Abstract
New Junior Editor
Welcome to Alix Rolfe who has joined us as Junior News Editor. She started ST3 training in Perth, Scotland, in August 2009 and then extended to include academic training at the University of Edinburgh and the birth of her son.
Her interests are mainly medical education and the clinical management of medically unexplained symptoms.
Who doctors the doctors?
‘En nuestra profesión es esencial ofrecer lo mejor de nosotros a los demás. Entonces. ¿por qué no asegurar que exista una buena atención para nosotros mismos en estos casos?
In our profession, it is essential to offer the best of us to others. So … why not ensure that we ourselves have access to good care in these cases?’
I found this quote on the Programa d'atencio integral al metge malait (PAIMM) website; you can read in Catalan, Castilian, French or English as you prefer.
PAIMM is the equivalent of Health for Healthcare Professionals for Spanish doctors. It was set up in Catalunya and is now a national service with guaranteed anonymity for doctors with mental health problems. www.paimm.fgalatea.org/eng/programa.htm
What makes a charismatic teacher?
Rob Buckman, who died recently, was a charismatic teacher.
I have never forgotten my oncology firm. Rob was one of the first doctors to formally teach about consultation. His warmth and ability to teach us to reflect on our words and feelings stayed with me, led me to doing an oncology house job and was a stepping stone to general practice. Have a look at him on YouTube and see what you think. Kermode-Scott, B. Obituary of Rob Buckman. British Medical Journal (2011) 343: p. d7087
Buckman, R. What you really need to know about cancer: a comprehensive guide for patients and their families. Firefly (2006). Accessed via www.youtube.com/watch?v=Jw4ppVMWsGA
Prescribing decisions
Our local Primary Care Trust (PCT) is very overspent and has a range of proposed costcutting plans. Across the board, cuts to the prescribing budget of £150 million pounds have been suggested. Many of these savings are linked to Quality and Outcome Framework (QOF) and Quality, Innovation, Production and Prevention (QIPP) targets. Have you ever asked yourself how we balance the needs of the community against those of individual patients? I disagree on clinical grounds with several of the proposed targets. What would you do under those circumstances? I think the current recession may bring up other ethical dilemmas.
One of the proposed changes is to reduce the percentage of synthetic insulin prescribed and return to prescribing human insulin. I think discussion about this raises another ethical problem. Drug companies promoted the use of synthetic insulin and are heavily involved in secondary care research. If, as is now being suggested, there is little advantage to using synthetic insulin (and a large cost disadvantage), then perhaps we should be asking how such products came into widespread use.
Loss of confidence in GPs
A diagnosis of cancer is a significant event often for both the patient and the doctor. It is often made harder for the both if the diagnosis is delayed as this may have significant consequences. There cannot be many of us who have not gone home and thought ‘why did I not pick that up earlier?’ The hardest diagnostic challenges are patients with vague symptoms and occasionally, time is our most useful tool. But, do the patients lose confidence in us?
A recent article describing a cohort study showed that patients do lose confidence in doctors when a diagnosis of cancer is made, even if it is diagnosed quickly. However, more confidence is lost if there are alarm symptoms and there is a delay in the diagnosis (defined as more than 14 days until cancer-specific investigations are initiated). Interestingly, those with vague symptoms tended to lose confidence in their GP less. But confidence in the GP still remained high at 80%, which is reassuring. Perhaps, the message from this is to make sure that red flags are investigated and, when watchful waiting is used, ensure that the patient returns within 2 weeks.
Mette, L., Rikke, H., Olsen, F., Vedsted, P. Patients' confidence in their GP before and after being diagnosed with cancer. British Journal of General Practice (2011) 61: p. e215–22
Why do patients with cancer die in hospital?
In an Irish review study, about a quarter of patients with cancer were diagnosed during their last admission and three quarters of those patients with cancer who died in hospital were admitted as an emergency with severe symptoms related to their cancer; 38% of patients who died in hospital were stuck there with no place of transfer available.
How does your practice plan the care of its cancer patients? You may find it useful to sit in the palliative meeting or perhaps explore the reasons why your practice does not have one.
