News & Views

Healthy working UK

Have you found the Healthy Working UK website? This was developed by the Royal College of General Practitioners with the Faculty of Occupational Medicine and the Society of Occupational Medicine to provide health care professionals with information, training and decision aids to support the management of health and work. Of note is an advice line for GPs, e-learning modules approved by the RCGP and a decision aid app for iphone/ipad or android phones on fitness to work www.healthylivinguk.co.uk.

Faith in consultations

You may have had tutorials where you have discussed the role of your beliefs in consultations. This has been in the news recently after publicity about a GP who is facing investigation after the family of a patient complained that he was using faith in his consultations.

Current interpretation of General Medical Council regulations is that praying with patients is not precluded if the patient is ‘receptive’ to the offer. You might want to think about your approach and whether you need to look at the guidelines. I sometimes actively ask patients if they have a faith or if it is of use to them when we are exploring areas of support.

Rape

It can be difficult to discuss how emotive consultations make us feel. The Havens is a charity that offers support and advice to victims of rape. There are some short You Tube videos that you could use as a basis of discussion for a tutorial. www.youtube.com/watch?v=j3TT0TfQHKM [date last accessed 3.9.2011].

Patients who discharge themselves

I wonder if you read a recent BMJ ‘views’ section proposing that patients who discharge themselves should evoke regret rather than just delight or anger. I must confess I sometimes am grateful when a patient ‘DNAs’ (does not arrive) as it gives me a chance to catch up. The article made me wonder if I should ask what we have done wrong when a patient DNAs. At the surgery, we record when children DNA hospital appointments as this may be a marker for a vulnerable child. Perhaps, you could audit patients who DNA, are any particular group of patients over-represented and do our appointment systems make DNAs more likely?

Warriner, D. Patients who discharge themselves need further thought. British Medical Journal (2011) 343: p. 371

Are all GPs natural leaders?

This question came up at a recent First5 Leadership course a couple of months ago and is something that is a little more difficult to answer than a simple yes or no. You need to look into the mirror (or if you really want the truth ask your partner or spouse!) and ask yourself what leadership characteristics do you exhibit?

I think we all can acknowledge that we show the potential for leadership skills such as the ability to work with a wide variety of people or taking overall responsibility for important tasks. Leadership is based on two sets of theory, namely what a leader has to be as a person (qualities) but also what s/he does to lead (functional). Research has shown that leadership is a trainable transferral skill rather than it being an exclusively inborn ability.

You may think that someone who exhibits an authoritarian leadership style would be worse than a democratic approach. Not so. Think about the last emergency you dealt with in your surgery of hospital. Do you think that it would be appropriate to ask the nurse helping you resuscitate a patient how she felt about fetching the defibrillator? Of course not! In fact, to achieve the best, leadership requires a dynamic approach relevant to the teams' preferred style of leadership and to the task ahead. So sometimes an assertive approach is needed. Other times a more democratic approach is needed, and sometimes, you need to delegate tasks to other team members. The latter is often difficult if you are the new doctor in the ward or surgery, but appropriate delegation of tasks is good leadership.

Once you have decided what sort of a leader you are—authoritarian, democratic or delegative—reflect how that changes when you are under pressure or things are difficult. Recognizing this change in you is essential to improving your overall leadership skills.

Further information about future RCGP Leadership courses can be found on the RCGP website www.rcgp.org.uk.

Making the right diagnosis

I am sure that we have all come across patients that do not conform to our diagnostic process. In fact, just the other day, we (that is myself and the consultant physician) had to step back and reanalyse our preliminary diagnosis in a man with weight loss, night sweats and weakness. Using pattern recognition and rules of thumb, we drafted a list of the ‘usual suspects’. Relying on rules of thumb, educated guesses or intuition is known as heuristics and speeds up the diagnostic process. This is often essential in a 10 minute consultation.

However, always relying on this process will lead to failure or wrong diagnosis or what experts call ‘irreducible uncertainty’. So, in the example above, concluding that his symptoms are due to lymphoma may miss an infective cause such as tuberculosis. Being aware of possible diagnostic bias can reduce this risk.

So what biases may compromise a clinician's critical eye? Using the same example, some of the more common biases include:

Be mindful of these five common cognitive biases before you order the next battery of investigations or stumble upon a clinical conundrum.

Williams, S. Tunnel vision. Medical Protection Society Casebook (2011)19 (2)

Oral anticoagulants

Patients on lifelong warfarin have already asked me when they will be able to use the new oral anticoagulants. We have also had emails from the Primary Care Trust (PCT) pharmacist reminding us that new drugs, such as dabigatran, manufactured by Boehringer Ingelheim, and rivaroxaban manufactured by Bayer, may not get PCT formulary approval.

This made me wonder how we keep up-to-date with new developments and how we weigh up the interests of individual patients against those of the patient community as a whole. If I were a patient on a drug that needed frequent monitoring and was then offered one that did not need regular monitoring, I would put quite a high value on it. If it was equally but not more efficacious than a standard treatment and more expensive, then how would I prioritize it if I were setting a PCT budget? These issues are happening in general practice as we speak, and GP commissioning means that we will not be able to hide our role in rationing behind that of a faceless primary care organization.

New National Institute for Health and Clinical Excellence guidance on management of hypertension

The National Institute for Health and Clinical Excellence (NICE) has released new hypertension guidance that recommends large changes in the way that we diagnose and treat hypertension.

Perhaps the greatest change is the recommendation that if clinic blood pressures consistently read over 140/90, then the patient should be offered ambulatory or if not tolerated home blood pressure monitoring.

The second change is a recommendation to use calcium channel blockers as first line except for patients under 55, where angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remain first line.

If blood pressure remains uncontrolled, addition of thiazide diuretics is recommended, but chlortalidone or indapamide rather than the previously widely used bendroflumethiazide or hydrochlorothiazide. A final major change is a strong recommendation for active treatment of hypertension in the over 80s with a threshold of 160 mmHg systolic and a target treatment of 150/90 or less.

These changes have process and cost implications. They also leave us with decisions about if or when to alter the care of current patients. You might want to consider how practices manage change in guidelines for patients on regular medication. You could also discuss how practices and the primary care organizations tackle recommendations such as ambulatory blood pressure monitoring that involve new workload with a need for new equipment and new skills. At our surgery (about 11000 patients), we have for some years offered ambulatory and home blood pressure monitoring. We have 2 ABPM machines and 10 Omron machines. Our nurses and reception team could probably describe the complexity of keeping track of loaned equipment.

NICE. Clinical Guideline 127 Clinical management of hypertension in adults. Accessed via http://guidance.nice.org.uk/CG127 [date last accessed 3.9.2011]

Adverse effects of vaccines

A committee of the United States Institute of Medicine has concluded that vaccines are safe and rarely result in adverse events. They divided vaccines into four categories:

In the first category, there is convincing evidence to support a causal relationship between the vaccine and harm. This group included some vaccines such as mumps, measles and rubella (MMR) and influenza vaccines that very occasionally cause anaphylaxis and the live polio vaccine that can cause paralytic polio.

In the second category, the evidence favours a causal relationship but is not convincing. For example, MMR vaccine probably causes temporary joint pains.

The committee also placed some vaccines into a third category where the evidence favours rejection of a causal relationship. Good examples of this are that MMR does not cause autism and killed flu vaccine does not cause Bell's palsy.

However, most adverse events were placed in the fourth category where the evidence was inadequate to accept or reject a causal relationship.

Accessed via www.iom.edu/Reports/2011/Adverse-Effects-of-Vaccines-Evidence-and-Causality.aspx [date last accessed 3.9.2011].