BJGP Discussion Forum
Feel free to comment on anything that we have published recently or add to existing discussions. We won’t assume that you want us to consider comments posted here for publication in the Journal; please let us know if you want us to do so. Letters we are unable to print in the Journal may be posted here instead. For more information see Writing for BJGP other sections.
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What you are saying
Date: 7 Oct 2013
Topic: Response to ‘Managing dyspepsia in primary care’
Comments by: Dr Sanjay Mittal MRCGP, NHS WOLVERHAMPTON CCG
In the letter ‘Managing dyspepsia in primary care’1 I was interested in your recommendation of a CA125 blood test for dyspeptic symptoms. Can't say I have ever been aware of a link (maybe I should know) but never missed an ovarian cancer diagnosis as far as I know.
With the number of female patients in their 40s presenting to us and moreso to community pharmacists with upper GI symptoms, are you suggesting we consider this relatively expensive (£20) blood test, which itself is questionable as a screening tool for ovarian cancer, in all of these patients?
I see no mention of this in the NICE guidelines and demonstrates another example of the inappropriate and therefore wasteful use of NHS resources at the altar of 'early cancer diagnosis'.
1. Perkins P. Managing dyspepsia in primary care. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X673621.
Date: 22 Sept 2013
Topic: Response to ‘No decision about me without me’: neutrality and assisted dying
Comments by: James Gerrard MRCGP, Windmill Health Centre, Mill Green View, Leeds
In her Viewpoint piece on assisted dying, Professor Ilora Finlay rightly points out the problem the Royal College of General Practitioners will face if it adopts a stance of ‘neutrality’ on the issue.1
In this context, neutral is an archetypal weasel word. It implies impartiality, while the very act of moving away from the RCGP’s carefully worded current stance signals the opposite. Though the RCGP may express its own idea as to what neutral means, it has no ownership over what others will infer.
As Finlay suggests, many will consider it implies support, especially as it announces a shift from the view that no change in legislation is required. As such it is likely that trust, in the RCGP by its members and in GPs by their patients, will be undermined. After all, if support for change is what is meant, why not say it?
The idea suggested in the RCGP discussion document that assisted dying is ‘not an issue that the College should seek to influence’2 either does not recognise the inevitability that the RCGP will influence opinion whatever its stated position (including, and perhaps especially if ‘neutral’) or, worse, seeks that influence while claiming not to. Further, the suggestion that a change from the current position allows the RCGP to ‘take a position that the legality of assisted dying is a matter for Parliament…’2 does not bear scrutiny. The RCGP already realises it is a matter for Parliament. Changing to a neutral stance won’t alter that.
The neutral position will not deliver what its proponents say they want it to, and as such is flawed. The current position of the College on assisted dying is consistent with RCGP values and is clearly expressed. Trust is the bedrock of the doctor-patient relationship. As several organisations have discovered recently, once lost it is not easily regained.
The most damaging thing about a ‘neutral’ stance is the potential for misinterpretation and the corrosion of trust which will ensue, having considerable implications for the future of the doctor-patient relationship and knock-on effects for GPs, the RCGP, and the health service.
1. Finlay I. No decision about me without me. Br J Gen Pract 2013. DOI: 10.3399/bjgp13X671650
2. Royal College of General Practitioners. Assisted dying: A consultation on the RCGP’s position on a change in the law. RCGP, 2013.
Date: 19 Sept 2013
Topic: Response to ‘No decision about me without me’
Comments by: Philip Hartropp FRCGP, Alwalton, Peterborough
I am writing with regard to the above article by Professor Finlay on the College's stance on assisted dying1 and, in particular, on the current absence of a ballot of all members of the RCGP.
As the East Anglian faculty representative on assisted dying I have organised my faculty to undertake such a ballot of our 1554 members. The turnout was low at 7.5%, but showed 47% in favour of maintaining Opposition, 33.3% sought the College to move to a position of Neutrality, and 19.7% sought a move to now support assisted dying. The confidence level was 95% +/- 8.7%. A collective view of opposition would now appear to be difficult to maintain.
My colleagues in the Northwest faculty have also undertaken a ballot with broadly similar figures obtained.
Although I am a board member of Dignity in Dying that campaigns for assisted dying and therefore wholly opposed to Professor Finlay's position I find myself in the rare position of sharing her platform in seeking a full ballot of all RCGP members.
I would however, ask Professor Finlay to be careful what she is seeking, as I believe the tide to be turning away from current opposition to be more in line with our colleagues in the Royal College of Nurses who favour neutrality, and democracy may prove to agree with the majority of people in the UK that consistently support assisted dying being legalised for mentally competent, terminally ill patients.
1. Finlay I. No decision about me without me. Br J Gen Pract 2013. DOI: 10.3399/bjgp13X671650
Date: 17 September 2013
Topic: Response to ‘No decision about me without me’: physician assisted dying
Comments by: Robert MacGibbon FRCGP, Westleton, Suffok
I read with some dismay the views of Ilora Finlay on physician assisted dying,1 published in response to Clare Gerada’s article last December,2 without a balancing viewpoint in this edition of the BJGP, and so close to the end of the consultation period.
As a retired GP who worked in the NHS for 40 years I would like to respond even at this late stage. ‘Assisted dying’ is not a euphemism for assisted suicide - it is about listening to and helping the wishes of a patient who is competent and fully aware that he or she is dying soon of a known cause. The patient’s doctor does not ‘believe’ he is dying. The doctor and another physician know he is dying and fully consult with the competent patient. Yes, it would be for GPs, who are willing, to be ‘in the front line’. We have a history of respecting and involving patients’ autonomy and wishes.
My experience of talking with ‘the man in the street’ is that people have thought about the issue for themselves and welcome the fact that doctors are debating it with the openness of mixed individual views. They see doctors as having differing views and see the point of the College having a neutral stance as a body rather than a blanket negative one. The idea that doctors are in some sort of ‘firing line’ when they are respecting the doctor/patient confidential, trusting and mutually agreed relationship, does not make sense to me. Doctors would not be ‘aiding and abetting…suicide’ they would be helping dying people to die with dignity.
The whole point of the College having a neutral position is to show Parliament that doctors hold a range of views and we all need to be in the debate as professionals and with members of the public. I agree that the College’s consultation needs to be ‘balanced and substantial’ and, yes, our College does acknowledge the ‘complexity’ of the issue, welcomes debate, and respects the differing views of its members.
I do not think there is a ‘risk’ of the public and Parliament misinterpreting our views if the College takes a neutral position as a body. On the contrary they will, and in my experience do, have respect for the fact that we welcome balanced informed debate among ourselves. And, from a position of neutrality, the College should then have the important role of advising on the safeguards and criteria of any Bill.
1. Finlay I. No decision about me without me. Br J Gen Pract 2013. DOI: 10.3399/bjgp13X671650
2. Gerada C. The case for neutrality on assisted dying — a personal view. Br J Gen Pract 2013. DOI: 10.3399/bjgp12X659376
Date: 16 Sept 2013
Topic: Response to ‘Access to chronic disease care in general practice’. Debating the use of the term ‘chronic disease’
Comments by: Rodger Charlton, Professor of Primary Care Education, Primary Care Education Unit, Division of Primary Care, School of Medicine, Queens Medical Centre, Nottingham
Is it time to stop talking about ‘chronic disease’?1 Language changes with time and with usage. The phrase ‘terminal care’ has made a transition to the more positive-sounding ‘palliative care’, not least because we are far more open in our discussions with patients than we were a generation or two ago and need to be sensitive to their interpretation of our terminology.
Doctors may understand the term ‘chronic’ in its primary dictionary sense of ‘persisting for a long time or constantly recurring’2 and so may the some of the public. But others are more likely to hear its secondary, informal meaning of ‘of a very poor quality’ and be offended, frightened, or bemused by this label being attached to their disease or, worse still, to their general health.
As we revise our curriculum at Nottingham we hope to incorporate further student experience that is community based with patients who have single morbidity or multiple co-morbidities. Our debate is not over the urgent need for such education with population demographics changing to an increasingly older population, but what we call it.
Could it be: long-term conditions; integration of care in complex disease; integrated care; managing complex conditions; community-based disease; advanced primary care; living with long-term illness or another new entity? Whatever term is adopted, it should be more optimistic and evolve from a discussion between disciplines and with patient participation groups.
1. Paul C. Access to chronic disease care in general practice: the acceptability of implementing systematic waiting-room screening using computer-based patient-reported risk status. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X671605.
2. Oxford Dictionaries. Definition of chronic in English.
Date: 10 Sept 2013
Topic: Initial management of dyspepsia in primary care: an evidence-based approach
Comments by: Robert MacGibbon FRCGP, Saxmundham
I am sad to read a review article on dyspepsia in our journal1 which correctly states that 80% of patients have no structural cause for their symptoms and yet fails to mention the many factors that should be addressed by us GPs at the first consultation. They are, for instance: alcohol, smoking, other dietary factors, stress, life events, etc, etc.
This article is written by secondary care physicians who I suspect haven't spent much time working on the community. Surely we must include the input of a primary care physician in an article about 'initial management'? Also, 'initial' treatment which starts with the use of expensive drugs almost reads like an advert from the pharmaceutical industry.
1. Ansari S, Ford A. Initial management of dyspepsia in primary care: an evidence-based approach. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X671821.
Date: 29 Aug 2013
Topic: Carbon footprint of patient journeys through primary care: a mixed methods approach
Comments by: Dr Mike Clayton, GP, Park View Surgery, Preston
May I add one further aspect to the discussion relating to patients travelling to and from surgeries and its environmental impact1,2 that I have yet to hear included in any public debate - and that is the obvious conflict with the "choice" agenda. We too are a practice in a deprived area, inner-city with high rates of chronic disease and yet a significant number of our patients still drive 3,4 or 5 miles through town to visit the practice. It is not uncommon for patients to ring saying they will be late as they are "stuck in traffic" or be stressed if the doctor is running late and they have only paid for 30mins on the meter. Ironically they will have driven past or close by to at least some 7 or 8 surgeries on their way in.
We will all be familiar with the disgruntled patient who does not see why they have to change doctors even if they have moved a considerable distance away. Yet government initiatives have been to promote keeping such patients on the list.3 The current patient choice agenda seems to pay little heed to such genuine wider concerns as this study demonstrates - and ignoring them does not make them go away.
1. Andrews E et al. Carbon footprint of patient journeys through primary care: a mixed methods approach. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X671579.
2. Ballard T. What sustainability means for primary care: primary care leads to better overall resource use and higher quality outcomes. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X671489
3. Your choice of GP practice: a consultation on how to enable to register with the GP practice of their choice, DOH, 4 March 2010.
Date: 16 Aug 2013
Topic: Response to: ‘How much do trainers know about the CSA exam?’
Comments by: Sue Rendel, Chief Examiner RCGP, firstname.lastname@example.org
Thank you to Tessa Hicks and Jon Elliman for their letter in the August edition of the BJGP.1 I would like to flag up how the RCGP can help those trainers who don’t feel confident to become more familiar with the nuts and bolts of the CSA so that they can help their registrars prepare for the exam.
We offer a range of resources to suit most learning styles:
- On the RCGP website there is useful information about the areas that the survey indicated that Educational Supervisors were least confident about e.g. the marking domains and the methods of marking. There are also documents describing the attributes of passing and falling candidates in the three domains.
- The RCGP runs a one-day course lead by Dr MeiLIng Denney, specifically designed for trainers to help registrars get through the MRCGP and covers both the CSA and the AKT. The course aims to answer the following frequently asked questions: What will my registrar go through? What does the new assessment centre look like? What are the examiners really looking for? What should I be doing the best prepare my trainee? Who is likely to struggle with the exam, and how can they be helped? The course runs throughout the year and further details can be found at: http://www.rcgp.org.uk/courses-and-events/business-development/mrcgp-for-trainers/mrcgp-for-trainers-16-january-2014.aspx
- There is a wide range of written material and DVDs to support both trainers and trainees: www.rcgp.org.uk/shop/books/mrcgp-study-aids.aspx
- All deaneries have CSA examiners working within them, many of whom are happy to come to talk to trainers groups about the exam, equally should you want some external input write to the RCGP and we will try to arrange for a senior examiner to come to meet your educators. The best way to contact us for advice about this is through email@example.com.
