Abstract
Website of the month
Although this may come a little late for those of you who took the Clinical Skills assessment (CSA) in February/March of this year, there are a couple of excellent websites that I can recommend from my own experience for those of you yet to sit it. Firstly, have a look at www.bradfordvts.co.uk. This site has great advice about the exam, including how it is structured and what the examiners are looking for. In addition, it also has advice about the areas that let people down—it is not always what you think. Another excellent website is www.pennine-gp-training.co.uk. This website comes recommended by both trainees and trainers because it contains a substantial number of possible CSA scenarios, often with a mark sheet similar to that found in the exam. However, none of these are substitutes for making up your own scenarios and plenty of practice.
Lancet access
A 3 year contract with Elsevier, the publisher of The Lancet, has been negotiated. If you already have an Athens account, you will be able to access when you log in. If you have not organized a free Athens account, talk to your trainer or practice manager; you should be able to get log in details from your Primary Care Organization.
Pilots of GP boundary changes
It has been announced that there will be pilots in London, Manchester and Nottingham to allow patients to register with GPs near to their workplace. You might want to discuss with your trainer or workshop colleagues what implications this may have for continuity of care, safeguarding and home visits. You may be able to think of other issues. Discussions such as these may produce useful ePortfolio entries under headings such as clinical governance or ethics.
Sessional GP groups
I wonder if you have asked yourself how you are going to replace the support you get on your vocational training scheme. There are plenty of resources for newly qualified GPs including First5 and local initiatives such as Faculties of the Royal College of General Practitioners and Countdown to Practice in London. Specific groups for sessional GPs have the advantage of giving newly qualified GPs access to the experiences of GPs who may have been working much longer.
The British Medical Association (BMA) has produced guidance on how to set up and develop a sessional GP group. The BMA also produces a regular newsletter for sessional GPs, including information specific to Wales, Scotland and Northern Ireland. Reading the letter while you are still in training might help inform your employment negotiations when you start work as a fully qualified GP. By the time this Newsletter comes to press, there should also be a new version of the BMA Locum Handbook available online.
Medicine on film
As a change from a tutorial with your trainer, consider watching a film instead. Although they may be highly stylized, it is interesting and useful to see how clinical problems and the medical profession are portrayed in different ways in films and on television. These portrayals may guide many patients' expectations of the health service. An interesting one that I watched was ‘Wit’, a television movie starring Emma Thomson as a university professor who is diagnosed with metastatic ovarian cancer. It follows her through various treatments, discussing her thoughts and feelings. I thoroughly recommend it for insight into the patient journey.
Cardiopulmonary resuscitation changes
More patients have discussed cardiopulmonary resuscitation (CPR) with me in the couple of weeks since Vinnie Jones appeared on television screens performing hands only CPR to staying alive by the Bee Gees than have brought it up for the whole of my GP career. As an n = 1 study, this is a very successful publicity campaign. www.bhf.org.uk/hearthealth/life-saving-skills/hands-only-cpr.aspx.
Tinnitus
The publicity for Tinnitus Awareness Week (February 2012) drew my attention to the British Tinnitus Society website. I work in an area that has poor audiology services and it was useful to find a resource for both patients and health professionals. You could at least read the ‘Top Ten Tinnitus Tips for GPs’.
In a recent buddy group discussion, it emerged that each month we were referring many patients with tinnitus for imaging or an opinion. A discussion based on the Map of Medicine guidelines ensued, and we are hoping to demonstrate that we have reduced unnecessary referrals. http://eng.mapofmedicine.com/evidence/map/tinnitus1.htmlwww.tinnitus.org.uk.
Ovarian cancer
A new online calculator has been produced to help identify the risk of ovarian cancer in a patient with a particular combination of symptoms and underlying predisposing factors. At the time of writing (January 2012), the website was incomplete, with just the risk calculator without information about the research on which the calculator is based. The risk is given both as a percentage and in visual form so might make a useful basis for discussion with patients.
The calculator calculates the risk for other common cancers and is based on UK population studies. www.qcncer.org/ovary.
