Abstract
Website of the month
I recently came across the website of the British Heart Foundation and was surprised by the substantial amount of information it contains. Initially, I was interested in clinical information and discovered the ‘Fact-File’ series. This is a quarterly publication designed for GPs, direct to your inbox, which highlights important up-to-date information about cardiovascular health. Personally, I found the section on paediatric murmurs particularly useful. There is also plenty of patient information about exercise, smoking and diet. Additionally, if a patient should ask about cardiopulmonary resuscitation training for themselves it gives contact details about the ‘Heartstart’ scheme which is designed in conjunction with the guidelines of the resuscitation council, parts of which can be introduced to children as young as four.
Apps for health care
The massive popularity of smart phones and tablets has inevitably brought with it a deluge of healthcare apps. Last year the department of health ran a survey allowing patients to submit and vote for their favourite apps. The favourite is an app designed to track your mood and alert others if it dips, but the range is huge and it is worth looking at the website to see the variety. However, I would be reluctant to suggest many to patients before we have more guidance and evidence for their effectiveness.
Recently, it was reported that the department of health is due to publish guidance about apps and may also suggest that we should be able to prescribe some to patients. I think that this will be a very interesting development that will help patients to take more control over their own health.
QOF changes
Next year sees some major changes to the Quality and Outcome Framework (QOF). Such changes have both clinical and administrative implications; you might find it useful to speak to your practice leads in these areas. Whatever role you have to play in your future practices, I think performance-related pay is likely to feature. You need to get a grasp of this sort of thing to allow you to function effectively in the system and to help you to discuss the issue at job interviews.
New areas include peripheral vascular disease and osteoporosis. There is also a large new section looking at Accident and Emergency (A&E) attendances specifying both internal and peer review of attendances and creation of an improvement plan to reduce avoidable A&E attendances. There have also been changes in some existing target thresholds and additions of new targets to some sections.
Spirituality in the consultation
Mention of faith and spirituality in consultations is controversial. Some time ago I received an e-mail from a sick GP colleague who reflected that she regretted her missed opportunities to discuss spiritual aspects of patient care. This made me wonder if by being politically correct and trying to avoid imposing one's own beliefs on patients, we miss out on a dimension of care. As trainers we may not teach you about things that are outside our comfort zone. I recently read two articles, which acknowledge some of these issues. The article by Dr Nichol looks at a workshop for trainers to consider teaching spiritual care. The article from Brazil (which can be accessed in English translation if you are not fluent in Portuguese) discusses the inclusion of spirituality as a more holistic approach to patients than a purely biomedical model.
Nichol, J. (2012). The use of a workshop to encourage trainers to consider spiritual care. Education for Primary Care, 23, 131–136.
Serpa de Souza Batista, P. (2010). Valuing spirituality in popular health education practices in primary care. Electronica de communicao informacao e innovacao em saude, 4(3), 49–55. doi:10.3395/reciis.v4i3.389en
The AKT—is it fit for purpose?
An interesting article in a recent edition of Education for Primary Care looked at the Applied Knowledge Test (AKT) to examine how good it is as an assessment, including how acceptable it is to those taking it. It found that the exam is reliable (Cronbach's alpha scores of 0.88–0.89), but scores less well for educational impact or validity. In addition, they were not able to comment on its cost-effectiveness, which is probably what interests some of us most.
Overall, the author feels that the AKT is an important part of the MRCGP exam and triangulates well with the other components. Furthermore, he suggests that more views of trainees taking the exam are needed.
Metcalfe N. H. (2012). Testing the test: an analysis of the MRCGP Applied Knowledge Test as an assessment tool. Education for Primary Care, 23(1), 13–18.
Principles of learning
Although we learn in different ways, with different learning styles; according to a group of cognitive psychologists there are a number of principles that can help us all to improve our learning. The group have written a ‘twelve tips’ article for the journal Medical Teacher, which highlights key learning principles and strategies. While I found this article quite hard going, once I was past the psychological jargon, it makes a lot of sense and is useful for structuring learning. In particular I think that it might help when preparing for the exams. I did have to read it a couple of times though.