I hope that you will find something here that appeals but if not please contact me with ideas for other resources that you think would be useful.
1. Hicks T, Elliman J. How much do trainers know about the CSA exam? Br J Gen Pract 2013. DOI: 10.3399/bjgp13X670534.
Date: 5 Aug 2013
Topic: The postcode lottery of GP training: Time Out of Programme
Comments by: Paul Main, Deputy Director, School of Primary Care, Severn Postgraduate Education. E-mail: firstname.lastname@example.org
I was encouraged to read the article by Franey et al1 about the undoubted value of an international Time Out of Programme Experience (OOPE), particularly in a low- or middle-income country. In the Severn School of Primary Care (Severn Postgraduate Medical Education) we have been promoting this activity for 5 years, inspired by the Crisp report.2 The many gains3 that accrue have directed our criteria for selection, which are: a) how will the OOPE benefit the candidate’s career progression in general practice? b) how will the OOPE benefit general practice in the NHS? c) how will the OOPE benefit the health of the country of the placement? d) why does the OOPE need to be taken at this particular time?
To date we have had overseas OOPE doctors (OOPEs) in Uganda, Malawi, Madagascar, KwaZulu-Natal, Solomon Islands, Zambia, Northern India, Costa Rica, Nicaragua, and the Cook Islands. Short descriptions of their inspirational experiences are available on our website: http://www.primarycare.severndeanery.nhs.uk/training/trainees/out-of-programme-experience-and-opportunities-oope/our-recent-oope-trainees-and-what-they-got-up-to/
We finance placements for our intending OOPEs on a local 3-day course in overseas medicine, which is aimed at doctors and nurses preparing to work in low resource countries. We provide a series of in-house meetings where returning OOPEs share their experiences and potential OOPEs have an opportunity to discuss preparatory arrangements. We emphasise and try to ensure that all our OOPEs have clinical supervision while in the low-resource country. For our OOPEs who go to KwaZulu-Natal, we have a former senior GP educationalist who is able to visit them and supply some in-country support. Importantly, we also provide individual debriefing for returning OOPEs to help with their reintegration into the NHS.
The sparsity of opportunities that Franey et al describe within GP schools is, I think, due to the perceived disruption of GP rotations in a short 3-year training programme. I would strongly argue that this a very small price to pay for the definite learning experiences for these trainees, who are high flyers and potential clinical GP leaders of the future, whether in the UK or overseas. We would encourage all GP schools to promote these OOPE placements, particularly in low-resource countries.
1. Franey C, Munir S, Seo H, Pettigrew L. The postcode lottery of GP training: time out of programme Br J Gen Pract 2013 DOI: 10.3399/bjgp13X670804.
2. Crisp N. Global health partnerships: the UK contribution to health in developing countries. London: DoH, 2007.
3. Hollister C. Out of programme experience (OOPE) in the developing world: how does it benefit GP training? Educ Prim Care 2012; 23(3): 204–207.
4. Main P. Other times, other places: out of programme experience (OOPE) during GP specialty training – a preliminary report. Educ Prim Care 2013. [in the press].
Date: 30 Jul 2013
Topic: Response from RCGP workplace based assessment (WPBA) Clinical Lead on ‘Formative assessments in medical education’
Comments by: Jane Mamelok, RCGP Workplace Based Assessment Clinical Lead, GP Director Health Education North West (Mersey), Regatta Place, Brunswick Business Park Liverpool, L3 4BL. E-mail: email@example.com
I write to respond to the recent review and correspondence in the BJGP by Drs Lakasing1 and Osborne.2 It is a requirement of the regulator that the learning outcomes detailed in specialty training curricula should be assessed appropriately including assessments in the workplace. While feedback is welcomed, I think it important to reflect on how far we have come since its early implementation in 2007.
Developing MRCGP as a tripos of assessments for licensing ensures breadth and depth of assessment across the curriculum blueprint. However the addition of formative assessments is not without problems. The requirement for consistency nationally with assessment schedules based on numbers and numerical scores has the potential for ‘trivialization’ reducing the opportunity for meaningful feedback.3 Combining that with the limitations in functionality of e-Portfolio platforms can lead to disengagement. The developments implemented in the last five years address those concerns, encouraging contemporaneous learning log entries fewer in number but with meaningful reflection rooted in personal experience. This is reinforced by the GMC who now steer trainees from all specialties towards supervised learning events,4 which focus on quality feedback leading to deeper learning, shown through evidence of reflection. The word pictures and assessments are continually reviewed providing tools for self-assessment benchmarking performance using them for greater educational impact that enhance and drive the learning.
This is a long way from the clunky e-Portfolio of 2007 that often crashed before work could be saved, perceived by many as a slave to numerical targets rather than an educational tool for professional development. The improvements in e-Portfolio functionality with greater alignment to the revalidation e-Portfolio enables trainees to build a strong portfolio of evidence and encourages meaningful feedback.
In answer to the question does training prepare graduates for their working lives? I would argue yes, and that Workplace Based Assessment encourages strategies that facilitate good practice for professional development and revalidation.
The question of sufficiency of evidence remains elusive and there is no consensus of opinion. What is clear is that it is dependent upon individuals’ performance and needs. The judgement for trainees at the extremes of the spectrum may require less evidence than those for whom borderline judgements become high stakes.5 Deaneries are mindful of their obligation to make the judgements of educational supervisors and ARCP panels dependable.
1. Lakasing E. Formative assessments in medical education: are excessive, and erode the learning and teaching experience. Br J Gen Pract 2013; 63(608): 145.
2. Osborne P. Registrar feedback on ‘Formative assessments in medical education’. Br J Gen Pract 2013; 63(612): 347.
3. van der Vleuten CP, Schuwirth LW, Driessen EW. A model for programmatic assessment fit for purpose. Med Teach 2012; 34(3): 205–214.
4. General Medical Council. Learning and assessment in the clinical environment: the way forward. GMC, London: 2011. www.gmc-uk.org/Learning_and_assessment_in_the_clinical_environment.pdf_45877621.pdf
5. Schuwirth LWT, Southgate L, Page GG, et al. When enough is enough: a conceptual basis for fair and defensible practice performance assessment. Med Educ 2012; 36(10): 925–930.
Date: 29 Jul 2013
Topic: Sudden sensorineural hearing loss
Comments by: Mengu Hicyilmaz, GPVTS, ENT Department, Princess, Royal University Hospital, Farnborough Common, Orpington, Kent, BR6 8ND. E-mail: firstname.lastname@example.org
Juliet Raine, FY2, ENT Department, Princess, Royal University Hospital, Farnborough Common, Orpington, Kent
Having submitted our letter prior to the August edition of BJGP, we were delighted to learn that sudden sensorineural hearing loss was being given due attention in the article by Otolaryngologist, Simon KW Lloyd.1 We hope that our reflections on the topic further highlight the importance of this oft-neglected ENT emergency.
We too would like to fly the banner for the correct initial diagnosis and subsequent rapid referral to ear, nose, and throat (ENT) clinic for patients who present with sudden onset sensorineural hearing loss. The loss of hearing in one ear is a life-changing event and deserves the same consideration as any other acute neurological deficit.
Within a 4-month attachment in ENT in the South East of England we have looked after two patients with sudden onset hearing loss, both of whom had a significant delay in their diagnosis. One patient was initially managed in primary care having had a presumed diagnosis of conductive hearing loss secondary to glue ear. The second patient self-diagnosed a temporary conductive hearing loss.
The incidence of sensorineural hearing loss is rare (estimates at 2 to 20 per 100 000 population). It often presents on waking as a painless loss of hearing and we have noted that patients may report a sensation of ‘pressure’ in the ear, similar to the presentation of a middle ear pathology. Simple bedside ear examination and tuning fork testing can aid in the diagnosis and differentiation from conductive hearing loss. However, the gold standard is formal pure tone audiometry. We would suggest that all patients with sudden hearing loss, of whatever aetiology, should have an ENT referral.
The majority of cases of sensorineural hearing loss are iatrogenic and there is little evidence base for treatment. However the consensus of ENT specialists is that early diagnosis allows rapid workup of potential reversible causes and early initiation of high dose steroids, oral or intra-tympanic, ideally within 24 hours of symptom onset.
We wonder how often sudden onset sensorineural hearing loss features in the differential diagnosis when such patients present to primary care. As a GP trainee one of us admits to not having heard of the condition before starting in ENT, the other does recollect teaching about it in medical school. The impression we have more generally is that perhaps it is not a condition that is much thought about outside of the ENT department; what is your experience?
1. Lloyd SKW. Sudden sensorineural hearing loss: early diagnosis improves outcome. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X670877.
Date: 29 Jul 2013
Topic: Response to ‘Global health: time for full integration into GP education’
Comments by: Dr Christopher Weatherburn, MRCP, MRCGP, GP and Health Inequalities Fellow, Postgraduate Department, Mackenzie Building, Kirsty Semple Way, Dundee. E-mail: email@example.com
I read with great interest the Debate & Analysis ‘Global health: time for full integration into GP education’ featured in the BJGP May 20131 and am keen to highlight that global health may not directly feature in postgraduate GP education curriculum it is covered by a number of headings including community orientation and a holistic approach.2 I can understand the logic behind full integration into the GP curriculum however personally feel this is not necessary as it is already being taught – in fact a special issue of the RCGP journal for associates in training was published in August 2012 dedicated to global health. In this issue Professor Greenhalgh writes ‘while education of health professionals is, at best, only part of the answer’.3
One of the key drives for global health is to influence government policy according to a recent publication titled Health in All Policies Seizing opportunities, implementing policies this was ‘written for policy-makers worldwide, at the national level within all government sectors influencing health’4 and released at in the eighth International Conference on Health Promotion, Helenski in June 2013. I believe there is a limit to what we as individual GPs can do and collectively through the RCGP we can contribute to improving global health without altering the postgraduate curriculum.
I had the pleasure of attending the RCGP annual primary care conference 2012 that focused on Global General Practice and found the messages extremely powerful, prompting me to question myself whether I should work in a developing country, I speculate others would decide to leave UK permanently. By increasing global health prominence in the postgraduate curriculum my fear is it could diminish the general practice workforce in the UK inadvertently worsening the recruitment crisis of general practice in the UK. It has been established from previous national surveys that there is a shortfall between number of doctors wanting a career in general practice and the number of GPs required across England.5 It is also well known that a significant number of medical graduates leave the profession – possibly they could be targeted and encouraged to consider a career as a global health specialists rather than encouraging GPs in training to work further in this field.
1. Watson J, Shiner A, Pettigrew LM, Irving G. Global health: time for full integration into GP education. Br J Gen Pract 2013; 63(610): 271–272.
2. Pettigrew L, Ramsay R. Incorporating global health and international experience into your career. InnovAiT 2012; 5(8): 447–455.
3. Greenhalgh T. Global health and primary care: building capacity. InnovAit 2012; 5(8): 456–461.
4. Leppo K, Ollila E, Peña S, et al (eds.). Health in all policies. Seizing opportunities, implementing policies. Finland: Ministry of Social Affairs and Health, 2013. http://www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf
5. Lambert T, Goldacre R, Smith f, Goldacre MJ. Reasons why doctors choose or reject careers in general practice: national surveys. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X659330.
