Abstract
Digital consultations
The pandemic has produced massive changes in the way we work. As well as us having to deal with huge stresses at home and at work, change itself can be stressful. It would be very easy to put the ‘before the pandemic’ into some sort of rose-tinted spotlight, and to try to get back to what we had before, without seeing some of the positives. I was lucky enough to have an office team (virtual) as well as my surgery team (albeit social distancing). I also already belonged to an online group (the RCGP Overdiagnosis Group) and joined several other communities of practice – one focusing on inequities and an international group on ‘Kindness in Medicine’. One of my discussion threads led to conversations with a colleague on the other side of London and an article on digital consultations. The article crystallised our thoughts about caring and listening in the consultation. These matter more than the medium used for consultation.
www.rcgp.org.uk/clinical-and-research/about/special-interest-groups/overdiagnosis-group.aspx
Etherington C and Risi L (2021) Listening to connect in the digital consultation. Available at: bjgplife.com/2021/07/12/listening-to-connect-in-the-digital-consultation (accessed 1 July 2021).
Hypertension
I believe that it is very important to share choices with patients. I find the National Institute for Health and Care Excellence (NICE) patient decision aid on hypertension very useful, particularly when discussing newly diagnosed hypertension, or when we are thinking about how to manage poor control. It helps the person think about lifestyle changes, medication changes and includes discussion about doing nothing.
Laryngopharyngeal reflux
The BMJ has produced an article summarising the assessment and management of laryngopharyngeal reflux. The article gives ideas about questions to help patients describe the sensation of a lump in the throat and a set of questions to produce a reflux index score.
Hamilton N, Wilcock J and Hannah S (2020) A lump in the throat: Laryngopharyngeal reflux. BMJ 371(8268): 285–287. DOI: 10.1136/bmj.m4091.
Delayed antibiotics
The National Institute for Health Research for Patient Benefit has supported a large systematic review and meta-analysis of randomised controlled trials and observational studies, comparing delayed antibiotic prescribing, immediate antibiotic prescribing and no antibiotic prescribing. Delayed prescribing seemed to be a safe and effective treatment. There was a significant reduction of reattendance and an increased patient satisfaction for delayed prescribing compared with no prescribing.
Stuart B, Hounkpatin H, Becque T, et al. (2021) Delayed antibiotic prescribing for respiratory infections. BMJ 373(8289): 143. DOI: 10.1136/bmj.n808.
Social prescribing
I have seen many stressed parents and children as we come out of this third lockdown. I have presented at a couple of workshops with librarians and teachers discussing the ways that local libraries could work with children and their parents in helping repair some of the wellbeing damage done by lockdown. I was overwhelmed by the interest shown by local librarians. If anyone would like an interesting quality improvement project, I am sure you could set up something really useful and positive by approaching your local library team.
As a result of the meeting, I was introduced to several social prescribing initiatives, with offers to support replication in other areas.
network.streetgames.org/our-work-changing-lives-health/youth-social-prescribing
www.eastlondonhcp.nhs.uk/ourplans/youth-health-champions.htm
Microaggressions
GP training is not easy. Training during COVID-19 has been even more difficult. Everyone deserves the best support possible. This reflection on microaggressions in medical training discusses the cumulative effect on trainees and flags the responsibility of every one of us to help change the system.
Overland M, Zumsteg J and Lindo E (2019). Microaggressions in clinical training and practice. Function and Rehabilitation 11(9): 1004–1012. DOI: 10.1002/pmrj.12229.
Starting statins
Over my career, the role of statins and other lipid-lowering therapy has been the subject of much debate, particularly in primary prevention. Yeber et al. published a meta-analysis of primary prevention trials looking at the expected risk above which statins provided net benefit. They showed net benefits at higher 10-year risk for coronary vascular disease than most current guidelines and also showed differing benefits according to gender, age and type of statin.
Yebyo G, Aschmann H and Puhan M (2019) Finding the balance between benefits and harms when using statins for primary prevention of cardiac disease. Annals of Internal Medicine 170(1): 1–10. DOI: 10.7326/M18-1279.
Polypharmacy
Despite our best efforts we have a backlog of support and care to give to our elderly patients. Such appointments are time consuming, but it is important to take enough time to do them well. One of the opportunities to intervene is following hospital discharge. This could be a time to review and rethink medication.
Parekh N, Ali K, Stevenson J, et al. (2018) Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK. British Journal of Clinical Pharmacology 84(8): 1789–1797. DOI: 10.1111/bcp.13613.
SPIKES
I was lucky enough to do a firm with Rob Buckman when I was a medical student, and he was a junior doctor. Conversations with him helped me think about communication with patients and was one of the experiences that made me sure I wanted to be a GP. Set-up, Perception, Invitation, Knowledge, Empathy, Strategy/Summary (SPIKES) still feel helpful today. It is useful to think about how this applies in the current digital first world, and how we need to adapt – for example in ‘Set-up’, thinking about who is with the patient at home, either for privacy or to ensure clarity and sharing. The model applies to some of the other consultations we are currently having, including conversations about long delays in surgery or investigations – these also involve delivering ‘bad news’.
Baile W, Buckman R, Lenzi R, et al. (2000) SPIKES – A six step protocol for delivering bad news: Application to the patient with cancer. Oncologist 5(4): 302–311. DOI: 10.1634/theoncologist.5-4-302.
‘Drug lunches’
COVID-19 has shown us how quickly new treatments, or adapted use of old treatments, can come into the public arena and influence patient requests. Over the last year, patients have requested oral and inhaled steroids, asked for prescription filtered masks, vitamin C prescriptions, garlic prescriptions – the list goes on. They have read all of these things or heard from friends. Doctors are not immune to influence. Many of us believe that we are not influenced by drug company advertising. Professor Adriane Fugh-Bergman has written an essay in the BMJ about industry-funded education. It makes interesting reading.
Fugh-Bergman A (2021) Industry-funded medical education is always promotion. BMJ 373(8296): 421–462. DOI: 10.1136/bmj.n1273.
Deaf patients
A Practice Pointer article gives a timely review of strategies to improve communication with D/deaf (Deaf refers to patients who primarily use sign language and identify with Deaf culture, deaf refers to people who use their spoken native language). The article gives tips for people who use spoken language, tips to help with the use of interpreters and ideas to look at your own practice. The authors suggest asking each patient ‘How can I help you hear and communicate?’.
Grote H, Izagaren F and O’Brien V (2021) How to communicate with patients who are D/deaf or have hearing loss. BMJ 373(8296): 452–454. DOI: 10.1136/bmj.n1382.
Movember
Over recent years November has become men’s health month. I sometimes use it as a prompt to revisit common men’s health issues. Considering the impact of the COVID-19 pandemic on mental health, I think the section on men’s mental health and suicide prevention is particularly valuable and provides a good resource for patients concerned about a friend or family member.
Uk.movember.com
16 days of action
This month is the 16 days of action campaign. This movement runs between 25 November and 10 December and aims to provide organisations with proactive steps to tackle domestic violence. The movement is supported by Public Health England and NHS England have signed up to the pledge. Are there any extra steps your practice could be taking to address domestic abuse?
16daysofaction.co.uk
ORCID iDs
Clare Etherington https://orcid.org/0000-0002-1446-627X
Kathryn Stevens https://orcid.org/0000-0002-7534-2932