News & Views

Self-treatment

The British Medical Association (BMA) recently reiterated guidance on treating oneself, family and friends. The key point is that we have a responsibility to ensure that our health problems do not interfere with patient care.

There has always been a ‘the show must go on’ ethos. Would you want to be treated by a doctor who was too unwell to work? When you are unwell it is often difficult to make an objective decision about fitness to work. You should be registered with a GP but, perhaps more importantly, you should see that GP rather than colleagues when you are unwell. The advice is also to avoid treating or prescribing for family and friends. You might want to ask yourself what you will do if one of your children is unwell. It can be very difficult to take time off work to take your child to see the GP; enhanced access times and walk-in centres might be helpful here.

Confidential advice for doctors in difficulty is available from the BMA Counselling Service (08459200 169) and the Doctor Advisor Service (020 7306 3272).

Self-diagnosis

I saw a retired chap a few weeks back with the presenting complaint of general fatigue for a couple of weeks for no apparent reason. After a thorough clinical examination, and some battery of tests, I could not find much to explain his tiredness—not an uncommon occurrence. He came back the other day, telling me that his tiredness had now resolved but that he had found the reason for his fatigue.

Often patients come in with preconceived diagnoses that may explain their symptoms. This process of self-diagnosis (or self-labelling) is said to occur in approximately 18% of consultations. From this, self-management is usually met with high degrees of patient satisfaction. As GPs, we are always encouraged to explore where these preconceived ideas (however bizarre) have originated. Often this may mean acknowledging the patient's self-diagnosis (or probability thereof) before exploring the self-diagnosis. Above all, this self-diagnosis should always be challenged and/or refined.

Patients may often make incorrect self-diagnoses without any consequences, e.g. the day after an episode of Channel 4's ‘Embarrassing Bodies’. But studies have shown that the accuracy of self-diagnosis can be correct with certain ailments such as recurrent urinary tract infections or recurrent anterior uveitis but less likely with pregnancy, vaginal candidiasis and scabies.

Patients may also have correct ideas that we had not thought of. So in my case, this chap's symptoms almost completely resolved after staying with his son for a week's holiday. His self-diagnosis proved to be correct—a leaking gas outlet indoors—verified by the gas engineer.

Goyder, C., McPherson, A., Glasziou, P. Self diagnosis. British Medical Journal (2010) 340: p. 204–6

www.bma.org.uk/ethics/doctor_relationships/doctorswhoarepatients.jsp

Removal of patients from GP lists

I am not sure how many of you will see this in the practices where you work, as it is not common. It is, however, a disruptive and disturbing process. I have removed one patient from my list in 20 years as a doctor and still have very vivid memories of the process.

Patients can complain about being removed so it is very important that the removal is done in a transparent way, with the patient being kept aware at every stage of the process.

If possible the steps should include

If the problem is urgent, e.g. a violent patient, you should report the incident to the police and inform the Primary Care Organization within 7 days. In such cases, it is then the responsibility of the primary care services to organize medical care. In my case, I found that the primary health care organization, the police and my medical defence organization were all very supportive.

Removal from the list is the end of the road in the doctor-patient relationship. You might want to look at the systems that your practice have in place to try to fend off problems at a much earlier stage. An article in the British Medical Journal a few years ago gave a thought-provoking description of some patients' reactions to being removed from the list; there are two sides to every story.

Stokes, T., Dixon-Woods, M., Windridge, K. et al. Patients' accounts of being removed from their general practitioner's list: qualitative study. British Medical Journal (2003) 326: pp. 1316. DOI: 10.1136/bmj.326.7402.1316

www.rcgp.org.uk/PDF/Corp_removal_of_patients_from_gp_lists1.pdf

Rural forum

A rural forum has been set up, aimed at all who have an interest in rural medicine and open to all Royal College of General Practitioners (RCGP) members. England, Scotland, Wales and Northern Ireland have 19, 31, 36 and 42%, respectively, of their population classified as rural. You might want to think about the differences and similarities between rural and urban primary care. On our local vocational training scheme, we encourage swaps between different practices to look at different patient groups and computer systems. Perhaps swaps further apart might be beneficial?

ruralforum@rcgp.org.uk

Fit notes

Have you learnt how to use the new fit notes yet? I like the option of being able to use information from telephone consultations; I am hoping it will save on consultations for routine post-operative certification. I am in the fortunate position of having had an occupational health consultant as one of my registrars so she gave me very useful advice about modifications to hours and activities that might facilitate return to work, but I wonder how many of us have had any formal training on this?