Date: 26 Jul 2013
Topic: Response to ‘Expectations for consultations and antibiotics for respiratory tract infection in primary care; the RTI clinical iceberg’
Comments by: Helen Salisbury, Oxford Department of Primary Care Health Sciences Journal Club. E-mail: firstname.lastname@example.org
Christine A’Court, Oxford Department of Primary Care Health Sciences Journal Club
Caroline Jones, Oxford Department of Primary Care Health Sciences Journal Club
Susannah Fleming, Oxford Department of Primary Care Health Sciences Journal Club
Daniela Gonçalves, Oxford Department of Primary Care Health Sciences Journal Club
Matthew Thompson, Oxford Department of Primary Care Health Sciences Journal Club
The paper ‘Expectations for consultations and antibiotics for respiratory tract infection in primary care; the RTI clinical iceberg’1 has striking workload implications for GPs given that 58% of the UK population surveyed reported an RTI in the preceding 6 months, for which one in five had contacted their GP surgery. It is an important finding that over half of those patients contacting the GP expected antibiotics (53.1%).
However, exactly how big the problem of over-prescribing is cannot be determined from this study as the survey did not ask responders if they had been prescribed antibiotics for an RTI. Presenting data on expectations for antibiotic prescription for an RTI next to data on antibiotic prescription for any condition, as the ‘clinical iceberg in RTI’ (Figure 2), is perhaps misleading. Furthermore, although we are told that ‘97% of participants were prescribed an antibiotic when they asked for one’, we are not told how many of the 74% who did not ask for antibiotics were prescribed them. Therefore it is not possible to attribute antibiotic prescription to patient demand.
Time pressures in primary care undoubtedly run counter to the need to minimise inappropriate antibiotic prescription as it takes longer to perform a full clinical and psychosocial evaluation of a patient, with education and safety-netting, than to issue an antibiotic. The paper overlooks the psychosocial drivers behind patients’ attendance with minor RTIs, presumably because they did not emerge as themes in the qualitative interviews; that those of lower socioeconomic status were more likely to have contacted their GP surgery than those of higher socioeconomic status hints at the possibility of life difficulties, coping skills, and educational attainment all influencing the need to consult in RTI.
On a more positive note, it is encouraging to learn that among the 14% of patients given a delayed prescription, a large minority (38%) did not collect them, confirming the usefulness of this strategy.
That 47% patients with RTIs consulted because their symptoms had not improved after several days confirms that patients often have unrealistic expectations about symptom or illness duration.2 Patient education on this topic needs to be delivered effectively by GPs in their consultations, and in any public health campaign to reduce demand.
1. McNulty CAM, Nichols T, French DP, et al. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI Clinical iceberg. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X669149.
2. Ebell MH, Lundgren J, Youngpairoj S. How long does a cough last? Comparing patients’ expectations with data from a systematic review of the literature. Ann Fam Med 2013; 11(1): 5–13.
Date: 19 Jul 2013
Topic: Response to ‘The pros and cons of early diagnosis of dementia’
Comments by: Alessandro Ferrari Jacinto, MD, PhD, Department of Psychiatry, Universidade Federal de São Paulo, Rua São Carlos do Pinhal, 508/121 – São Paulo / SP – 01333-000. E-mail: email@example.com
Ricardo Nitrini, MD, PhD, Department of Neurology, Universidade de São Paulo
Sonia Maria Dozzi Brucki, MD, PhD, Department of Neurology, Universidade de São Paulo
Claudia Sellitto Porto, MD, PhD, Department of Neurology, Universidade de São Paulo
Fabio Gazelato de Mello Franco, MD, PhD, Hospital Israelita Albert Einstein
Vanessa de Albuquerque Citero, MD, PhD, Department of Psychiatry, Universidade Federal de São Paulo
I read the paper ‘The pros and cons of early diagnosis of dementia’ published by Fox et al1 with great interest, which raised the question of how Brazilian doctors’ knowledge on the detection of cognitive impairment in older people could be improved. Such papers can help us discuss the paths we should take regarding early detection of dementia. Questions concerning the ‘pros and cons’ in an aged, developed nation with a model healthcare system as the UK may serve to help a relatively young nation like Brazil, whose health system is still ‘under construction’, to make better decisions in the future. The Brazilian population has aged rapidly in the last three decades (from 43 years in 1950 to 74 in 2011) due to improvements in health care coupled with a lower fertility rate.2 Since 1988, all Brazilian citizens have had the right to free health care under the ‘Unified Health System’ (UHS)2 whose core function, at least in theory, is the provision of primary care. UHS health practitioners play a major role in dementia issues since 75% of our population receive health care exclusively from the UHS.
Previous studies have shown Brazil’s dementia prevalence to be similar to rates observed worldwide.3,4 A focus of interest for researchers has been to verify whether UHS GPs have detected cognitive impairment in their caseload of older patients during routine check-ups. We conducted a study5,6 in which a geriatrician randomly screened 248 older people from the primary care sector. Cases suspected of cognitive impairment underwent a complete assessment (neuropsychological, blood exams, and CT). After expert consensus, the 43 patients found to have either mild cognitive impairment or dementia had their medical records checked with a striking finding: only 16% of these 43 patients’ GP medical records registered a cognitive complaint or specific diagnosis.
In order to ascertain whether GPs in the UHS had good knowledge on dementia issues, another study was conducted involving the application of a ‘knowledge quiz’ to a convenience sample of 24 GPs. This unpublished data collected from this preliminary study using the Turner et al7 questionnaire revealed that the GPs held only 50% of the basic knowledge required for early detection of dementia (mean score 7.08±2.10, range 0–14). Thus training the GPs to deal with dementia appears to be the way forward in enhancing care for the older population in Brazil
1. Fox C, Lafortune L, Boustani M, Brayne C. The pros and cons of early diagnosis of dementia. Br J Gen Pract 2013; DOI: 63(612): 510–512.
2. Portal Brasil. Brasilia: Unified Health System (Primary Care Units). 2013. http://www.brasil.gov.br/sobre/health/service/primary-care-units
3. Herrera E, Caramelli P, Silveira ASB, Nitrini R. Epidemiologic Survey of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord 2002; 16(2): 103–108.
4. Nitrini R, Mathias SC, Caramelli P, et al. Evaluation of 100 patients with dementia in São Paulo, Brazil: correlation with socioeconomic status and education. Alzheimer Dis Assoc Disord 1995; 9(3): 146–151.
5. Jacinto AF, Brucki SMD, Porto CS, et al. Detection of cognitive impairment in the elderly by general internists in Brazil. Clinics 2011; 66(8): 1379–1384.
6. Jacinto AF, Brucki SMD, Pereira AS, et al. Screening of cognitive impairment by general internists using two simple tests. Neuropsychologia 2012; 6: 42.
7. Turner S, Iliffe S, Downs M, et al. General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia. Age Ageing 2004; 33(5): 461–467.
Date: 19 Jul 2013
Title: Long-acting reversible contraception
Comments by: Scott Wilkes, GP/Hon Clinical Senior Lecturer, Institute of Health and Society, Institute of Health & Society, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX. E-mail: firstname.lastname@example.org
I would like to draw the attention of your readers to the conclusions of a paper recently published in the Journal of Family Planning and Reproductive Healthcare,1 the conclusion of which is that the levonorgestrel-releasing intrauterine system (LNG IUS; Mirena® Bayer) should be offered first-line without restriction to young and nulliparous women.
It is now 8 years since the National Institute for Health and Care Excellence (NICE) issued its guidance encouraging increased access to long-acting reversible contraception (LARC).2 LARC methods are more cost effective than the combined oral contraceptive pill and will reduce the number of unintended pregnancies. This includes the ‘fit and forget’ use of the IUS.3 The IUD/IUS is not contraindicated in young in nulliparous women of any age and this message seems not to be reaching our GP colleagues with nine out ten GPs still advising women to use the contraceptive pill as a first-line choice for young nulliparous women.4 The overriding message is that the levonorgestrel-releasing intrauterine system is a first-line contraceptive option for young and nulliparous women.
1. Armitage CM, Mitchell C, Wigan C, Smith DA. Uptake and continuation rates of the intrauterine system in a university student general practice population in the UK. J Fam Plann Reprod Health Care 2013; 39(3): 186–189.
2. National Institute for Health and Clinical Excellence. Long-acting reversible contraception. CG30. London: NICE, 2005. http://nice.org.uk/nicemedia/live/10974/29912/29912.pdf
3. Draper IB, Haque MS, McManus RJ. Routine intrauterine device checks: are they advisable. J Fam Plann Reprod Health Care 2012; 38(1): 15–18.
4. Middleton AJ, Naish J, Singer N. General practitioners’ views on the use of the levonorgestrel-releasing intrauterine system in young nulligravid women, in London. Eur J Contracep Reprod Health Care 2011; 16(4): 311–318.
Date: 15 Jul 2013
Topic: Family medicine in the emergency department. Ministry of Health – Jordan Experience
Comments by: Dr Wafa Halasa, Senior Consultant Family Medicine, Ministry of Health, Amman, Jordan. E-mail: email@example.com
Increasing demands on health services have resulted in a number of innovations in delivering care. In November 2005, a unique new care model was started in the emergency department of Al-Bashir Hospital, the largest government hospital in Amman, Jordan. Family medicine physicians (specialists and residents) started working and are still working in newly added clinics to the emergency department, providing 24-hour primary care services to non-urgent patients – ‘inappropriate attenders’, on a non-appointment basis, with the aim of decreasing the pressure on the overburdened emergency department.1
In 2006 the total number of patients was 99 286 (272/day) in 2007 102 127 (280/day) and in 2008 total 143 186 (392/day), a 40% increase. In 2009 the number of patients continued to rise, reaching a maximum of 649/day during the month of May. In October 2009 a nominal fee was re-established, that led to a dramatic decrease in the number of patients, falling to 8126 (271/day) in November. By 2010 the total number was 111 962 (307/day), a 37.2% reduction from 2009. In 2011 the total was 116,862 (320/day).2
Research from several countries support the new role of family medicine physicians in the emergency department. Boeke et al, in Amsterdam, the Netherlands, concluded that ‘The new care method that combined the involvement of a GP in the ED and allocation of patients by triage to either the GP or the accident and emergency department physician, resulted in greater patient satisfaction and maintained the quality of care, with fewer additional examinations.’3
Dale and his coworkers at King’s College School of Medicine and Dentistry have been researching the demand for ‘emergency’ primary care since 1988. They concluded that employing GPs in the accident and emergency departments to manage patients with primary care needs reduced rates of investigation, prescription, and referral when compared with hospital doctors.1
1. Robertson-Steel IRS. Providing primary care in the accident and emergency department. BMJ 1998; 316(7129): 409–410.
2. http://www.moh.gov.jo/EN/HealthStatisticsandIndicators/Pages/Home.aspx (not in English [accessed 17 Jul 2013])
3. Boeke AJ, van Randwijck-Jacobze ME, de Lange-Klerk EM, et al. Effectiveness of GPs in accident and emergency departments. Br J Gen Pract 2010; DOI: 10.3399/bjgp10X532369.
Date: 15 Jul 2013
Topic: The RTI clinical iceberg
Comments by: Jan Matthys, UZ Ghent, 6K3, De Pintelaan 185, 9000 Gent, Belgium. E-mail: firstname.lastname@example.org
In their NICE study on expectations for consultations and antibiotics for respiratory tract infection in primary care, the authors describe the point of view from the patients in an RTI clinical iceberg; the authors come to the conclusion that most who ask for antibiotics are prescribed them.1
In the triade patient–doctor–society, from the point of view of the society, as mentioned by the authors, more and more countries do national public campaigns to promote appropriate use of antibiotics in the community.
Otherwise, from the point of view of the doctor, one can also ask questions about the ICE (Ideas, Concerns, Expectations) of patients in general practice consultations, and their relation with medication prescribing. Now, do most patients expect antibiotics? Surely not.
