Abstract
Thanks
I need to say thank you for Oliver van Hecke who has contributed to this column for 2 years, giving us a viewpoint from the other side of the world and the other end of the career trajectory. He is now embarking on an academic career and I wish him all the best with his doctorate.
Adieu!
There will be always be firsts. Just the other day I did my first consultation ‘within’ a camper van, seeing to an elderly woman who was stricken with diarrhoea. Space was indeed limited but we managed to shuffle by and even set up the bed for an abdominal examination! And that is what I like about general practice—our ability to adapt. There are indeed many changes happening in ‘GP-dom’; for the most part confusing and frustrating. As young GPs and trainees, we have shown our ability to adapt to Modernising Medical Careers (MMC), Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA) and Workplace Based Assessment (WPBA). But I believe that if we place good patient care ‘first’, above all else, then we can rest assured that our patients will stand by us. I was the first junior News & Views editor for InnovAiT; the time has come to move on. I want to thank Clare for her mentorship and Chantal for giving me this opportunity. I would strongly urge all of you to get involved with the College and InnovAiT.
Asylum seekers
I wonder if you know how your practice registers patients. Practices vary a great deal in the degree of vigour that they use to determine the entitlement of patients to National Health Service (NHS) care. Paqueta de Zulueta in a recent British Medical Journal article pleading for compassion in the care of asylum seekers echoed some of the discomfort I feel when I see patients, who may not have such items, being asked to produce utility bills or passports. The NHS, however, is cash strapped and the newspapers are filled with articles about ‘health tourism’ and the money owed to primary and secondary care trusts by foreign nationals. You could discuss the advantages and disadvantages of such controls in a tutorial or a vocational training scheme session.
De Zulueta, P. Asylum seekers must retain access to primary care. British Medical Journal (2011) 243: p. 849.
Supporting self-care for minor ailments
The Royal College of General Practitioners (RCGP) has released an online course looking at ways in which you can encourage patients to look after their own minor illnesses. The course features definition of a ‘minor’ illness, reflection on the concerns of both patients and doctors about missing serious illness, discussion including a patient video about ways of altering your consultation skills to make consultations more ‘self-management’ friendly and advice about other resources available. In the modern world where many patients live isolated from family and social support networks and where we are under pressure to make our care cost effective, I believe that patient education is part of our duty of care.
I have to declare an interest; I am one of the co-authors of the course. www.e-lfh.org.uk.
Ethical decision making
The Human Fertilisation and Embryology Authority has altered the way egg donors are paid, essentially tripling the possible payment. The rationale for the change is to attempt to remedy the low number of donors and to cut down the number of women travelling abroad to countries where regulation may be less strict.
If you were on the committee making the decision how would you have weighed up the advantages and disadvantages? You could try to use an ethical framework to formalize the process. You could add in discussion about whether sperm donors or blood donors should be paid. These sorts of discussions could be written up in your eportfolio.
Receiving information
Have you considered how you will go on receiving medical information once you leave your training practice? During the pandemic flu epidemic, 80% of locum GPs did not receive the necessary information. There has been a recent agreement to use the personal contact details of salaried and locum GPs held on medical performers lists to ensure that they receive important Primary Care Organization (PCO) information. When you move on from your final year of training, it is important that you ensure that the PCO has up to date contact details.
Sharing good practice
The network (a free online community of medical students, junior doctors and newly qualified GPs and consultants) has launched a ‘Projects’ section to share details of quality assurance, service redesign, patient safety or education projects. It is hoped to avoid ‘reinvention of the wheel’, improve quality of care and to publish a selection in the Right Care Casebook Series
Video recording
The General Medical Council has released supplementary guidance on obtaining patient consent for video and audio recordings of consultations. Guidance about the practice recording of telephone consultations is also included.
www.gmc-uk.org/guidance/ethical_guidance/making_audiovisual.asp [accessed 15.10.2011]
111 Services
A new non-emergency helpline to replace NHS Direct is currently being piloted and is expected to be used throughout England by 2013. Similar changes to 24 hour services are not currently planned for Wales, Scotland or Northern Ireland.
Patients are being advised to dial 111 if:
They do not believe that it is a 999 emergency
They think that they need to go to Accident and Emergency or another NHS urgent care service
They do not think that it can wait for an appointment with their GP or
They do not know who to call for medical help
You might want to consider how such a service would affect primary care. If there are doctors in your practice who are involved in commissioning or providing out of hours care, they might be interested in discussing the issues with you.
Actinomyces
It is not routinely recommended to change the coils of women who have actinomyces-like organisms (ALOs) visible on cervical smears. These are Gram-positive non-sporing anaerobic or microaerophilic bacteria that are normal commensals of the vagina. In the past, the presence of ALOs on a smear has led to the recommendation that the coil should be removed and the smear repeated after 3–6 months. Current guidance is that in such women, a clinical history should be taken to decide whether the woman has asymptomatic colonization or symptomatic infection (pelvic pain, fever and bowel symptoms) and action only taken in the presence of symptoms. www.cks.nhs.uk/cervical_screening/management/scenario_managing_cervical_cytology_results/incidental_organisms [date last accessed 25.09.2011]
Osgood—Schlatter disease
I found it helpful to read a ‘10 minute consultation’ summary of the diagnosis and management of Osgood—Schlatter disease. I get a lot of anxious parents wanting me to stop their adolescent child from exercising so it was reassuring to see that my advice about graded exercise is up to date. Sometimes, queries from patients make you wonder if facts that you learnt 20 years ago are still applicable. One of the reasons that I enjoy training is that it forces me to keep up to date on anything that can crop up in consultations.
Weiler, R., Ingram, M., Wolman, R. Osgood-Schlatter disease. British Medical Journal (2011) 343: p. 421
Spotting the sick child
Spotting the Sick Child is a free online resource giving information about the seven most common acute childhood problems: rash, breathing difficulties, dehydration, fever, fits, abdominal pain and head injury. Learning material includes videos, case analysis, medical information and simulations.
Rational testing
The British Medical Journal has run a series of articles on ‘Rational Testing’. I found the one on ‘non-responding’ cough quite useful. It was useful to read an article that acknowledges that symptoms of lower respiratory tract infection take a median of 3 weeks to resolve and a reminder to counsel patients accordingly. There is also a helpful table of investigations to consider when a patient with a lower respiratory infection presents for a second time.
Chalmers, J., Hill, A. Investigation of “non-responding” presumed lower respiratory tract infection in primary care. British Medical Journal (2011) 343: p. 843–5
Cancer risk modification
This week the newspapers have several stories about medications reducing the risk of developing certain cancers. A study published in the Lancet showed that prescribing aspirin to patients at high risk of developing colon cancer significantly decreased the risk. A large European trial showed that women on the oral contraceptive pill may have a reduction of nearly 50% in the incidence of ovarian cancer.
Tsilidis, K., Allen, N., Key, T et al. Oral contraceptive use and reproductive factors and risk of ovarian cancer in the European Prospective Investigation into Cancer and Nutrition. British Journal of Cancer (2011) 105: p. 1436–42
Burn, J., Gerdes, A., Macrae, F. et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. Lancet, Early Online Publication, 28 October 2011 doi: 10.1016/S0140–6736(11)61049–0 [date last accessed 29.10.2011].