Abstract
PEP—online self-assessment learning tools
The RCGP has two web-based self-assessment exercises available.
Founded on the nMRCGP (New Membership of the Royal College of General Practitioners) methodology, they consist of items mapped across all appropriate GP curriculum areas, and all scenarios reflect real clinical events encountered in the surgery. They are formative tools that identify and summarize your learning needs.
Both nPEP and modularPEP offer an interactive report facility to help you identify learning needs.
Details on how to purchase, associated costs and further information can be found on their respective websites:
Doctoring the doctor and a new RCGP e-learning update
If a doctor is doctoring a doctor
Does the doctor doing the doctoring
Doctor the doctor being doctored
The way the doctor being doctored
Wants to be doctored,
Or does the doctor doctoring the doctor
Doctor the doctor being doctored
The way the doctoring doctor usually doctors?
Lipsitt, D., Schneck, S. Doctoring doctors. Journal of the American Medical Association (1999); 281(12): p. 1084
Health professionals, like their patients, become ill. If you have had any experience in dealing with patients who are also health professionals, you will Associate in Training (AIT) know that the entire ‘style’ of consultation is different. Doctors in particular are poor patients. We tend not to consult our GP as it is viewed as a sign of ‘weakness’. We are not meant to fall ill or fail. Instead, we would rather subscribe to having a ‘corridor consultation’. We often find innovative ways of obtaining health care and are at risk of inappropriately self-diagnosing, self-prescribing and even self-referring.
But poor practitioner health adversely affects the care of patients, health care costs, the lives of the physician's colleagues, family and friends and the physician themselves. So says a new RCGP e-learning initiative which explores the issues around doctors' health and what can be done to improve care of your patients who are themselves practitioners.
The e-course—Health for Healthcare Professionals—consists of seven sessions with an estimated completion time of 5 hours which can be done at your own pace. The course is free fro RCGP members and AiTs and is part of the RCGP Certificate in Practitioner Health. After completing the online courses, you can further your skills and receive a certificate by attending a face-to-face training day. You can access the course on http://elearning.rcgp.org.uk/.
Newspaper headlines
How do you manage patients who come in to discuss cuttings from the newspaper (or the internet)? This week there have been new studies suggesting that users of oral contraceptive pills containing drospirenone rather than levonorgestrel are more likely to develop venous thromboembolism.
Locally, the headlines in the free newspaper advertised the death of a neonate at our local hospital, implying system failure as a cause.
You might want to think how you handle consultations about such stories; what you would do if you had no previous knowledge and how you would go about assessing the evidence. You could probably think up an example case to practise as a Clinical Skills Assessment or use the oral contraceptive papers as a way to practise critical reading.
Parkin, L., Sharples, K., Hernandez, H. et al. Risk of venous thromboembolism in users of oral contraceptives containing drospirenone or levonorgestrel: nested case-control study based on UK General practise Research database. British Medical Journal (2011); 342: p. 961
Jick, S., Hernandez, R. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. British Medical Journal (2011); 342: p. 960
Ovarian cancer
The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for the recognition and initial management of ovarian cancer.
There are specific recommendations for its detection and testing in primary care. As well as urgent referral for high suspicion of cancer, e.g. patients with a pelvic mass, the guidelines suggest measuring the serum cancer antigen (CA) 125 concentration in women, particularly those over 50 having persistent or frequent (more than 12 times a month) abdominal distension, feeling full or loss of appetite, pelvic or abdominal pain, unexplained weight loss or fatigue or increased urinary urgency or frequency. The guidelines remind us that women over 50 are unlikely to present with their first ever symptoms of irritable bowel syndrome at this age.
National Institute for Health and Clinical Excellence. Recognition and initial management of ovarian cancer. (2011). Accessed via www.nice.org.uk/nicemedia/live/13464/54266/54266.pdf.