In a study on ICE, an analysis of 350 new contacts showed that the expression/unveiling of expectations of patients (P = 0.009, OR = 2.0, 95% CI = 1.2 to 3.4) was associated with not prescribing new medication (dichotomised into the categories present/absent); in a subgroup analysis of respiratory complaints (n = 90), evidence was even found for fewer antibiotic prescriptions when two or three ICE components were present, compared to the group with no or only one ICE component, namely 6/36 versus 20/54 prescriptions of antibiotics (P = 0.056, OR = 0.34; 95% CI = 0.10 to 1.04).2
The conclusion of Cliodna McNulty, may give the impression that patients especially expect antibiotics and this is not the truth. As many patients who contact their GP surgery expect advice and reassurance rather than antibiotics, there is an opportunity for GP practices to give more advice about how patients may relieve symptoms. Systematically disclosing the patients’ real expectations and concerns could lead to less unnecessary use of antibiotics.
There remains an important link between the stages of the ICEberg namely how the GP deals with request of patients for antibiotics.
1. McNulty CA, Nichols T, French DP, et al. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X669149.
2. Matthys J, Elwyn G, Van Nuland M, et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract 2009; DOI: 10.3399/bjgp09X394833.
Date: 12 Jul 2013
Topic: Use of Glycated Haemoglobin (HbA1c)
Comments by: Steven Levene, FRCGP, East Leicester Medical Practice, 131 Uppingham Road, Leicester LE5 4BP and National Institute for Health Research Collaboration for Leadership in Applied Research and Care for Leicestershire, Northamptonshire and Rutland (CLARHC), Department of Health Sciences, University of Leicester, 22–28 Princess Road West, Leicester, LE1 6TP. E-mail: email@example.com
Azhar Farooqi, OBE, FRCGP, East Leicester Medical Practice, 131 Uppingham Road, Leicester
Joanne Sexton, SRN, East Leicester Medical Practice, 131 Uppingham Road, Leicester
John Bankart, PhD, Primary Care and Health Sciences, Keele University, Staffs
Following the current WHO1 and NICE2 guidance on the use of glycosylated haemoglobin (HbA1c) for the diagnosis of diabetes, our practice invited patients to return for repeat testing who, during routine screening for cardiovascular risk, had an HbA1c result of 6.5 % DCCT [48mmol/mol IFCC] or greater, the cut point for diagnosing diabetes.
Of 93 patients with an initial abnormal result, we were able to re-test (using the same accredited laboratory) 83, in whom the mean absolute change in HbA1c was 0.57%, with a standard deviation of 0.46%, and an intra-class correlation co-efficient of 0.752 [0.505, 0.999]. Of the 83 re-tested, only 30 (36.1%) had the diagnosis confirmed by a repeat HbA1c of 6.5% or more.
Gender, age, and ethnicity did not predict the absolute change in HbA1c. The correlation between the initial HbA1c and change in HbA1c was 0.26 [P = 0.02] and a higher initial HbA1c predicted confirmation of the diagnosis (means of 7.13% in those confirmed and 6.71% in those unconfirmed). There was also a positive correlation between the two tests’ interval length and the absolute value of the change [r = 0.31, P = 0.005]. Confirmation rates declined with increased intervals from 100% at 0–14 days to 41% at 15–30 days, to 25% at 31–92 days, and to 21% at 93 days or more.
However, only 28% of the absolute change score (adjusted r-squared) was accounted for by the initial HbA1c and the interval between the two tests. The remaining 72% may be due to a combination of variability in the assay (reported as up to 5% of the value3), the effect of changes in lifestyle to blood glucose profiles (especially if the patient is told of possible diabetes), and intra-personal variation in HbA1c.
Repeating the test within 2 weeks, as recommended by the WHO, proved difficult, due to delays in laboratory turnaround, contacting patients, and booking suitable appointments in already busy clinics. Our finding that diabetes was not confirmed in 59% in patients re-tested within 15 to 30 days (a more realistic target in practice) raises concerns about fluctuations in HbA1c levels and the risk of misdiagnosis.
We acknowledge the increased risk of microvascular damage with HbA1c results of ≥6.5%, and the need to identify patients with diabetes at the earliest opportunity. However, we wish to avoid labelling patients incorrectly or prematurely with a life-changing diagnosis that has profound implications (for example, medical interventions, insurances, resources). We propose that our analysis is repeated in larger populations. If our findings are confirmed, expert bodies need to review the guidance (in particular the timing of repeat tests, diagnostic thresholds, and laboratory turnaround standards) to ensure accurate identification of those at greatest risk, optimal use of finite human and laboratory resources, and implementation that is feasible in ‘real world’ practice.
1. World Health Organization. Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus. Geneva: WHO, 2011. http://www.who.int/diabetes/publications/report-hba1c_2011.pdf
2. National Institute for Health and Clinical Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. NICE Public Health Guideline 38. London: NICE, 2012. http://www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf
3. College of American Pathologists. National Glycohemoglobin Standardization Program website monitoring data. http://www.ngsp.org/CAP/CAPLN12a.pdf
Date: 4 Jul 2013
Topic: Antibiotic overprescribing – who are the bad guys?
Comments by: John Sharvill, FRCGP, Balmoral Surgery, Canada Road, Deal. E-mail: firstname.lastname@example.org
The July Journal includes many articles on trying to reduce antibiotic prescribing in respiratory infections.1–5 May I bounce back a few obstacles?
Azithromycin to be taken three times a week? We have a growing cohort from secondary care of people with chronic airways disease, emphysema, and now also asthma, including children, who are put on this long term. Flares of chronic airways disease are poorly defined but antibiotics are considered good for this.
New syndromes like persistent wet cough in childhood seem to benefit from antibiotics. Ear, nose, and throat surgeons believe antibiotics work in sinus pain, despite vague NICE advice that seems to apply to primary care only.
There seems to be an epidemic of apparent urine infections diagnosed and treated with antibiotics in any ill older person in casualty. Any residential home resident where the staff can ‘dip urine’, and prescribing allied professionals are perhaps greater causes of current questionable prescribing.
Ill, hot children who attend hospital in our area always come out on antibiotics, usually co-amoxiclav.
All this makes it hard to stem the tide of antibiotic overuse. Add to this the failure of European or worldwide regulators to reduce pharmacy dispensing without prescription and it makes me wonder why we, as GPs, are seen as the bad guys.
The article on pharmacy advice also contrasts with the practice in southern Europe, where pharmacies appear to be pretty willing to sell antibiotics.
1. Moore M. Antibiotics: time to act. Br J Gen Pract 2013; 63(612): 340–341.
2. McNulty C, Nichols T, French DP, et al. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract 2013: DOI: 10.3399/bjgp13X669149.
3. Elshout G, van Ierland Y, Bohnen AM, et al. Alarm signs and antibiotic prescription in febrile children in primary care: an observational cohort study. Br J Gen Pract 2013: DOI: 10.3399/bjgp13X669158.
4. Vodicka TA, Thompson M, Lucas P, et al. Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review. Br J Gen Pract 2013: DOI: 10.3399/bjgp13X669167.
5. Le Corvoisier P, Renard V, Roudot-Thoraval F, et al. Long-term effects of an educational seminar on antibiotic prescribing by GPs: a randomized controlled trial. Br J Gen Pract 2013: DOI: 10.3399/bjgp13X669176.
Date: 3 Jul 2013
Topic: Femoroacetabular impingement research gaps – caution required!
Comments by: Richard Weiler, Locum GP, Hertfordshire and Consultant in Sport & Exercise Medicine, UCLH, 250 Euston Road, London. E-mail: email@example.com
Andrew Rolls, Chartered Physiotherapist, Buckinghamshire
Thomas et al's description of femoracetabular impingement (FAI) is a little concerning – not because of what the paper informs about this potentially debilitating condition, but because there are so many significant research gaps on FAI limiting our clinical knowledge.1
Owing to complex anatomy, groin pain is a very challenging and common musculoskeletal condition, especially for those who participate in sport, making correct diagnosis a considerable first hurdle to overcome.2 Some studies suggest femoroacetabular deformities are present in as many as 25–50% of young asymptotic men,3 while accuracy of clinical-examination tests in detecting resulting labral tears are poorly defined.4
A great deal more research is required before we can confidently advise on diagnosis and management of FAI. In the meantime, with most focus seemingly on surgical interventions, there is great potential for ‘over’ exuberant surgical management in lesser-experienced hands than the authors.
1. Thomas GER, Palmer AJR, Andrade AJ, et al. Diagnosis and management of femoroacetabular impingement. Br J Gen Pract 2013; 63(612): 513–515.
2. Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med 2009; 43(3): 213–220.
3. Reichenbach S, Jüni P, Werlen S, et al. Prevalence of cam-type deformity on hip magnetic resonance imaging in young males: a cross-sectional study. Arthritis Care Res (Hoboken) 2010; 62(9): 1319–1327.
4. Leibold M, Huijbregts P, Jensen R. Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review. J Man Manip Ther 2008; 16(2): E24–41.
Date: 2 Jul 2013
Topic: Cardiovascular safety of non-steroidal anti-inflammatory drugs
Comments by: Kavitha Nadesalingam, Rheumatology Registrar, Yorkshire
David Kirby, Clinical Assistant, St James’s University Hospital, Leeds, Yorkshire. E-mail: firstname.lastname@example.org
The Medicines and Healthcare Products Regulatory Agency have directed that diclofenac is now contraindicated in patients with congestive heart failure (New York Heart Association classification II-IV), ischaemic heart disease, peripheral vascular disease (PVD) and cerebrovascular disease, due to the increased risk of arterial thrombosis.1 Patients on diclofenac should see their GP at their next routine appointment to be switched to an alternative treatment.1
We carried out an audit in an urban general practice of 13000 predominantly Caucasian patients in Yorkshire to establish the number of patients affected by these recommendations and the subsequent impact on GP workload.
We identified 933 patients with one or more of the diagnoses recognised as contraindicating the use of diclofenac. 480 patients had ischaemic heart disease alone of whom 21 had been prescribed diclofenac in the last 12 months, with 10 on repeat prescription. 33 patients had congestive heart failure alone of whom only one had been prescribed diclofenac (not on repeat prescription). 61 patients were diagnosed with PVD alone. 4 had been prescribed diclofenac of whom 1 required a repeat prescription.193 patients had a diagnosis of cerebrovascular disease alone. 11 had been given a prescription of diclofenac, 6 on repeat prescription. 166 patients had more than one of these conditions, and 4 had been prescribed diclofenac on repeat prescription.
In total 41 patients with any of the relevant diagnoses had been given diclofenac in the preceding 12 months, of whom 19 had diclofenac on repeat prescription. Our results are somewhat reassuring as only 0.3% of our patient population have been exposed to diclofenac in the last 12 months with only 0.1% having diclofenac on repeat prescription. Although the service burden of these new recommendations is slight, the impact that the discontinuation of diclofenac will have on patients requiring them (particularly those that use diclofenac routinely) cannot be discounted.
1. Medicines and Healthcare Products Regulatory Agency. Drug Safety Update. Vol 6, issue 11. London: MHRA, June 2013: A2.
Date: 24 Jun 2013
Topic: Use of PHQ-9 scores to guide treatment decisions in primary care
Comments by: Tony Kendrick, professor of primary care, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton, SO16 5ST. E-mail: email@example.com
Paul Little, professor of primary care research, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton
Shaw and colleagues (May Journal) stated no changes in depression management were seen in studies they reviewed of using patient health questionnaire (PHQ-9) scores to guide primary care treatment.1 This statement is an inaccurate reflection of the literature they reviewed and cannot go unchallenged.
