Abstract
Finishing training
Once you have cleared all the hoops and hurdles for your final year of training, you should have a few months left to make the most of your remaining protected learning time. As well as the necessary work to complete your portfolio and deal with your Certificate of Completion of Training (CCT) you may wish to try some other activities.
You probably need to update your curriculum vitae (CV). You could share ideas in your study group or use tutorial time. If all your training has been done on one computer system, or in one practice, why not arrange a swap to another practice where you could familiarize yourself with a different system and see a different range of patients? It is recommended that you have an appraisal. Although you may feel that this is just a rehash of the personal development plan you will have completed for your final education review, it is an opportunity to discuss your plans with someone outside the practice and is a halfway house to the real appraisal you will need to remain on the Primary Care Trust (PCT) Performers' List. You could take the opportunity to practise using the National Health Service (NHS) Toolkit and work out how and what data you are going to collect for future appraisals, which will become part of your revalidation evidence. Although audit is no longer formally assessed in the portfolio, you might find it helpful to start one at your training practice before you leave. Most practices will be more than happy to let you come back 6 months later to complete, and you may find this an easier way to get your audit for appraisal than to set one up from scratch while you are establishing yourself as an independent practitioner.
Have a look at the support that will be available for you. If there is no group for newly qualified GPs in your area, why not set one up? You may find your local GP tutor or postgraduate centre would be happy to help.
Out of hours
Many GPs now spend 18 months of training in general practice. The out-of-hours training requirements have risen pro rata. In some areas it has been difficult for trainees to access these extra training sessions. The National Health Service (NHS) Workforce Director General has written to Primary Care Trusts (PCTs) to remind them of their obligation to increase out-of-hours training. In practical terms, it can be difficult to squeeze the sessions in, especially if you include gaps for annual leave and exams. It is probably sensible to space them fairly evenly, as if they all bunch into the last couple of months of your training, access to enough slots could limit you. In our area, sessions at busy bank holiday times are often removed from the teaching availability lists.
One size fits all?
I sometimes wonder whether you read a piece in this column and say ‘I don't buy it’. As Malcolm Gladwell writes, ‘Good writing does not succeed or fail on the strength to persuade’. Instead, it succeeds on the strength to engage you, or to make you think, to give you a glimpse into someone else's head—even if in the end you conclude that you still do not agree. The piece below may just illustrate this.
You may have read the Head-to-Head section in a recent British Medical Journal about whether guideline development has gone astray. The development of guidelines has progressed enormously—from advice from a panel of experts, to consensus statements, to nowadays, inclusion of patient views and public preferences. Although guidelines have improved the delivery of proven treatments and patient health, there is the more sceptical view that clinical guidelines are often formulated by monodisciplinary specialists with specific patient types in mind. The emphasis is dominated by ‘ideal patients' without co-morbidities. However, as you may have noticed general practice is all about comorbidity or, rather, multi-morbidity: what we need is a guideline for each patient, not a guideline for each disease.
In a short editorial by Martin Dawes, he relays an account of a GP seeing a 79-year-old woman who has osteoporosis, type 2 diabetes mellitus, hypertension and chronic obstructive pulmonary disease; she has come in complaining of knee pain that you attribute to osteoarthritis. While deciding what to do about her arthritic pains, you wonder how this all fits in with the recommendations of the five individual guidelines. Often we are unaware of are unfamiliar with the latest updated guidelines; often there is lack of agreement between guidelines.
But I wonder whether we can amalgamate guidance for the most common chronic disease groupings into tables of risk-benefit for all interventions based on the patient's age, gender and morbidities? The example that Martin Dawes gives is a 60-year-old man with diabetes, congestive heart failure, lung disease and stroke with suspected colorectal cancer. The pay-off time (minimum time until benefits exceed harms) for colorectal cancer screening is said to be 7.3 years, whereas life expectancy of this patient is 3.7 years, making screening, in this case, questionable. Such a risk-benefit system might be simple to implement within an electronic medical record system where the (multi-) morbidities are known. Agree or disagree?