Paediatric tips for GP trainees
Managing sick children in general practice requires a different approach from that used for adults. In relation to this, the British Journal of General Practice is running a series of short articles for GP trainees in preparation for their various rotations. The most recent one focuses on paediatrics. The article is useful, in that it is written from the perspective of a GP registrar and highlights the subtle nuances in dealing with children (and parents). Importantly, the authors normalize the fears we all might have about cannulating a small child for example. The authors candidly highlight the dos and don'ts during this rotation such as checking (and rechecking) doses in the British National Formulary for Children. Definitely worth a look for those starting their paediatric block soon.
Burke, M., Goodman, A. Tips for GP trainees working in paediatrics. British Journal of General Practice (2011); 61: p. 68–9
Health outcomes of long-term conjugated estrogen use
In 2004, the Women's Health Initiative Estrogen-Alone Trial was stopped early after 7 years of follow-up because of an increased risk of stroke and little likelihood of altering the balance of risk to benefit by the planned trial termination date. However, researchers decided to continue monitoring patients for outcomes despite the study protocol discontinuation to gain insight into the long-term effects of conjugated equine estrogen (CEE) therapy.
Their study examined the health outcomes of over 10 000 US women (aged 50–79 years) with prior hysterectomy randomized to treatment with CEE (0.625 mg/day) after a mean of 10.7 years of follow-up. The primary outcomes were coronary heart disease (CHD) and invasive breast cancer. A global index of risks and benefits included these primary outcomes plus stroke, pulmonary embolism, colorectal cancer, hip fracture and death.
Overall, most of the negative and positive effects of CEE therapy were not maintained during the post-intervention period with almost all health outcomes showing little difference between the placebo and estrogen groups. Importantly, the results over the follow-up period showed that lower breast cancer incidence in the CEE group persisted (0.27% compared with 0.35% in the placebo group). Interestingly, the risk of stroke was no longer elevated during the post-intervention follow-up period and was 0.36% among women receiving CEE compared with 0.41% in the placebo group. Health outcomes were more favourable for younger compared with older women for CHD, total myocardial infarction, colorectal cancer, total mortality and global index of chronic diseases.
Although this study would probably not change your hormone replacement therapy prescribing practice radically, it does add that among postmenopausal women with prior hysterectomy, CEE use for a median of 5.9 years was not associated with an increased or decreased risk of CHD, deep vein thrombosis (DVT), stroke, hip fracture, colorectal cancer or total mortality. A decreased risk of breast cancer persisted.
Lacroix, A.Z., Chlebowski, R.T., Manson, J., et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial. Journal of the American Medical Association (2011); 305(13): p. 1305–14
Maternal deaths
My thanks to Dr David Moore, a First Five reader who sent a summary of his study group's learning points from the latest confidential enquiry into maternal deaths.
Leading direct causes of death were sepsis, pregnancy-induced hypertension and thromboembolism
Arrange active follow-up of high-risk mental health patients (e.g. severe depression and psychosis) Check blood pressure (using a manual cuff and not electronic) and dip the urine in pregnant women as a routine part of the consultation Think about pregnancy (ectopic) in any woman of childbearing age Check family history of mental health problems Consider diarrhoea, vomiting and fainting as symptoms of ectopic pregnancy Consider having a pregnancy test kit in your doctor's bag Use a professional interpreting service not family members Have a high level of suspicion in pregnancy for DVT Consider cardiac disease in pregnancy, e.g. myocardial infarction Hyperemesis is a risk factor for DVT and if symptoms are not controlled and the patient is dehydrated, she may need admission/low-molecular weight heparin injections
Sepsis was the leading cause of death—think of pregnancy as an ‘immunocompromised state’, with increased susceptibility to infection and potential for rapid deterioration, and a lower threshold for antibiotics. Give intramuscular benzypenicillin in sepsis and arrange a blue light ambulance. Give advice about handwashing before and after going to the toilet to prevent bacteria going from the skin to the genital tract. [www.cemach.org.uk/Publications-Press-Releases/Report-Publications/Maternal-Mortality.aspx (date last accessed April 2011)].