The observational study conducted in Southampton practices, in the year following the introduction of the DEP3 QOF indicator rewarding the use of symptom questionnaires at follow-up of depressed patients between 5 and 12 weeks, showed that follow-up scores appeared to influence decisions to change treatment significantly.2 After controlling for confounders, patients who showed an inadequate response in questionnaire score change at follow-up were nearly five times more likely to experience a subsequent change in treatment compared to those with an adequate response (odds ratio 4.72, 95% confidence interval 2.83 to 7.86).2
Shaw and colleagues downplayed the evidence of the quasi-randomised trial from the USA which found that feeding back PHQ-9 scores to primary care physicians at diagnosis and follow-up led to significantly increased rates of remission and response, clearly showing benefit to patients.3 They failed to point out that changes in management in the intervention arm of the trial were actually more numerous too. More patients received antidepressant treatment at baseline, and antidepressant regimen changes over the following six months among partial or non-responders were all more numerous in the intervention arm.4 Although these differences in treatment changes were not statistically significant, they were all in the direction expected if feedback of PHQ-9 scores was influencing treatment,4 suggesting the trial was under-powered to detect small but clinically significant differences in care in those cases where treatment changes were indicated.
Research in specialist practice, specifically excluded from Shaw and colleagues’ review, has even more convincingly demonstrated the benefits of monitoring depression treatment with symptom questionnaires. Systematic reviews and meta-analyses in specialist psychological and psychiatric care have shown that outcomes can be improved with an effect size of between 0.1 and 0.3 standard deviations, being most beneficial when patients are involved in rating their own problems and receive feedback on progress, in addition to feedback to the practitioner.5
Now that the use of symptom questionnaires is an optional component of the QOF incentivised initial and follow-up assessments in depression, it will be interesting to see whether practices continue to use them, given the evidence that patients like them,6 and that they can help improve patient outcomes in depression.3
1. Shaw EJ, Sutcliffe D, Lacey T, Stokes T. Assessing depression severity using the UK Quality and Outcomes Framework depression indicators: a systematic review. Br J Gen Pract 2013; DOI:10.3399/bjgp13X667169.
2. Moore M, Ali S, Stuart B, et al. Depression management in primary care: an observational study of management changes related to PHQ-9 score for depression monitoring. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X649151.
3. Yeung AS, Jing Y, Brenneman SK, et al. Clinical Outcomes in Measurement based Treatment (COMET): a trial of depression monitoring and feedback to primary care physicians. Depression and Anxiety 2012; 29(10): 865–873.
4. Chang TE, Jing Y, Yeung AS, et al. Effect of communicating depression severity on physician prescribing patterns: findings from the Clinical Outcomes in Measurement-based Treatment (COMET) trial. Gen Hosp Psychiatry 2012; 34(2): 105–112.
5. Knaup C, Koesters M, Schoefer D, et al. Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis. Br J Psychiatry 2009; 195: 15–22. DOI: 10.1192/bjp.bp.108.053967.
6. Dowrick C, Leydon GM, McBride A, et al. Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. BMJ 2009; 338(7697): 1–9.
Tony Kendrick chaired the expert advisory group on mental health which recommended the introduction of QOF incentives for the systematic assessment of depression, and is a member of the NICE national QOF Indicators Advisory Committee.
Date: 22 Jun 2013
Topic: How much do trainers know about the CSA exam?
Comments by: Tessa Hicks, GPST3 and Severn Deanery Education Scholar, Severn Deanery School of Primary Care, Swindon
Jon Elliman, Associate Postgraduate Dean, Severn Deanery School of Primary Care, 6 Raglan Close, Swindon, SN3 1JR. E-mail: firstname.lastname@example.org
Despite the MRCGP having three components, GP trainees spend a lot of time worrying about, and preparing for the CSA. Anecdotal reports from them would suggest that there are significant differences in the amount and quality of support they get from their educational supervisors (ES) which is specifically aimed at this exam. Many ES assume that much of the preparation for it is done on the day release courses.
Despite the high pass rate for the exam in Severn (92% overall pass rate for all attempts in the latest statistics1) we thought it would be interesting to find out how much ES actually know about the CSA (most of whom will not have taken it). At a recent ES conference we did a brief quiz to assess knowledge of the structure, cost, and marking criteria for the exam. 40 ES answered the quiz.
The results showed that 25% did not know what CSA stood for, although 90% did know about the exam format, and that it takes place at the RCGP headquarters in London. 63% knew at what stage of GP training the CSA could be taken.
50% knew what the CSA cost, but otherwise greatly underestimated the cost. This was particularly true for the cost of re-sits (65% underestimated), and only 15% appreciated that there is a maximum of four times that the CSA can be attempted.
Perhaps more worryingly from the trainees’ point of view, less than one-third knew about the marking domains and allocation of marks — obviously important to understand in order to give constructive feedback for CSA preparation.
Lastly, around 60% of ES thought that the pass mark was lower than it is, which was reflected in over-optimistic views about the percentage of candidates who pass the exam!
Overall, the above seems to reflect that ES are not aware of the high costs, lower pass rates, and limited number of re-sit attempts — all of which are obvious causes of concern to candidates, and why it looms so large in their ST3 year.
In terms of helping candidates with CSA preparation, lack of knowledge about how the exam is marked has implications for how effective ES feedback can be. The results of this mini-survey would seem to justify the anecdotal concerns of differences in support that candidates may receive from their ES, and is therefore an area that needs to be addressed.
1. Royal College of general Practitioners. MRCGP Annual Reports 2011–2012. London: RCGP. http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam-overview/mrcgp-annual-reports/mrcgp-annual-reports-2011-2012.aspx
Date: 18 Jun 2013
Topic: Polymyalgia rheumatica: Diagnosis, prescribing and monitoring in general practice
Comments by: Karena Hanley, Assistant Programme Director, Donegal G.P. Training Scheme
Evelyn Mc Manus, Rathford Health Centre, Milford, Donegal, Ireland. E-mail: email@example.com
We commend the study on the management of Polymyalgia rheumatica (PMR) in general practice by Helliwell and Mallen, as published in your May issue and agree that more work on this topic in primary care is needed.1 We conducted a national randomised questionnaire survey of GPs in Ireland in 2008. A sample of 150 GPs was randomised from the ICGP database with a response rate of 78.1%. The questionnaire was based on current practices used in diagnosing PMR, referral, and recommended criteria for diagnosis.2
In agreement with Helliwell and Mallen, an elevated ESR (used by 96% of GPs in our study) and also a rapid response to steroid therapy (used by 83%) were important diagnostic and confirmatory factors for GPs in the management of PMR. Only 45% were using CRP to diagnose PMR it is more specific than ESR in diagnosis and monitoring.3 Up to 22% of patients may have a normal ESR. Only 1.2% will have both a normal ESR and CRP.
None of our responders could quote published guidelines on the diagnosis of PMR, yet the survey suggested they were using the main components of guidelines to make the diagnosis.
75% of responders agreed that commencement of steroids to treat PMR is appropriate in a general practice setting. Five per cent felt it was never appropriate for the GP to commence steroids. There variation in the confidence felt by practitioners in dealing exclusively with this condition. 37% of GPs reported they would refer less than a quarter of their cases. 32% of GPs stated they would refer more than three-quarters of their cases. 68% were confident of diagnosis in the majority of patients within 1 month of diagnosis. Experience appeared to influence confidence in diagnosis. Dividing around the median number of years in practice (16 years) the more experienced group of responders were significantly more likely to be confident of the diagnosis of PMR within a month of presentation compared with the less experienced group. (x²= 10.5, P = 0.033).
The goal of PMR management is to control symptoms with a minimum of drug induced side effects. The publication of excellent easy-to-follow guidelines from the British Society of Rheumatology make this condition easier to manage in primary care(4).
1. Helliwell T, Hider SL, Mallen CD. Polymyalgia rheumatica: Diagnosis, prescribing and monitoring in general practice. Br J Gen Pract 2012; DOI: 10.3399/bjgp13X667231.
2. Bird HA, Leeb BF, Montecucco CM, et al. A comparison of the sensitivity of diagnostic criteria for PMR. Ann Rheum Dis 2005; 64(4): 626-629.
3. Subrahmanyam P, Daspupta pmr B. Medicine. Rheumatology 2006; 34(2/2): 10.
4. Bhaskar Dasgupta B, Borg FA, Hassan N. BSR and BHPR guidelines for the management of polymyalgia rheumatic. Rheumatology doi:10.1093/rheumatology/kep303b.
Date: 7 June 2012
Topic: ENT Emergency Clinics: Reducing inappropriate referrals
Comments by: Sridhayan Mahalingam, Academic FY2 in Primary Care and Population Health Sciences, St George’s, University of London, Cranmer Terrace, London, SW17 0RE. E-mail: firstname.lastname@example.org
Chris Pepper, Specialist Registrar in ENT, Division of Population Sciences and Education, St George’s, University of London, Cranmer Terrace, London, SW17 0RE and ENT Department, St George’s Healthcare NHS Trust, Blackshaw Road, London
Pippa Oakeshott, Reader in General Practice, Division of Population Sciences and Education, St George’s, University of London, Cranmer Terrace, London
Cox and colleagues1 highlight the problem of increasing numbers of outpatient referrals, many of which are thought to be inappropriate. Ear, nose, and throat (ENT) problems are common in primary care2 and appropriate referral is crucial. We investigated GP referrals to the one-stop emergency ENT clinic at St George’s Hospital, London. Criteria for referral to this clinic include: otitis externa (needing microsuction), recurrent epistaxis, fractured nose (needs to be seen within 7–10 days of injury), foreign bodies in the ear, sudden unilateral sensorineural hearing loss, and Bell’s palsy.
We collected prospective date on 100 consecutive primary care referrals in April–May 2013. The patients’ mean age was 41 years (range 1–88), 24 were children less than 12 years old, and 47 were male. Referrals were triaged by an ENT senior registrar or consultant and 65 were accepted.
Of the remaining 35 referrals deemed inappropriate, seven were for microsuction of wax, six patients had neck lumps or hoarse voice (two week referral), three had otitis media (referral to paediatric/general ENT clinic), two had possible cholesteatoma (referral to otology clinic), four had tinnitus or vertigo (referral to audiovestibular clinic), two had chronic sinusitis (referral to rhinology clinic), two had hearing aid problems (referral to audiology clinics), and nine had other conditions.
We believe that recognition of criteria for emergency ENT clinic referrals and an awareness of the many different subspecialist ENT clinics available may help GPs refer more appropriately and provide efficient care. Hospitals should keep GPs regularly updated in their acceptance criteria for the different clinics and publish this information on their websites. This is important in view of Cox and colleagues’1 findings that referral management schemes are expensive and do not seem to reduce outpatient attendance rates.
1. Cox JM, Steel N, Clark AB, et al. Do referral-management schemes reduce hospital attendances? Time-series evaluation of primary care referral management. Br J Gen Pract 2013; 63(611): 386–392.
2. Grifffiths E. Incidence of ENT problems in general practice. J R Soc Med 1979; 72(10):740-2.
Date: 3 June 2013
Topic: Hard chairs
Comments by: Miss Cicely Stanley, 23 Bowhay Lane, Exeter, Devon
I take a cushion with me when I visit the doctor. It is placed on the very hard plastic seat I now have to sit on. There are no arms to the new type of chair, the frame of which is metal. Without anything to ease myself down on to the seat or push myself up when leaving I have great difficulty as my knee and other joints are in a bad state and painful.
My own doctor and other GPs are opposed to the introduction of this type of chair. The reason for the change is hygiene – as cited by the health centre manager. I don’t know why she would wish older, or any other disabled people, to experience this quite unnecessary pain and difficulty when for many, many decades a plain, two-armed chair has not been an extra hazard. Most chairs in the waiting room are now without arms and disliked by patients in general. Welded together, it brings people that much closer.
I feel this quest for hygiene is being taken out of all proportion and yet piles of magazines are available for anyone to leaf through. Surely they carry germs and in any case, germs can be airborne.
