Abstract
First5
First5 is a Royal College of General Practitioners (RCGP) initiative to support new GPs from completion of training to first revalidation 5 years later. There have been other initiatives in the past to help support the transition to independent practice (I was a Higher Professional Education Director in London supporting GPs within 2 years of qualification until 2006 when funding was withdrawn) but this is the first formal programme run by the College. The aims of the programme include support for revalidation and Continuing Professional Development information specifically designed for newly qualified GPs. As well as the formal survey being sent to all College members within the first 5 years of certification of completion of training; the new First5 continuing professional development fellow Dr Clare Taylor would be interested to hear from you if you have any suggestion at
General Medical Council revalidation consultation
There is also a last call to be involved in the General Medical Council (GMC) revalidation consultation process. The GMC has a website inviting you to submit your views about revalidation and it is staying open until the end of May 2010.
Consultation skills
Having just spent 5 days examining candidates for the Clinical Skills Assessment (CSA) at Croydon, a couple of articles on aspects of the consultation caught my eye.
Patients (and actors) like to think that you are listening to them. In a study asking patients' views on non-verbal cues in the consultation, eye contact, tone of voice and time spent entering data onto the computer featured the most. One interviewee was quoted:
You can feel (the personal attention by) how someone looks into your eyes, not making any notes or writing on a computer at that time; I can see the interest.
It can be very difficult in the middle of a consultation when you are wondering why on earth the patient has come, to take a breath and properly listen. I think there are many ways you can practice this. Try videoing some consultations and just looking at the videos instead of presenting them as a case observation tool (COT). You could share with your trainer, other GPs in your study group or just turn the sound off and watch your body language and the patient's body language. One common distraction, the computer, is not present in the CSA but it is still easy to look at papers or fiddle with a pen and appear not to be listening.
Another group of consultations that can be challenging are those where the patients arrive with, these days, information printed out from the Internet. The same issue of the College Journal had an article about the reactions of GPs to such consultations. Although such consultations can sometimes be interesting, they are usually time-consuming so it was nice to know that other GPs worry too. I liked the quote from the GP who was concerned about the patient knowing something that we do not know.
I am threatened by the possibility that they have read something that I don't actually know and understand
If you come across topics that you have not learnt about in the CSA examination, you have to use a strategy that shows that you are thinking and that does not make the patient just feel fobbed off by a ‘come back next week’.
Marcinowicz, L., Konstantynowicz, J., Godlewski, C. Patients' perceptions of GP non-verbal communication: a qualitative study. British Journal of General Practice (2010) 60: p. 83–7
Ahluwalia, S., Murray, E., Stevenson, F., Kerr, C., Burns, J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to the consultation. British Journal of General Practice (2010); 60: p. 88–94
Podcast on claims process
The odds of you being sued at this stage of your career are highly unlikely, but perhaps more senior partners at your practice have had the unfortunate experience. Mistakes are common; we are fallible. Doctors frequently feel angry and distressed when the first indication of a claim is a letter from a claimants' solicitor. Often it is more the uncertainty of what happens next, which causes more anxiety and distress for us.
The Medical Defence Union (MDU) has launched an online podcast about the claims process explaining the legal definition of clinical negligence, what claimants must do to succeed in a claim and common reasons for claims. It reiterates that in order to prove clinical negligence and to succeed in a claim, claimants must satisfy all three criteria, namely,
that the doctor owed them a duty of care,
that the doctor breached that duty and
that the patient suffered harm as a result
Listen to the podcast at: www.themdu.com/section_GPs_and_primary_care_professionals/topnav_Our_services_5/nav_MDU_Publications_4/subnav_Podcasts_6.asp?articleID=2128.
In the bag
No doubt, towards the end of your GP training, you are thinking of perhaps purchasing your own personal doctor's bag. But have not you found that you have to be quite disciplined to keep track of emergency drugs and their expiry dates?
A new website called DoctorsBagUK is a website where you can securely record what is in your bag (including drugs, equipment and controlled drugs) and when it will expire. Every time you give a drug from your bag you simply log on with your user name and password to update your online doctor's bag whether at home or in the surgery. There is also the facility to have a printed record of the drugs in your doctor's bag at any one time as evidence for the medicines management part of Quality and Outcomes Framework (QOF), which requires doctors to keep their bags regularly updated and to have a system to check drugs are in date. There is, however, a nominal fee for this service.
The major benefit of the personalized drug database is that you are prompted to replace each expired item well in advance by email until replaced; you can also alter the recipient of the email, for example, to the practice pharmacist. The most useful feature I think involves controlled drugs, where one can demonstrate an audit trail recording what drug was given to which patient and when. They do of course offer the disclaimer that doctors are still are responsible for checking the name, dose and expiry dates of drugs themselves before administering the drug.
More info at www.doctorsbaguk.com/.
Vitamin D deficiency
We have a growing population of patients who have been diagnosed with vitamin D insufficiency and deficiency. I learnt about osteomalacia and rickets at medical school but have had to learn with time in a London-based practice about vitamin D deficiency, particularly in patients with pigmented skin. I found a recent summary article in the British Medical Journal useful in pulling together all the pieces of information I had collected. In particular, there are useful tables giving sources of vitamin D, risk factors for insufficiency and deficiency, treatment regimes and drug preparations available.
Vitamin D supplementation and treatment has been recently discussed in our practice as we have had various patients sent to us from hospital outpatients with requests for us to prescribe unlicensed medication, often not available from UK sources and sometimes amounting to costs of several hundred pounds per month per patient. Our Primary Care Trust has pushed the local hospitals into agreeing prescribing guidelines, as costs to local pharmacies are far greater than those of hospital pharmacies that can negotiate bulk deals. We are still trying to agree unified local advice for pregnant and breastfeeding women.
You might want to think about how you are going to keep up with changes in practice once you are no longer in a learner-based environment.
Pearce, S.H.S., Cheetham, T.D. Diagnosis and management of vitamin D deficiency. British Medical Journal (2010); 340: b5664
Schools and sick-notes duty
You will be glad to hear that GPs do not have to provide sick notes for pupils who miss school exams. Medical proof is no longer required and the relevant parties have been informed of this.
Learning disabilities
Keep an eye open for a General Medical Council (GMC) online resource about people with learning disorders. People with learning disorders are over 50 times more likely to die before the age of 50 years than the general population. This stems in part from the fact that some congenital causes of learning disability, for example, Downs syndrome, are also associated with physical disease such as heart disease. However, some of the excess mortality may be because the health needs of this group are not as well met as those of the general population. Think about when you last did a cardiovascular screen on a middle-aged patient with learning disability. Have you ever done a smear test on a woman with learning disability and if not how would you go about finding out if she needs one? The GMC hopes to work with people with learning disability this year to create the learning resource.
Safety update on anti-obesity drugs
A recent European review concluded that the cardiovascular risks of sibutramine outweigh its benefits, to such an extent that no new prescriptions of sibutramine are to be issued. In the same breath, the remaining anti-obesity drug, orlistat, has been available as prescription-only drug Xenical 120 mg but also as 60 mg capsules without a prescription at pharmacies since January 2009 (under the brand name Alli).
A recent Medications and Healthcare Products Regulation Agency (MHRA) drug update advised possible drug interactions between orlistat and levothyroxine. This could be due to decreased absorption of iodine salts or levothyroxine (or both). They advise these medicines may need to be taken at different times to reduce the risk of interaction, and the dose of levothyroxine may need to be adjusted. The same applies with those patients taking orlistat and antiepileptic medication particularly sodium valproate and lamotrigine.