Abstract
Change in curriculum
If you started training in August 2011, you should have been notified of some changes to the curriculum. You can download a summary document from the Royal College of General Practice website. General practice is undergoing massive change so it is inevitable that the curriculum for GP training should change to reflect this. You may find that older textbooks refer to the previous curriculum versions. www.rcgp-curriculum.org.uk/curriculum_documents/changes_to_the_curriculum.aspx.
Lost in transliteration
I was entertained by recent British Medical Journal filler where the author read Shakespearean quotes to his medical Dragonspeak voice recognition programme. Medical notes were translated accurately but ‘let me not to the marriage of true minds admit impediments’ (from Sonnet 16) became ‘nor a marriage of true my Sinemet vitamins’
Packer, C. Lost in transliteration. British Medical Journal (2011) 343: p. 259.
Risk explanation
It can be hard to think of learning log entries for some parts of the curriculum, such as evidence-based practice. Many of us struggle with statistics, so how are we supposed to explain risks or benefits to patients. Two recent British Journal of General Practice articles looked at how the way we choose to explain things to patients or colleagues affect the choices that they make.
You could reflect on the way you explain the pros and cons of particular treatments to patients. Do you describe something as having a 96% chance of a positive result or a 4% chance of a negative result? I was very aware during the swine flu epidemic that I had decided that a 24-hour reduction in symptom duration was not worth the side effects of taking Tamiflu so it is not surprising that during the whole epidemic, I only wrote three prescriptions for antivirals.
Risk explanation is one of the things that you are often asked to do in the Clinical Skills Assessment and that you can practice in role-plays with colleagues.
Hudson, B., Toop, L., Mangin D., Pearson, J. Risk communication methods in hip fracture prevention: a randomized trial in primary care. British Journal of General Practice (2011) 61: p. 502–3.
Halvorsen, P., Wisloff, T., Stovring, H., Aasland, O., Kristiansen, I.S. Therapeutic decisions by number needed to treat and survival gains: a cross-sectional survey of lipid-lowering drug recommendations. British Journal of General Practice (2011) 61: p. 504–6.
Controversy over gatekeeping
GPs are proud of being gatekeepers and believe that the gatekeeper role contributes to the cost-effectiveness of British general practice. A Danish paper uses data about poorer cancer survival in British and Danish patients to suggest that gatekeeping may have serious side effects. Roger Jones in his editorial espouses the ‘heresy’ that population health outcomes and percentage of gross national product spent on health care in non-gatekeeper systems matched or bettered the UK. You are training for a world where health care is undergoing massive change. Is gatekeeping something that you believe in and would fight for? If we are challenging such an established tenet of British general practice are there other immutable processes that should be examined?
‘Holding relationships’ (maintaining a constant doctor–patient relationship providing ongoing support without expectation of cure) could be regarded as an extreme example of gatekeeping. Most GPs have a small number of patients who could be described as having ‘medically unexplained symptoms’ or being ‘heart sink’ patients. In a qualitative study, both GPs and patients described the value that they got out of the relationships.
In your training, you will almost certainly spend some time discussing what ways you are going to use to deal with such patients. Acting as a gatekeeper and avoiding unnecessary investigations and referrals for these patients is traditionally regarded as one of the aspects of good general practice. Playing devil's advocate one could ask if arranging regular appointments for this group of patients (often used as part of a contract rationing access to care) is fair to the rest of our patients, as such frequent attenders get a much greater percentage of our time. You could use an ethical framework to look at the justice aspects of the situation.
Jones, R. Editor's briefing. British Journal of General Practice (2011) 61: p. 483.
Vedsted, P., Oleson, F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? British Journal of General Practice (2011) 61: p. 512–3.
Cocksedge, S., Greenfield, R., Nugent, G., Chew-Graham C. Holding relationships in primary care: a qualitative study of doctors' and patients' relationships. British Journal of General Practice (2011) 61: p. 506–7.
Exercise is good for you
I spend a significant length of time trying to persuade patients to become more active as I think it is easier to lose weight if you exercise more as well as altering your diet.
Two recent studies add ammunition to my arguments. The first measured the activity of nearly 3000 older health professionals known to be at risk of cardiovascular disease. The most active women had a significantly lower rate of cognitive decline over 5 years.
The second study used doubly labelled water to measure activity including fidgeting and standing (a proxy of total energy expenditure) in a group of about 200 men and women over 75. The higher the level of energy expenditure, the lower the rate of cognitive decline over a 2–5 year period.
Vercambre, M., Grodstein, F., Manson, J., Stampfer, M.J., Kang, J.H. Physical activity and cognition in women with vascular conditions. Archives of Internal Medicine (2011) 171(14): p. 1244–50.
Middleton, L., Manini, T., Simonsick, E. et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine (2011) 171(14): p. 1251–7.
Discontinuation of aspirin
A large retrospective study has shown a nearly 50% increase risk of non-fatal myocardial infarction or death from coronary heart disease in primary care patients on discontinuation of secondary prevention aspirin. Previous studies have been based in secondary not primary care.
In practical terms, such patients can discontinue because they run out of repeat prescriptions on a batch dispensation, aspirin gets overlooked on a subsequent hospital admission and aspirin is stopped several times for cancelled surgical procedure. What steps does your surgery take to check that patients on repeat medications remain on them?
García Rodríguez, L.A., Cea-Soriano, L., Martín-Merino, E., Johansson, S. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. British Medical Journal (2011) 343: p. 195.
Treatment of pain in patients with dementia
How would you decide if a patient with dementia (or learning disability) was in pain? This could be something that you could discuss at a vocational training session or a tutorial and might be an interesting way of completing a learning log entry on learning disability or care of older adults.
A recent study on patients with severe to moderate dementia showed that a systemic approach to pain management reduced agitation and the prescription of psychotropic drugs.
Husebo, B., Ballard, C., Sandvik, R., Nilsen, O.B., Aarsland, D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. British Medical Journal (2011) 343: p. 193.
Zwakhalen, S.M.G., Hamers, J.P.H., Abu-Saad, H.H., Berger, M.P.F. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatrics (2010) 6: p. 3.
Missed pill rules
When the missed pill rules changed in 2005, I struggled to concisely explain them to patients and must confess I sometimes gave patients a more simplistic explanation based around the mantra ‘never have more than 7 days without a pill inside you’.
The rules have now been rewritten in a simplified form once more, emphasizing the need for regular pill taking particularly around the pill-free interval. A recent Journal of Family Planning and Reproductive Healthcare discusses the pros and cons of the new advice. The Faculty of Family Planning and Reproductive Healthcare Clinical Effectiveness Unit produces regular guidance on all aspects of family planning. There is usually a useful and short summary of each new set of advice.
Mansour, D. Revision of the ‘missed pill’ rules. Journal of Family Planning and Reproductive Healthcare (2011) 37: p. 128–31.