My uncle, a doctor in the regular army since WWI, and back from being a POW in Thailand after WWII, was astounded at the introduction of everything being sterilised for babies. (He was happy to see his first baby daughter playing with coal in the then usual coal bucket). His comment was ‘People will not have natural immunity to anything soon’. He was CMO, Southern Command, Wilton, at the time of his tragic death.
I would be interested to know where this 'patient's chair' directive came from. I understand they are quite expensive.
Date: 24 May 2013
Topic: The real cost of primary care
Comments by: Phil Taylor, MA, MRCGP. E-mail: email@example.com
The crisis in Accident and Emergency departments leads me to share the results of an analysis from Eastern Devon.
Two years ago we worked with hospital colleagues to identify the cause of the large increase in emergency admissions in our area. East Devon has a population structure equivalent to that projected for England and Wales in 2042; we found that people aged over 80 formed the bulk of the increase in emergency admissions and, to a lesser extent, attendances at the Emergency Department of our main acute hospital. We worked in partnership with the acute hospital to address this problem.
It seemed to us inconceivable that consultations in primary care by this group wouldn’t also have risen dramatically. We analysed data from our practice computer system, comparing consultation statistics between 2004 and 2012. We found that in 2004 our GPs and nurses saw 63 377 patients in the surgery, made 2531 home visits and had 4609 telephone consultations. In 2012 these figures were 78 597 (24% increase), 3241 (28% increase), and 18 810 (408% increase) respectively. Our practice population had grown by 10% over this time period. All components of our work had increased substantially but telephone consultations had shown an extraordinary rise.
We were not able to analyse these figures by age group, but data from the NHS Information Centre (provided from the QRisk studies of Professor Julia Hippisley-Cox) from 1995/6 onwards show that, whereas the average consultation rate per year for a registered patient rose from 3.9 to 5.5, there were much higher rises in the over 85s, for whom consultation rates approximately doubled, from 7–14 consultations per year.
Nationally, including the 2004 contract change, real terms PCT spending on primary care rose by 22% (just under 3% a year) between 2003/04 and 2011/12. Almost all of this increase occurred between 2003 and 2005. In comparison, PCT spending on secondary care jumped 40.1% over the same period, increasing from £49.1 billion to £68.8 billion. This is equivalent to an average increase of over 5% a year. Between 2010/11 and 2011/12 there has been a real terms reduction in spending on primary care of 1.2%.1
It is a great privilege to provide primary care for older people and, as a profession, we need to campaign for resources which reflect their needs. This means investing in primary care as well as secondary, community, and social care. The legacy of the 2004 GP contract, with its sudden 14% increase in GP income, is a failure to consider workload or workforce planning 9 years later. At present it seems that the NHS knows the cost of primary care, but not its value.
1. Charlesworth A, Jones NM. A review of NHS expenditure and labour productivity. The anatomy of health spending 2011/12: a review of NHS expenditure and labour productivity. London: Nuffield Trust, 2013.
Date: 22 May 2013
Topic: Are we overusing Thyroid function tests?
Comments by: Alexander Werhun, GPST3 ACF, Mount Pleasant Health Centre, Exeter, EX4 7BW. E-mail: firstname.lastname@example.org
William Hamilton, professor of primary care diagnostics, University of Exeter
The prevalence of hypothyroidism in the UK is 2%. It is ten times more common in women, with incidence figures of 4.1/1000 women/year and 0.8/1000 men/year. Thyrotoxicosis is much less common, with a prevalence of 0.4%. It is also more common in women (0.77/1000 women/year v 0.14/1000 men/year). The standard investigation if either disease is suspected is blood thyroid stimulating hormone (TSH).
Guidance from the British Thyroid association (2006) states that TSH should be tested if thyrotoxicosis is suspected, with a normal TSH effectively ruling out hyperthyroidism, and for hypothyroidism it advises that, because the typical signs are often not present, clinical judgement is important in deciding whom to investigate.1
We studied the yield of thyroid disease obtained from the number of TSH tests requested, in an Exeter, Devon, practice serving an urban population of 18 178. Of the 2717 patients who had TSH testing in 2012, 398 (15% were already taking thyroxine for hypothyroidism, and 77 (3%) were on treatment for active thyrotoxicosis or having annual TSH monitoring for previous hyperthyroidism. Thus there were 2267 patients who had TSH testing for diagnostic purposes. These tests identified 48 (2.1% of tested patients) patients newly diagnosed with hypothyroidism over the past year. Ten of these were at higher risk: seven patients became hypothyroid while receiving carbimazole treatment for thyrotoxicosis, two after having a thyroidectomy, and one after radio-iodine treatment. Arguably, this leaves 38/40 newly diagnosed with spontaneous hypothyroidism. There were seven new diagnoses of hyperthyroidism in the past year.
The study by Vanderpump et al provides demographic data on UK thyroid disease incidence and prevalence: using their data we would expect 39 new diagnoses of hypothyroidism and six of hyperthyroidism annually – remarkably close to our observed figures.2 Although the high number of tests to identify each case suggests indiscriminate testing, the practice is one of the lowest in Devon for TSH testing (14th out of 108: personal communication Professor Chris Hyde).
The local cost of a standard TSH test is £1.67 (to which must be added the costs of phlebotomy, transport and clinic time). Nationally 10 million thyroid function tests are requested each year, at a cost of over £30 million to the NHS.3
Our study shows a high ratio of TSH testing to each diagnosis of thyroid disease, which could indicate that we are testing for hypothyroidism rather indiscriminately, with significant costs to the health budget. The next question will be to find out how this can be improved.
1. Association of Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation. UK guidelines for the use of thyroid function tests. London: Association of Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation, 2006. http://acb.org.uk/docs/tftguidelinefinal.pdf
2. Vanderpump MPJ, Tunbridge WMG, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995; 43(1): 55–68.
3. UK guidelines for the use of thyroid function tests. Royal Liverpool & Broadgreen University Hospitals NHS Trust. http://pathlabs.rlbuht.nhs.uk/tft_guideline_summary.pdf
Date: 20 May 2013
Topic: Are there enough GPs in England to detect hypertension and maintain access?
Comments by: Christine A’Court, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG. E-mail: email@example.com
Helen Atherton, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
Andrew Dalton, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
Susannah Fleming, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
Jennifer Hirst, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
David Nunan, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
Mary Selwood, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
Richard J McManus, Department Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford
We read with interest the paper by Baker et al exploring the interrelationship between size of hypertension register, GP provision, and access (defined as the ability to get an appointment within 48 hours), assessed in 8052 practices.1 It suggests a conundrum in primary care: the ‘better’ a practice’s recognition and presumably management of hypertension, the worse the access, given finite staffing resources. The same inverse relationship may apply in other chronic diseases such as diabetes mellitus, where the recognition of risk factors or disease in often asymptomatic individuals also leads to additional workload. As acknowledged by the authors, no information was available on how different members of the primary healthcare team are used, but it appears that, ‘an extra GP per 1000 patients would be associated with a 6% increase in detected hypertension’.
The study used data from 2008–09, preceding publication of the NICE 2011 guidelines on diagnosis of hypertension. Where implemented, these guidelines may impact on the size of hypertension registers due to the use of out-of-office monitoring to reduce the white-coat effect, therefore a reduction in inaccurate labelling and an associated reduction in future workload.2,3 Furthermore, alternate methods may have better answered the research question: use of structural equation modelling would have allowed the authors to model their whole conceptual framework simultaneously, allowing fuller account to be taken of the internal interactions.
Nonetheless, the study does provide data supporting the interesting hypothesis that there is insufficient capacity in primary care to provide both good access, as well as detection and on-going care for long-term conditions. Additional resources seem unlikely under current financial constraints but novel interventions such as self-management4 and more creative use of the primary healthcare team as well as better diagnostic methods may mitigate these effects.
1. Bankart MJ, Anwar MS, Walker N, et al. Are there enough GPs in England to detect hypertension and maintain access? A cross-sectional study. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X667204.
2. Krause T, Lovibond K, Caulfield M, et al. Management of hypertension: summary of NICE guidance. BMJ 2011; 343: d4891.
3. Lovibond K, Jowett S, Barton P, et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet 2011; 378(9798): 1219–1230.
4. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet 2010; 376(9736): 163–172.
Date: 19 May 2013
Topic: Quality assurance of appraisal summaries for revalidation
Comments by: Mary Harding, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts AL8 6JL
Jonathan Freedman, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Claire Powell, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Mark Brownfield, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Debra Gilbert, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Robin Davies, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Rodney Brittan, Hertfordshire CCGs, Charter House, Parkway, Welwyn Garden City, Herts
Christine Poulton, Programme Manager, GP Appraisal and Revalidation, Hertfordshire & South Midlands, Charter House, Parkway, Welwyn Garden City, Herts
Susie Kittle, Medical Appraiser Coordinator, Hertfordshire & South Midlands Charter House, Parkway, Welwyn Garden City, Herts
Objective assessment of whether doctors meet the GMC standards for revalidation1,2 is a new challenge. In Hertfordshire GP Senior Appraisers started to quality assure appraisals in January 2013 with the aim of ensuring that they were up to sufficient standard to enable the Responsible Officer to base revalidation recommendations upon their outcomes. A Quality Assurance form was developed, and all appraisal summaries were allocated to one of seven senior appraisers to be checked against the form. After 3 months the senior appraisers were sent (without knowing it) the same appraisal summary in order to ascertain whether this process was accurate and objective. The results showed surprising lack of unanimity.
In some areas there was total agreement - for example: whether last year's PDP had been reviewed, whether it covered the scope of the doctors work, whether a balance of different types of educational activity was maintained and whether patient and colleague surveys with reflection were present. However there were complete splits on issues which we had expected to be cut and dried. There were 5:2 splits on whether learning credits were discussed and verified, whether complaints/audits with review and reflection were present, and whether statements were objective and supported by evidence. There were 3:4 splits on whether last year's appraisal summary had been reviewed and discussed, and whether 2 significant events were present with reflection and learning points.
This is a work in progress. We have discussed these results and revised the wording and the statements on the QA form. Furthermore this is a tiny sample, of one appraisal summary and seven senior appraisers’ views of it. However, revalidation is now with us, and our findings suggest that application of the GMC minimum standards for revalidation decisions may be problematic.
1. General Medical Council. Supporting Information for appraisal and revalidation. London: GMC, 2012. http://www.gmc-uk.org/doctors/revalidation/revalidation_information.asp
2. Royal College of General Practitioners. Guide to the revalidation of general practitioners. London: RCGP, 2012.
Date: 18 May 2013
Topic: Measles targets and herd immunity
Comments by: Petre Jones, MRCGP, The Project Surgery, 10 Lettsom Walk, London, E13 0LN. E-mail: firstname.lastname@example.org
Measles epidemics occur in populations with sufficient numbers of susceptible individuals for each infected person to meet and pass on the virus to one or more other susceptible individuals. Herd immunity suggests that if enough people are rendered immune such meetings will be rare enough for the virus not to be passed on and the whole population to be protected. If immunisation rates for the population were high enough we should therefore prevent epidemics such as the current one in south Wales. So if general practice can and does deliver high measles immunisation rates from ages 2–5 years why do we currently have a problem?
Unfortunately both the model of herd immunity and our immunisation rate markers are flawed. Human communities do not consist of randomly moving particles bumping into each other by chance, they cluster in social groupings. Equally just because 90 or 95% of 5-year-olds are immunised over a 10-year period does not mean that 95% of people under 15 have been protected. If unimmunised people move into a community the coverage will drop. Moreover if the newcomers cluster together they will form a subgroup at high risk of an outbreak.
In our small inner city practice in an area of high turnover and immigration, despite a consistently high immunisation rate, we have discovered an important group of susceptible teenagers were not previously aware of among whom a measles outbreak remains. Despite immunisation rates consistently over 90%, of our 256 10–16-year-olds, 51 were not fully immunised. The autism fallacy accounts for 5 not taking up immunisation but 46 were new entrants to the UK after the age of 5. In our area therefore, despite high immunisation rates, we are at high risk of an epidemic. Herd immunity does not apply.
