Abstract
Arthritis UK bursaries
Arthritis Research UK has a rolling programme of prizes and training bursaries for GP specialty trainees. In the UK, musculoskeletal conditions affect more than 10 million people or one in four of the adult population. Last year, the National Health Service (NHS) spent more than £11 million a day on their treatment. More than one in five general practice consultations relates to the musculoskeletal system. The Royal College of General Practitioners (RCGP) curriculum states that GPs need to lead on the diagnosis and management of common musculoskeletal conditions as well as being aware of uncommon but important conditions and to be able to manage or refer these appropriately.
The Arthritis UK prize is open to any General Practice Specialty Trainee on a UK Training Scheme. To enter, applicants are asked to submit a piece of original work (up to 3000 words) in the field of musculoskeletal medicine. This could be:
An audit Critical appraisal Case-based discussion Significant event analysis Service development
Arthritis Research UK also offers a number of training bursaries for GPs who wish to develop a specialist interest in musculoskeletal (MSK) medicine and surgery; it will fund up to half of the tuition fees for a postgraduate course in the field of arthritis, musculoskeletal medicine or surgery leading to a PGCert, PGDip, Masters degree or similar recognized qualification. On completion of their chosen course, Arthritis UK hopes that recipients of the GP training bursary will become local MSK champions, in particular identifying learning needs at a local level, helping Arthritis Research UK to deliver education to non-specialist GP colleagues and to set the agenda for future MSK research in primary care.
New online courses
When I look at eportfolios for Panel Reviews, I notice that some aspects of the curriculum, such as learning disability or genetics, can be hard to cover. The RCGP in conjunction with Healthtalkonline has produced an Autism in General Practice course that is free to Associates-in-Training (AiTs). The course uses video clips of patients and their carers. One of the founders of Healthtalkonline was Dr Ann Macpherson whose obituary you may have seen in various newspapers and medical journals in June. She and Dr Andrew Herxheimer used the website to share personal stories of health and illness from over 2000 patients and carers.
e-GP has received an upgraded Learning Management System to facilitate tracking of courses completed or started and to allow reports to be run for appraisal and revalidation.
www.e-lfh.org.uk/projects/egp/index.html
The Medicines and Healthcare products Regulatory Agency has produced a free online learning package on pharmacovigilance. As well as a ‘test yourself’ section, there are sections on classification of adverse drug reactions, monitoring adverse drug effects, where to get information, and the use of ‘yellow cards’.
Countdown to practice
The London Deanery has produced a series of resource packs for pre- and post-CCT doctors including Careers, Teaching Skills and Negotiating with Influence. Plans for future packs include Commissioning Skills and Leadership. The packs could be used for your own learning or as a basis for study group or vocational training scheme discussion.
Migrant health guide
The Health Protection Agency (HPA) in conjunction with the RCGP and the Royal College of Nursing (RCN) has produced a free-to-use online web resource to support primary care practitioners who look after patients who have come to live in the UK. There are sections on entitlement to care (which may be useful summaries for the Applied Knowledge Test), a section on assessing migrant patients and lists of health topics and pages specific to particular countries. There are some links to patient leaflets in a range of languages, although for many of the illnesses that I scrolled through there were only English language leaflets available.
Relationships with patients
Besides general practice, I have a fervent interest in legal medicine. In Melbourne, where I currently practise, a female GP has been reprimanded by the General Medical Council-equivalent, the Australian Health Practitioners’ Regulatory Agency (AHPRA), for unprofessional conduct.
The details of the case are fairly ordinary. Doctor meets and treats patient who is in a vulnerable position. In this case, she treats the patient for clinical depression. Shortly thereafter, they enter into a relationship that eventually turns sour. The remarkable fact here is that she is only found out once the case is brought to the attention of the authorities 15 years later.
As the GMC guidance reiterates: you must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them. Similarly, if you have grounds to believe that a colleague has or may have demonstrated sexualized behaviour when with a patient, you must take appropriate steps without delay.
General Medical Council. Maintaining boundaries-guidance for doctors http://www.gmc-uk.org/guidance/ethical_guidance/maintaining_boundaries.asp [date last accessed 08.07.2011] (2006).
Quality and Outcomes Framework changes
What changes have you noticed in the data that you are supposed to collect for the Quality and Outcomes Framework (QOF)?