I am not sure that limiting the first 6 months' certificates to a maximum of 3 months' duration will make much difference to my current practice; I cannot think of many situations where I would immediately offer a long-term sick note.

www.dwp.gov.uk/docs/fitnote-gp-guide.pdf

Changes to the disease notifications process

If you do not already know, there have been changes in the law relating to the notification of disease to public health. This has come into effect already on 1 January in Scotland and on 6 April in England and Wales.

Importantly, all medical practitioners are now required to notify a number of specified diseases on the basis of clinical suspicion rather than awaiting laboratory confirmation. For example, a clinically suspected case of Escherichia coli O157 infection must now be notified. If you have good reason to believe that another doctor has already notified, then there is no reason to do so, but prior notification by the lab does not remove the doctor's responsibility to notify.

In addition, doctors should notify a number of health risk states where there may be a significant risk to public health. Cases of patients who die with, but not necessarily because of, any notifiable disease or other infectious disease or contamination that presents, or could present, significant harm to the health of others. Doctors must now notify on cases where contamination from environment could have played a part, such as with chemicals or radiation.

Besides adding a number of illnesses to the list including Legionnaires Disease, some individual clinical diagnoses are no longer notifiable, e.g. food poisoning, although if you become aware of a serious outbreak, you are still required to notify this as a health risk state.

For urgent notification of matters of serious public health significance contact the local health protection unit office or out-of-hours phone of the local hospital and ask for the on-call public health.

Further details can be found depending on your geographical location at:

Public Health (Control of Disease) Act 1984, Health Protection (Notification) Regulations 2010. Accessed via www.opsi.gov.uk/si/si2010/uksi_20100659_en_1 Health Protection Legislation (England) Guidance 2010. Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_114510

Public Health etc. (Scotland) Act 2008. Accessed via www.scotland.gov.uk/Topics/Health/NHS-Scotland/publicact/Q/editmode/on/forceupdate/on

Diabetes and Ramadan

Have you ever thought how fasting affects diabetes during Ramadan? Well, Ramadan, the ninth month in the Islamic calendar starts Wednesday 11 August 2010 for Muslims in the UK. It is a period of prayer, fasting, charity-giving and self-accountability for Muslims. Fasting is obligatory upon each sane, responsible and healthy Muslim.

Despite the prevalence of diabetes mellitus being considerably higher among the Muslim population and that diabetics are exempt from fasting, most Muslims with diabetes will choose to fast. There are obvious concerns that fasting may lead to hypoglycaemia, hyperglycaemia with or without ketoacidosis and dehydration. There is also some reluctance to take medications during the fast.

In a review article in the Journal of the Royal Society of Medicine (JRSM), the authors give guidance towards the care of the Muslim patient with diabetes during Ramadan. They suggest a pre-Ramadan medical assessment, where among other things, specific advice is given about the potential risks of fasting and how to prevent complications, e.g. when to break the fast.

It seems those at most risk are type I diabetics and type II diabetics on sulphonylureas. In the first instance, type I diabetics should be strongly advised not to fast. However, if they choose to do so, the general advice for long-acting insulin (glargine and detemir) is to reduce the dose by 20%; type II diabetics on diet control and metformin should be able to fast without problems; the authors do suggest altering the timing of metformin to one-third at dawn and two-thirds at dusk. Sulphonylureas should be used with caution. Newer agents such as incretin-based therapies appear to be safe.

Karamat, M.A., Syed, A., Hanif, W. Review of diabetes management and guidelines during Ramadan. Journal of the Royal Society of Medicine (2010) 103: p. 139–47

New diabetic classification

A working group supported by National Health Service (NHS) Diabetes and the Royal College of General Practitioners (RCGP) has proposed a new classification system for diabetes that includes gestational diabetes as a form of non-diabetic hyperglycaemia and includes an ‘unknown’ category to place people before a definite classification has been made.

Figures presented at the Diabetes UK Conference 2010 suggested that about 40% of people classified as having type 1 diabetes have type II diabetes and about 6% of patients diagnosed with type II diabetes do not have the condition at all.