We cannot afford to rest on our laurels. Having reached high immunisation rates overall is good but not good enough especially in areas of high population turnover and immigration. Measles susceptibility is an ever-present danger.
Do we need to routinely do a third MMR at age 10–12, or immunise all new entrants along with TB screening?
Date: 12 May 2013
Topic: Should we charge for A and E?
Comments by: Daniel R Gibney, 4th year Medical Student, Manchester Medical School, 61 Bayswater Road, Wallasey, Merseyside, CH45 8NF. E-mail: email@example.com
I recently spent three weeks in Florence, Italy, in an emergency department at the regional trauma centre where, within a triage system of red, yellow, green, and white, white cases are non-urgent primary care complaints such as coughs, constipation, and earache. Patients over 14 years of age in this category are charged €25 when they have been seen, to discourage patients with non-urgent conditions, encouraging them to seek advice from their GP instead, and recouping the costs of unnecessary attendances.
With A&E attendances in the spotlight and NHS budget constraints such a topic of public debate, are we on the way to charging for some services? Would a charge for unnecessary attendances help to relieve pressure on A&E departments or would it discourage patients from seeking help and put them at risk of harm? Would this just increase GP workload even more? Could it be that patient education, instead of charging, is the way to reduce unnecessary attendances? Are charges of this kind becoming inevitable in the NHS?
Date: 9 May 2013
Topic: Paediatric consultant GP hotline audit
Comments by: Mando Watson, The Bays South, Wharf Road, St Mary's, Hospital London, W2 1NY. E-mail: firstname.lastname@example.org
Robert Klaber, The Bays South Wharf Road St Mary's Hospital London
Chiara Haynes, 37 Woodbury Drive, Sutton, Surrey
Katherine Holt, Flat 4, 190 Brixton Road
Morag Lenman, 34 Bramfield Road, London
It has long been recognised that the telephone is a good way to improve communications between specialists and primary care physicians.1 Written communication is often of variable quality and poor educational value. Despite several examples of successful GP hotlines in the literature, it is an area that has never seemed to take off in the NHS.2
The paediatric consultants at St Mary’s Hospital run a free advice hotline. They receive calls from local GPs between 12–2pm and give advice relating to queries about children. It is hoped that in addition to providing invaluable telephone support, the hotline helps to streamline or avoid paediatric referrals.
Calls to the hotline were audited over a one month period. The purpose of the audit was to analyse:
The number of GP practices using the hotline, the type of queries the calls were about, the type of advice usually given, whether the hotline avoided subsequent clinic referrals and whether GPs were satisfied with the service.
We analysed 23 calls from 13 different surgeries, which account for around 25% of the 50 practices that are located within 2km of the hospital. Frequent clinical topics discussed included: dermatology, gastroenterology, urology, prescribing and behavioural problems. Some calls avoided referrals and although half of the queries resulted in a referral to paediatric outpatients, these were better directed because of the call. Approximately one third of the queries were dealt with by reassurance and GP follow-up
Feedback from GPs was universally positive. They liked the time slot, didn’t have too much difficulty getting through and preferred telephone contact over email. Paediatricians thought providing the service was worthwhile and appreciated the opportunity for case discussion and strengthening links with local GPs.
We think that the GP hotline is a successful, useful and much appreciated service which succeeds in preventing inappropriate referrals and directing necessary referrals to the correct clinic. The service is under-used at present and there is a need to publicise it more. A voicemail option would be useful, particularly if usage increases: topics for future GP education would be paediatric prescribing and dermatology.
A new referral template for paediatric outpatients is in development which will have the paediatric hotline number prominently displayed to encourage GPs to consider calling for advice before making a formal referral.
1. Harrison R, Clayton W, Wallace P. Can telemedicine be used to improve communication between primary and secondary care? BMJ 1996; 313(7069): 1377–1380.
2. Roland M, Bewley B. Boneline: evaluation of an initiative to improve communication between specialists and general practitioners. J Public Health Med 1992; 14(3): 307–309.
Date: 9 May 2013
Topic: Management of opioid addiction in primary care: a pragmatic approach prioritising wellbeing not ideology
Comments by: Henk de Vries, MRCGP, The Quays, Wilberforce Health Centre, Story Street, Kingston-upon-Hull, HU1 3TD. E-mail: email@example.com
The management of opiate addiction and capitalising on recovery potential raises important issues in the delivery of drug and substance misuse services. Currently the majority of shared-care patients are looked after by GPs through a Local Enhanced Service Contract (LES) or Direct Enhanced Service Contract (DES) which means that the practice gets paid for each patient they see with variable degrees of contract monitoring. Recently this has changed into PBR contracts and in Hull J2R delivers a contract through payment-by-results, which is a much more detailed and specified contract.
Recently the Royal Colleges of GPs and Psychiatry have raised the GPs or psychiatrists who deliver this service should become GPsWIs with a formal accreditation at GMC level1 and this will have major implications for contract monitoring, audit, and revalidation in this particular area. It will also have major implications for funding of this drug service, which for the majority until recently was done through The Local Authorities, now the Health and Wellbeing Board.
Although this all seems to be a very positive development, I struggle with two issues. A recovery model is only applicable to very few patients who may be suitable for this and it is very unpredictable which patients are going to recover. In my experience this is no more than 1–2% and I am not sure whether a score list for recovery potential is prospectively that applicable. A more expensive service delivery may therefore come at the cost of the amount of patients we can treat at the moment for only a very modest fee, for harm reduction.
However more important than that is its actual concept: it is not that difficult to treat a patient with an addiction once it is established that it is an addiction problem. However the majority of the patients I see in my practice have a combination of depression, pain, and drug-seeking behavior, that low and behold has overlapping drugs. All opiates, prescribed or unprescribed, all GABA-antagonists, and all benzodiazepines have a potential in the treatment of all afore mentioned conditions and it is this overlap which is so difficult to manage. A specialist service for addiction only is not sufficient. A separate service for a community pain clinic or a psychiatry service for depression is neither. I believe in a generalist approach, confirm Iona Heath’s oration at The Harvey Lecture,2 which should be delivered in a generalist setting.
In a generalist setting it is possible to deliver training to recently qualified GPs or newly qualified GPs in addition to core general training, how manage drug seeking behavior, depression, and pain control safely and robustly. This involves learning to develop sensitivity for objective signs and symptoms of these conditions by direct clinical observation, case discussions in an appropriate teaching environment. Skills like observing a closed-body language, a monotone soft voice, thought intrusion as well as objective signs of pain, like a limp, abdominal guarding, and drug-seeking behavior would be the core issues to address. The RCGP part II course does not cover Miller’s pyramid in ‘can-do’ and ‘demonstrate-how-to-do’ and last but not least actually ‘does’.
If we were to be specially accredited for this than the new 4th year of GP training would be useful to spend time on this,3 as this what often drives consultations in deprived areas, hence why the multimorbidity curves have shifted to the left in this area.4 The most efficient way to deal with these complexities is still general practice and that is probably where it is best to deal with the core of the patients for whom we will only achieve harm reduction.
1. Harris L, Gilvarry E. Delivering quality care for drug and alcohol users: the roles and competencies of doctors. 31st of January NTA/RCGP joint conference, Recovery in Primary Care: Shaping, Leading and Influencing. Presentation.
2. Heath I. Divided we fail. The Harveian Oration. London: Royal College of Physicians, 2011. http://www.rcplondon.ac.uk/sites/default/files/harveian-oration-2011-web-navigable.pdf
3. Royal College of General Practitioners. RCGP response to unanimous decision to extend and enhance GP training. London: RCGP, 2012. http://www.rcgp.org.uk/news/2012/september/rcgp-response-to-unanimous-decision-to-extend-and-enhance-gp-training.aspx
4. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380(9836): 37–43.
Date: 2 May 2013
Topic: Perinatal OCD
Comments by: Geoffrey Allen. E-mail: firstname.lastname@example.org
I found this article by Challacombe and Roe interesting and timely.1 The idea of harming your baby can be terrifying for a new mum and the distress is aggravated by the fact that such thoughts ‘should not be felt’ by a caring mother. Clearly the difference between obsessive–compulsive disorder (OCD) and other more serious forms of mental illness is that with OCD there is no desire to carry out the thoughts.
I have been in practice over 30 years in Derby and feel OCD in general is underdiagnosed. When I see a patient with anxiety, problem drinking, or depression, I ask if they have problems with excessive checking or contamination fears. Although I have not kept any figures, a significant number have OCD; some for years and there is often well-meant collusion with friends or relatives. Questions about OCD could be incorporated into anxiety/depression health questionnaires.
OCD is often a chronic illness. Even after appropriate referral and therapy, I find relapse is common. I now negotiate treatment goals with the aim of ‘minimising its effects on everyday living’. Patients seem relieved about this, as they get frustrated and disappointed that their problem was not ‘cured’ by therapy. They are often thorough and conscientious and can make excellent parents and valued workers.
1. Challacombe FL, Wroe AL. A hidden problem: consequences of the misdiagnosis of perinatal obsessive–compulsive disorder. Br J Gen Pract 2013; 63(610): 275–276.
Date: 24 Apr 2013
Topic: Clinical reasoning, evidence-based knowledge, and evidence-based physical examination combined with the GP’s gut feeling may overcome pitfalls in diagnostic uncertainty
Comments by: Bernard Klemenz, MD, MRCGP, GP Principle, Northern Road Surgery, 56 Northern Road, Cosham, PO6 3DS. E-mail: Bernard@doctors.org.uk
I enjoyed reading the article ‘Diagnostic uncertainty: dichotomies are not the answer’ by Bethany Shinkins.1 In order to minimise diagnostic uncertainty the GP has to combine not only positive and negative predictive values of diagnostic tests, like CRP or tumour markers. Being aware of the clinical examination operating characteristics and their sensitivity and specificity (for example, Psoas sign, guarding, and vomiting in appendicitis) may further improve the capability in ruling in or ruling out a disease.2 Unfortunately evidence-based physical examination is not part of the medical student’s curriculum as yet.3
Previous research has shown that physicians make a diagnosis from the patient’s history in 70–90% of cases, based on the chief complaint or the history. Putting the patient at the centre of the diagnosis-making process will reduce further diagnostic pitfalls.4,5 The art of medicine is to translate the patient presenting symptoms into a correct diagnosis.6
Reflecting on one’s knowledge and being aware of one’s limitations is essential to overcome insufficient knowledge, which can result in not diagnosing a disease. Being able to use the internet as part of the diagnostic workup of a patients’ disease reduce diagnostic uncertainty further.7,8 This is aided by using principles of clinical reasoning.
In rare diseases the GP is not only able to use clinical reasoning, but it seems that the experienced GP can count on his ‘gut feelings’, which is increasingly recognised as part of the diagnosis-making mental process.10,11 This ‘gut feeling’ saved an unborn child and its mother’s life. A 28-month pregnant patient presented with severe headache and consulted several doctors before, who related her headache to pre-existing migraine. I did not necessarily know the diagnosis, but felt that something was seriously wrong and admitted her directly to hospital. The possible fatal diagnosis was Sinus venous thrombosis, which a GP may only see once in his lifetime.
Sometimes we have to realise, that there is no diagnosis to a patient symptoms, despite using evidence-based medicine, evidence-based physical examination combined with clinical reasoning. Then our true capacities as a GP will help to overcome the suffering of patients with so-called ‘medically unexplained symptoms’. These symptoms though may be explainable in the future through on-going research. We all know that the game of science is, in principle, without end … and there may be a light at the other end of the tunnel for some patients with still unexplainable symptoms.12,13
1. Shinkins B. Diagnostic uncertainty: dichotomies are not the answer. Br J Gen Pract 2013; 63(608): 122–123.
2. Simel DL, Drummond R. The rational clinical examination. Evidence-based clinical diagnosis. Columbus, OH: McGrow-Hill Companies, 2009: 53–60.