National Society for the Prevention of Cruelty to Children
The National Society for the Prevention of Cruelty to Children (NSPCC) produces a variety of publications for health professionals and patients. The patient leaflets are available in downloadable PDF format and might be useful for you to read as well as share with patients. The most recent leaflet, ‘All babies count: support for parents’ is designed to help parents adjust to having a new baby and gives advice about bonding, feeding, crying babies, domestic violence and postnatal depression among other topics. www.nspcc.org.uk/Inform/publications/leaflets_for_parents_wda75350.html.
Anaphylaxis
Do you know when to refer your patients and how likely it is that they have had an anaphylactic reaction? National Institute for Health and Clinical Excellence (NICE) guidelines discussing what to do after a patient has had a suspected anaphylactic reaction that has required emergency treatment have recently been published. This has been well summarized in the British Medical Journal (BMJ) and, as well as giving guidance about management in the acute phase, they also discuss the importance of age-appropriate referral pathways to specialist allergy services. While awaiting the appointment, an emergency adrenaline injector can be given but patients must be shown how to use it and what to do in the case of a further reaction. The summary also highlights communicating to the patient the reasons for a referral and stresses that information about patient support groups should be given.
Dzingina, M., Stegenga, H., Heath, M., Jones, D., Rogers, G., Kleijnen, J., et al. (2011). Assessment and referral after emergency treatment of a suspected anaphylactic episode: summary of NICE guidance. British Medical Journal, 343, p. d7595. doi: 10.1136/bmj.d7595
Epilepsy guidelines
I find the management of epilepsy a challenge. Since my neurology house job over 20 years ago, there have been massive changes in both classification and treatment. The new NICE guidelines clarify the use of both old and newer drugs. They specify that the type of drug used should be determined by the epilepsy syndrome, if known, or by the type of seizure. There are also reminders about choice of epilepsy medication in women of child-bearing age. http://guidance.nice.org.uk/CG137.
Prostate-specific antigen testing
The argument for and against prostatespecific antigen (PSA) testing continues. A recent article in the Journal of Family Practice looks at the recent evidence, including a BMJ systematic review and meta-analysis and concludes that, although more cancers are picked up, no more lives are saved. This is far from ideal, considering the physiological, psychological and potential financial costs of being diagnosed with prostate cancer. However, they do suggest that a small sub-group may benefit. These are men aged 50–75 years who have no cardiovascular risk factors. The rest reap no benefit at all. The debate continues.
Slatkoff, S., Gamboa, S., Zolotor A., Mounsey, A., Jones, K. (2011). PSA testing: when it's useful, when it's not. Journal of Family Practice, 60 (6), p. 357–360
Multiple myeloma
Myeloma is often a very difficult presentation, possibly with vague symptoms, slightly odd routine blood results and an insidious course. These patients can present late and challenge the GP to work out what is going on even though myeloma accounts for about 10% of all haematological malignancies. Over half of patients wait at least 6 months before diagnosis, with a third waiting over a year. The latest in the BMJ ‘Practice—easily missed’ series discusses multiple myeloma in more detail. It explains why it is often missed and how this can have adverse effects for the patient. The most common symptoms and investigations are discussed. It has definitely made me think a little bit more about how I manage older patients with vague symptoms and what investigations might be important.
Hsu, D., Wilkenfeld, P., Joshua, D. (2012). Easily missed? Multiple myeloma. British Medical Journal, 344, p. d7953. doi: 10.1136/bmj.d7953
Palpitations
A patient comes in saying that he had palpitations 4 days ago and is concerned. What do you do? Most likely it is either a very short burst of tachycardia for reasons never explained or the patient has noticed a few ectopics; but, are you sure that it is not serious? A recent article in the American Family Physician describes how palpitations should be managed in the community and when to refer. However, most areas will have local guidance and should have a specific pathway. As this tends to be a common presentation, it will not be long before you come across it.
Wexler, R.K., Pleister, A., Raman, S. (2011). Outpatient approach to palpitations. American Family Physician, 84 (1).