Gibbons, R.J., Antman, E.M., Smith, S.C. Has guidelines development gone astray? British Medical Journal (2010) 340: pp. c343
Dawes, M. Co-morbidity: we need a guideline for each patient not guidelines for each disease. Family Practice (2010) 27: p. 1–2
Liquid detergent eye injuries
A recent letter in the British Medical Journal (BMJ) highlights the risk of liquid fabric detergent capsules. Because the ingredients combine to give an alkaline solution, they have a high risk in terms of ocular injuries. The letter reminded us that alkali ocular damage can be permanent and that in children visual deprivation from non-healing or scarring injuries could cause amblyopia. Immediate irrigation and the need to keep the capsules out of the way of children are the take-home messages.
Kennedy MR, Corbett M., Wave of paediatric eye injuries from liquid detergent capsules, British Medical Journal (2010) 340: pp. c1186
Peanut allergy
I struggle giving advice to parents who ask what to do antenatally and during early childhood to cut down the chances of children developing peanut allergy. An article on the Uncertainties page of the British Medical Journal (BMJ) summarized the latest advice on peanut avoidance.
Pregnant and breastfeeding mums are advised that they can eat peanuts regardless of family history of allergy. After 6 months of life, ideally of exclusive breastfeeding, it is suggested that allergenic foods such as peanuts, shellfish and milk should be introduced one at a time.
Parents who have strong family histories of allergy, or where the child already has another kind of allergy, such as eczema, are advised to speak to their GP or health visitor before giving peanuts for the first time. I still do not think that the information we are being given helps us much with answering the parents’ questions. I cannot imagine our local paediatric service would be able to cope with every child with eczema being referred for peanut allergy testing so I will probably go on suggesting that parents avoid giving children under 3 years whole peanuts as they are a choking hazard.
There are several trials currently investigating whether early exposure to peanuts is beneficial but the results will not be available for several years.
Sick children
I expect you all worry about missing serious illness in a child. At the surgery I tend to squeeze sick children in between my other patients and have to have a very good reason for not offering to see a sick child under one in preference to a telephone consultation. I find that if you agree that you will see the child as soon as it arrives, the parents will often bring the child to the surgery instead of pushing for a home visit.
Two recent articles caught my eye. The Lancet published a review of 30 studies on the identification and investigation of sick children. As might be expected, cyanosis, rapid breathing, petechial rash and poor peripheral perfusion were confirmed as red flags. In the developed world, the chances of any one child with an acute infection being seriously ill are low, so admitting or investigating all is not an option. In the only primary care study included, parental concern and clinician suspicion were identified as red flags. A separate study, a presentation from the March meeting of the Society for Academic Primary Care, was previewed in Pulse. Limb pain and confusion in early febrile illness were both identified as red flags, indicating increased likelihood of meningococcal disease.
So in the world of primary care where serious illness is rare what should we do? I think it is useful to see as many children as possible in your training so that you get an idea of the range and level of illness. Use time; there is nothing to stop us seeing a sick child several times in 1 day. Look for red flags. Listen to the concerns of parents and your own gut feelings. Above all safety net.
Van den Bruel, A, Haj-Hassan T, Thompson M, et al. Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. The Lancet (2010) 375 (9717): p. 834–45
Pulse 6 March 2010
Cochrane review for otitis externa
Otitis externa is a condition we see frequently in general practice. Often it is because of the very repetitive nature of the condition. Although there was a paucity of high-quality trials, a recent Cochrane review assessing the effectiveness of interventions for acute otitis externa concluded that topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases, the choice of topical intervention did not appear to influence the therapeutic outcome significantly. It added that patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately 6 days after treatment has begun; if they have symptoms beyond the first week, they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further 7 days.
Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004740.DOI:10.1002/14651858.CD004740.pub2
Vitamin D for severe chronic obstructive pulmonary disease
Weight loss is common in people with advanced chronic obstructive pulmonary disease (COPD), and being underweight is clearly associated with a higher risk of dying. Dietary advice can help to maintain an ideal weight. That said, Belgian researchers from Leuven University have recommended vitamin D supplements to all patients with severe COPD as they believe that vitamin D might also be important in pulmonary function. Vitamin D deficiency in COPD is thought to be a consequence of increased skin ageing secondary to smoking and reduced sunlight exposure as a result of low exercise tolerance. It was found that the degree of vitamin D deficiency correlated to the severity of lung symptoms.
Janssens, W. et al. Vitamin D deficiency is highly prevalent in COPD and correlates with variants in the vitamin D binding gene. Thorax (2009) Dec 8. [Epub ahead of print]