Blaney, J., Crawford, G., Elder, T., Johnstone, G., et al. Hospital cancer deaths: late diagnosis and missed opportunity. British Medical Journal Supportive and Palliative Care (2011) 1: p. 113–4
Spirituality in general practice
Many GPs are uncomfortable about discussing spiritual aspects with patients. A recent British Journal of General Practice looks at qualitative research on the role of GPs as spiritual caregivers.
The second of the two pages of the article has a table of role, barriers and facilitating factors for spiritual care. I think they make an interesting base for reflection.
Vermandere, M., De Lepelaire, J., Smeets, L., Hannes, K., et al. Spirituality in general practice: a qualitative evidence synthesis. British Journal of General Practice (2011) 61: p. 680–1
Website of the month
The diagnosis of the menopause and its management are a subject that has often challenged me. Patients often have their own ideas about what is going on and how they would like to manage it, frequently with alternative remedies, many of which I have not heard about. One website repeatedly recommended by colleagues and patients themselves is www.menopausematters.co.uk. This website is written by specialist doctors [part-funded by the National Health Service (NHS)] and is a true treasure trove of information.
Within the pages of this website lies information for medical professionals and patients, describing the symptoms and various therapy options available for the menopause, both traditional and alternative. Leaflets are available for printing as required. Unlike many websites, it also cites many of its sources of information and can also help you find specialists in your area should you need them.
This is an excellent website and I was even able to recommend it during my Clinical Skills Assessment. If you are aware of other websites that colleagues and patients recommend, get in touch so we can spread the word.
Increasing role for exercise
Do you often recommend exercise to patients? There is an increasing body of evidence that it can make a huge difference to patients of all ages and with many different symptoms. A recent small trial has shown significant improvements in chronic back pain in patients who undertook yoga for 3 months instead of usual care. Although there were significant limitations to the trial, such as small numbers, lack of blinding and most of the participants being female, it still highlights that physical therapies should be considered and may well lessen the dependence on medication. I would have liked to have been told whether there were any significant costs savings though.
Tilbrook, H., Cox, H., Hewitt, C., et al. Yoga for chronic low back pain: a randomized trial. Annals of Internal Medicine (2011) 155(9): p. 569–78
Vitamin D and flu jabs
I was interested to see a novel idea from the South Island in New Zealand, which has a climate not dissimilar to ours. There is growing evidence that vitamin D has in a role in many things, from decreasing the risks of heart disease and some cancers to improving bone strength and density. Although the optimum dose has not yet been finalized, many patients, especially the elderly and those who do not receive adequate sunlight, may benefit from supplementation. This trial gave vitamin D tablets once a month to eligible patients when they attended for their flu jab and produced a significant increase in uptake.
The idea of combining the two strategies appeals; although initially it might take time to set up and patients have to be identified, it may well have significant long-term consequences and perhaps other health promotion ideas could also be included. Watch this space.
Lawless, S., White, P., Murdoch, P., Leitch, S. (Preventing) two birds with one stone: improving vitamin D levels in the elderly. Journal of Primary Health Care (2011) 3(2): p. 150–2
Literacy challenges
The Medical and Dental Defence Union of Scotland (MDDUS) recently published an article about the need for increased awareness of poor literacy in our patients. Around one in six patients is thought to have a level of literacy lower than that expected of an 11 years old. But, this is often not immediately obvious as many adults are embarrassed and have learnt to live with their literacy level.
The MDDUS advises extra vigilance and suggests watching out for subtle signs such as poor form filling and unexpected difficulty in explaining and discussing symptoms. Although increasing amounts of written material are given out, this should always be supplemented with verbal instruction; information leaflets are not a substitute for discussion [a point to bear in mind for the Clinical Skills Assessment (CSA)!]. As the General Medical Council good medical practice states ‘share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression and the treatment options available to them, including associated risks and uncertainties. You must make sure, wherever practical, that arrangements are made to meet patients' language and communication needs’.
Although a 10 minutes consultation allows little time for communications skills assessment of the patient, a basic awareness could easily prevent future significant events and improve health outcomes.