Cutting, M., & Saks, N. (2012). Twelve tips for utilizing principles of learning to support medical education. Medical Teacher, 34(1) 20–24. doi:10.3109/0142159X.2011.558143
Touch in the consultation
As part of a portfolio of evidence I have been collecting to get my part 2 certificate in health for health care practitioners, I have been looking at more complex aspects of the consultation. I think decisions about whether or not to touch patients in consultations are difficult. A GP recently discussed the results of a questionnaire he handed out to 220 patients in his practice (195 returned). Most patients said that they would be comforted by a doctor's touch, with slightly more female patients feeling this and slightly more patients suggesting that touch by a female doctor would be appropriate. Patients preferred to be touched on their arm or back. The patient population surveyed was relatively socioeconomically deprived and ageing with little ethnic diversity.
I do not think this gives us carte blanche to touch our patients in all circumstances, but I think discussion with your trainer or peers might be useful.
Singh, S., & Leder, D. (2012). Touch in the consultation. British Journal of General Practice, 62(596), 147–148. doi:10.3399/bjgp12X630133
Abnormal blood results
One of my pet hates is reading blood results relating to a patient that I do not know when one of the results is mildly outside the normal range. It can be tempting to ignore slightly abnormal results. A recent study by some Dutch GPs acts as a reminder that some borderline results should not be ignored. They performed hepatitis B and C tests on laboratory samples that demonstrated mildly elevated serum alanine aminotransferase (ALT) levels. They found that in primary care patients with an ALT between 50 and 100 IU/l, the risk of hepatitis C infection is significantly increased.
The same issue of the British Journal of General Practice also has an article by Oliver van Hecke (previous editor of this column) about his 2-week visit to a general practice in the southern Netherlands.
Helsper, C., van Essen, G., Frifling B. D., & de Wit, N. J. (2012). Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care. British Journal of General Practice, 62, 144–145.
Hyperparathyroidism
Hyperparathyroidism is a diagnosis that you may have given little thought to over the years except for rote learning again and again for medical school and postgraduate exams. At the time I would have been able to state the different types of hyperparathyroidism and their bloods tests, but like many things this information just cannot be permanently stored in my head. Luckily, the British Medical Journal has recently published an educational article about the most common type we are likely to see ‘primary hyperparathyroidism’. It is a good article that highlights the pathophysiology and importantly the likely presentations in primary care and when it is worth thinking about. Once assessed a suspected case will be referred on to the endocrinologist and management initiated, but hopefully this article will stop some of the cases being missed and will allow GPs to discuss with their patients what is likely to happen to them once they reach secondary care.
Pallan, S., Rahman, M. O., & Khan, A. K. (2012). Diagnosis and management of primary hyperparathyroidism. British Medical Journal, 344, e1013. doi:10.1136/bmj.e1013
Aspirin and cancer
The argument for and against continues as new evidence has emerged for the benefits of aspirin. A big study in the Lancet has pooled data from 51 trials, with over 70 000 patients, examining the effect of aspirin on the short-term incidence of cancer. The results suggest that several years of aspirin use, at a dose of 75 mg daily, can substantially reduce the incidence of cancer. They also state that the incidence of a major bleed does increase initially, but decreases with longer follow-up. We already know that the incidence of colonic cancer especially is reduced by long-term aspirin use. Additionally, another study in the Lancet suggests that taking daily aspirin also reduces the risk of metastasis. However, there is still not enough evidence for us to start prescribing for our patients and we will have to wait for further guidance.
Rothwell, P. M., Price, J. F., Fowkes, F. G. R., Zanchetti, A., Roncaglioni, M. C., Tognoni, G., & Meade, T. W. (2012). The Lancet, Early online publication. doi:10.1016/S0140-6736(11)61720-0