Some will be data that we are no longer obliged to collect; some from access indicators and some for diabetes, stroke and coronary heart disease. There are new indicators for epilepsy, learning disability and dementia. Getting involved in a health check for a patient with a learning disability would be a useful way of covering a section of the curriculum that is often hard to complete; do not forget to write a learning log entry if you do so.
The other new use of points is ‘improving Quality and Productivity in the NHS’. The aim is to reduce emergency hospital admissions, to reduce inappropriate outpatient referrals and to promote cost efficient prescribing. I think that it is an interesting move to give QOF points for what on the surface look like cost-cutting processes. It is up to us as a profession to make sure we use these to identify better ways of referring and prescribing that improves the care of our patients. I am less comfortable with the list of low priority procedures being circulated around many primary care organizations. I feel that it is difficult to explain to a patient that they have seen a consultant, been told that they need surgery but that now, retrospectively that need for surgery is not going to be locally funded. What is happening in your areas?
Insulin passports
This month, August 2011, the NHS has to provide all adults who use insulin with an information booklet and an insulin passport that details all of the insulins and other medication used by the patient. Like all other hand-held patient documents, utility will depend on both patients and health professionals learning about the passport and keeping it updated.
New generation antiepileptic medication and birth defects
New research from Denmark has shown that exposure to new generation antiepileptic medication (AEM) during the first trimester of pregnancy does not increase the risk of major birth defects. There was no statistical significance among 1500 women exposed to lamotrigine, oxcarbazepine, topiramate, gabapentin or levetiracetam during the first trimester; 3.2% of infants with a major birth defect versus 2.4% of pregnancies of infants from unexposed pregnancies. Although the study is consistent with a growing body of research about the safety of new generation AEM, it does not show the long-term neurodevelopmental effects.
Mølgaard-Nielsen, D., Hviid, A. Newer-generation antiepileptic drugs and the risk of major birth defects. Journal of the American Medical Association (2011) 305: p. 1996–2002.
While you wait
Does your practice offer facilities for self-service blood pressure monitoring for patients? If your practice does not have such equipment, try motivating your practice to acquire this. Although not a new concept in the UK, it offers patients tired of reading magazines in GP waiting rooms the opportunity to take control of their own health.
Meanwhile, for those patients who prefer to take their blood pressure in the comfort of their own home, Finnish researchers have proposed the optimal schedule for home blood pressure monitoring. They propose that taking measurements twice daily, in the morning and evening, for a period of at least 3 days (preferably seven) offers a ‘thorough image’ of a patient's blood pressure.
Niiranen, T.J., Johansson, J.K., Reunanen, A., et al. Optimal schedule for home blood pressure measurement based on prognostic data—The Finn-Home Study. Hypertension (2011) 57: p. 1081–6.
Running out of alternatives
‘So, are you the type of doctor who prescribes antibiotics?’ I was asked by someone. I looked at her strangely and asked what she meant by this. She said that if she wants antibiotics for her sore throat, she just goes to the one particular GP because he always prescribes antibiotics.
Dr Margaret Chan, World Health Organisation (WHO) director–general, recently said that ‘The world is on the brink of losing these miracle cures. The world is heading towards a post-antibiotic era in which common infections will no longer have a cure, and once again, kill unabated’.
As I write from a (distant) Australia, Europe is in the middle of an Escherischia coli outbreak. Last year, scientists announced clusters of patients in the Indian subcontinent and the UK with New Delhi metallo-beta-lactamase-1 (NDM-1), an enzyme that causes resistance to almost all antibiotics. The widespread non-prescription use of antibiotics in India is a likely contributing factor. There are few new antibiotics for gram-negative organisms in the pharmaceutical pipeline and ‘none’ against NDM-1 producers.
Evidence from the Australian Group on Antimicrobial Resistance—aptly named AGAR—suggests rising antimicrobial resistance in primary care. The group is campaigning for new media campaigns that inform people of the limitations of antibiotics similar to those aired in France and Belgium.
Given that some of you will start out in general practice in August for the very first time, it is your responsibility to change public perception about antibiotic use, and yes, it is still difficult for experienced GPs, but the alternative is …?
Kumarasamy, K., Toleman, M.A., Walsh, T., et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infectious Diseases (2010) 10: 597–602.