record of having been fully immunized. If I had not done some reading about persistent cough and Bordetella because of seeing the first child, I probably would not have tested the second.
Harden reminds us that a recent study showed that 20% of adolescents with cough lasting for more than 2 weeks have serological evidence of recent whooping cough and that it has been estimated that people have up to 3 episodes of whooping cough in a lifetime, despite immunization.
Harnden, A. Easily Missed? Whooping Cough British Medical Journal (2009) 338: p. 1443–4.
Preventing postherpetic neuralgia
Post-herpetic neuralgia (PHN) is not uncommon in general practice and is often quite debilitating. Antiviral agents, used at the time of the rash, are one of the best-established approaches thought to prevent the development of PHN. However, a recent Cochrane review concluded that there was no significant difference between oral aciclovir and control groups on the incidence of PHN 4 months (risk ratio [RR], 0.75; 95% confidence interval [CI] = 0.51 to 1.11; P=0.15) or six months (RR, 1.05; 95% CI, 0.87 to 1.27; P = 0.62) after the onset of the acute herpetic rash. Similarly, when comparing famciclovir versus placebo, neither 500-mg nor 750-mg doses of famciclovir significantly reduced the incidence of herpetic neuralgia. The authors caution that the above evidence was only based on six small randomized controlled trials. Does this make you decide for or against antiviral treatments? Think about what you are going to do next time you see a patient with shingles.
Li, Q., Chen, N., Yang, J., et al. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Systematic Review (2009) (2): CD006866 (Review).
Back pain
We have already had our first patient requesting acupuncture for her low back pain, as she had read in a national newspaper that this was now a recommended treatment. Patients often read about recommendations at the same time or before we see them. Resources often do not become immediately available in the local area.
Patients presenting with issues of this sort make good cases for the Clinical Skills Assessment so it is worth thinking about how you will negotiate with and explain to them.
I was lucky this time as I knew the patient well and was able to listen to her, examine her, reassure her that there were no ‘red flag’ symptoms and teach her some simple back exercises.
National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain (2009) (Clinical guideline 88) www.nice.org.uk/CG88.
Hypothyroidism
I find patients with borderline thyroid function tests (TFTs) difficult to manage. We see many middle-aged female patients who complain of tiredness and weight gain. Many have normal blood tests but a few have normal thyroxine (T4) levels with slightly raised thyroid-stimulating hormone (TSH).
The Mayo Clinic Guidelines give a useful practical approach; treat if TSH is greater than 10 and look at other factors such as autoantibody levels, lipid levels and change over time if TSH is above 5 but less than 10.
The RCP issued a statement on the diagnosis and management of primary hypothyroidism in November 2008 (available as a free download from the RCP website). This deals with two further problems commonly encountered in the interpretation of TFT.
Some patients with normal TFT will ask for treatment with thyroid extracts or triiodothyronine. The college statement makes it clear that there is no place for treatment with anything other than T4. The statement also emphasizes that patients whose symptoms persist despite TFT within the reference range need further investigation or referral.