3. Klemenz B. Teaching clinical reasoning at medical school is unavoidable. BMJ rapid response. http://www.bmj.com/rapid-response/2011/11/02/teaching-clinical-reasoning-medical-school-unavoidable
4. Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. Res Med Educ 1988; 27: 242–247.
5. Peterson MC, Holbrook JH, Von Hales D, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156(2): 163–165.
6. Knill-Jones. Diagnostic systems as an aid to clinical decision making. Br Med J (Clin Res Ed) 1987; 295(6610): 1392–1396.
7. Klemenz B, McSherry D. Obtaining medical information from the internet. J R Coll Physicians Lond 1997; 31(4): 410–413.
8. Klemenz B, McSherry D, Grundke V. Clinical problem solving by computer. J R Coll Physicians Lond 1997; 31(1): 32–36.
9. Kassirer JP, Kopelman RI. Learning clinical reasoning. New York: Lippincott Williams & Wilkins, 2009.
10. Gigerenzer G. Gut feelings – short cuts to better decision making-How to improve physician judgments. Penguin Books, 2007: 167–169.
11. Van den Bruel A. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012; 345: e6144.
12. Popper K. The logic of scientific discovery. New York: Harper & Row, 1968: 53–54.
13. Danczak A. Managing medically unexplained symptoms in the consultation in Burton C ABC of Medically unexplained symptoms. London: BMJ Books, 2013: 52–55.
Date: 11 Apr 2013
Topic: Response to ‘The challenge of communication in interpreted consultations in diabetes care’
Comments by: Peter Campion, Emeritus Professor of Primary Care Medicine, University of Hull
Seale is right to observe that this is the first published empirical study of interpreter-mediated consultations in UK primary care: in the past 10 years, with several colleagues I was unsuccessful in getting funding for such a study.1 The paper is shocking to the extent that it shows in one UK setting, but there is no reason to suppose this was atypical, a flagrant disregard for well evidenced guidelines2,3,4 on the need for proper interpreters in consultations between health professionals and people with Limited English Proficiency (LEP).
One of their most glaring findings is that in interpreted consultations professionals used mostly third-person pronouns (she, his) while in non-interpreted ones almost entirely second-person forms (you, your): in other words the health professionals were saying to the interpreters ‘does he take sugar?’ They note ‘Thus a concordance analysis showed that “does he” is the most common two-word phrase associated with providers’ usage of “he” in these consultations (33 times), and the most common verbs occurring before “him” in provider talk in these consultations are “see”, “ask”, “give”, “tell”, and “help”.’ All guidance points to the importance of addressing the patient directly, ‘do you take sugar?’ allowing the interpreter simply to relay the same words.
The various qualitative findings point to serious shortcomings in consultations interpreted by ‘informal’ (usually family members) interpreters, and highlight the need for proper provision.
The implication of this study, as noted by Joe Kai in his editorial, is surely that the cost of paid interpreters (whether face-to-face or a telephone service) is likely to outweigh the loss of effectiveness in diagnosis and management by health professionals hindered by a ‘language barrier’.
1. Seale C, Rivas C, Kelly M. The challenge of communication in interpreted consultations in diabetes care: a mixed methods study. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663082.
2. Burnett A. Meeting the health needs of refugee and asylum seekers in the UK an information and resource pack for health workers. London: Department of Health, 2002. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4010199
3. Department of Health, Equality and Human Rights Group. Guidance on developing local communication support services and strategies. London: DoH, 2004. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4082350.pdf
4. Tribe R. Asylum 4: working with interpreters. The Psychologist 2007; 20(3): 159–161. http://www.thepsychologist.org.uk/archive/archive_home.cfm?volumeID=20&editionID=145&ArticleID=1158
Date: 5 April 2013
Topic: Response to ‘HIV testing: the danger of keeping secrets’
Comments by: Chris G Williams, MSc, School of Medicine, Cedar House, Ashton Street, University of Liverpool, L69 3GE. E-mail: CGWilliams@doctors.org.uk
Alastair Miller, MA FRCP DTM&H, Consultant Physician, Tropical & Infectious Disease Unit (3Z), Royal Liverpool University Hospital, Liverpool
During the 1980s and early 1990s, the advocacy group ACT UP (AIDS coalition to unleash power) had a slogan1 – ‘ignorance = fear, silence = death’. McElveen’s comment on information silence about HIV infection between primary and secondary care reminds us that the message is still relevant today. The solution, however, is more complicated than making communication of a patient’s HIV status to their GP automatic.
HIV infection hidden from primary health care is already a sizeable challenge: 20–49% of people living with HIV choose not to disclose their status to GPs;2–8 a legacy of the historical and deep-seated stigma surrounding this condition. Without action, this challenge will grow with HIV prevalence.
Non-disclosure becomes a more significant problem in the context of economic constraint. Previously, the HIV specialist could manage a variety of ailments for the HIV patient, but prescribing of non-antiretroviral therapy (ART) is increasingly being devolved to primary care. ART interacts with many commonly prescribed medications, for example: simvastatin; omeprazole; midazolam. Drug interactions are exceedingly complex and need considered management with expert advice. An invaluable and comprehensive resource is the Liverpool drug interactions website (www.hiv-druginteractions.org). Benn et al found devolution of statin prescribing from HIV specialist to GPs led to life-threatening drug reactions, where GPs were fully informed of HIV status.9 Clearly, if the primary care prescriber is unaware of the patient’s HIV status and ART use, they cannot consider the risk of drug interactions.
Non-disclosure originates in discrimination of people living with HIV: fear of discrimination drives the insatiable need for confidentiality. McElveen is quite correct in that we are only strengthening this attitude by allowing it to overshadow information sharing for comprehensive care. Yet discrimination is an unfortunate, and unacceptable reality. Some fear communication between HIV specialists and GPs will cause information to leak out to non-clinical staff.2,8 From experience, this can happen and lead to enacted stigma. Such experiences can erode the patient–doctor relationship, which is of utmost importance in HIV. A poor relationship may lead to patient dissatisfaction, related non-adherence to medication, resistant, and progressive disease as well as transmission of hard-to-treat virus.
To draw an oft-presented analogy, confidentiality is the plaster to the infected wound of stigma and discrimination. Policies of non-discrimination are more effective than policies of confidentiality in facilitating patients to disclose their HIV status to GPs.2 GPs are positioned to address patient concerns: participatory action techniques using group discussion would allow local problems to be unearthed, understood, and addressed through education and personal experience. The HIV specialist is positioned to perform surveillance of non-disclosure, and encourage disclosure. McElveen argues that we change practice to protect the patient. We agree, but the balance between patient safety and confidentiality is underpinned by discrimination. We must act to make our spaces safe: there should be no legitimate fear of discrimination for people living with HIV within health services.
1. AIDS Coalition To Unleash Power (ACT UP). Silence = death, campaign report. http://www.actupny.org/reports/silencedeath.html
2. Shaw M, Tomlinson D, Higginson I. Survey of HIV patients' views on confidentiality and nondiscrimination policies in general practice. BMJ 1996; 312(7044): 1463–1464.
3. Madge S, Mocroft A, Olaita A, Johnson M. Do women with HIV infection consult with their GPs? Br J Gen Pract 1998; 48(431): 1329–1330.
4. Moss TR, Goy L, Hawkswell J, Brar H. Comment: Do women with HIV infection consult with their GPs? Br J Gen Pract 1998; 48(433): 1525–1526.
5. Casserly SM, Scott GR, MacDougall M. General practitioner involvement and patient outcomes in HIV management. Int J STD AIDS 2009; 20(7): 503–505.
6. Evans HE, Mercer CH, Rait G, et al. Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995–2005. Sex Transm Infect 2009; 85(7): 520–526.
7. Desai M, Field N, Crompton J, Ruf M. Information for action: a method to inform HIV shared care planning in primary care at the PCT level. Sex Transm Infect 2011; 87(4): 295.
8. Knapper C, Drayton R, Browning M, Lomax N. Confidentiality: a continuing barrier to disclosure of HIV status to GPs? The experience and concerns of HIV patients in a Welsh HIV clinic. Birmingham: BHIVA Conference, 2012. http://www.bhiva.org/documents/Conferences/2012Birmingham/Presentations/Posters/Management-Issues-in-HIV/P229.pdf
9. Benn PD, Miller RF, Evans L, et al. Devolving of statin prescribing to general practitioners for HIV-infected patients receiving antiretroviral therapy. Int J STD AIDS 2009; 20(3): 202–204.
Date: 5 Apr 2013
Topic: Response to ‘Don’t shoot the messenger: the problem of whistleblowing in general practice’
Comments by: Steve Cox, GP, St Helens, WN4 0XD, Merseyside. E-mail: Steve.email@example.com
John Holden, GP, St Helens, Merseyside
We agree that there are unique problems for GPs in whistleblowing.1 However, over five years we found whistleblowing on 43 occasions (42% of the total) to be the commonest presentation of clinical poor performance in our district.2 We attribute this to having experienced people available locally who are trusted to handle concerns seriously, confidentially and discretely.
Although action is needed to enhance whistleblowing, this must be accompanied by annual reporting of numbers of whistleblowing incidents in each district so that we may know whether there are indeed trusted people available everywhere? The lessons of several national inquiries must not be lost during times of major NHS changes.
1. Mathers N, Sillitoe L. Don’t shoot the messenger: the problem of whistleblowing in general practice. Br J Gen Pract 2013; DOI 10.3399/bjgp13X665459.
2. Cox SJ, Holden JD. Presentation and outcome of clinical poor performance in one health district over a five-year period: 2002–2007. Br J Gen Pract 2009; 59(562): 344–348.
Date: 5 Apr 2013
Topic: The Numbers Needed to Inform Consent?
Comments by: Terry Kemple, Horfield Health Centre, Lockleaze Road, Horfield, Bristol BS7 9RR. E-mail: firstname.lastname@example.org
Is consent ever informed if the numbers that describe risk remain a mystery to most people? Better ways and numbers1 to explain overall benefits and risks like numbers needed to benefit (NNB) and numbers needed to damage (NND) are welcome, but may fail to inform most decisions. Doctors often don’t know the numbers needed to treat (NNT) and numbers needed to harm (NNH) or don’t explain the true benefits and harms of tests and treatments. Patients usually consent with only a poor understanding of their risks.
Patients usually overestimate the benefit of treatments.2 For example, many people using statins or antihypertensive’s believe they are substantially reducing their risk of heart attack or stroke. Assuming that the treatment is safe and used for 5 years, only a few patients would take a drug if they thought that they had a 5% chance or less of benefiting (NNT 20). Half of the patients would take a drug if the chance of them benefiting was 20% (NNT 5). If the benefit was 5% or less then the number of patients willing to take a preventive drug was doubled if their doctor recommended the treatment. Most interventions are not that good.
Different doctors and patients cope with the same risk differently and the subsequent management of the same conditions varies widely.3
How can understanding of risk and consent become better informed?
GPs need to know and explain the frequency of benefits and harms of the tests and treatments that they recommend to patients. To be able to do this risk scores like NNT, NNH, NNB, NND for tests and treatments need to be easily accessible to inform everyday decision making and GPs need to benchmark their own understanding and tolerance of risk and make this clear when they make recommendations to patients.
If patients can make sense of their risk they will make more informed and personal choices about their care (and may often decline care).
1. Shapley M, Mansell G, Barraclough K, Croft P. General practice by numbers: presentation to final outcome. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X665468.
2. Trewby PN, Reddy AV, Trewby CS, et al. Are preventative drugs preventive enough? A study of patients’ expectation of benefits from preventive drugs. Clin Med 2002; 2(6): 527–533.
3. Ingram JC, Calnan MW, Greenwood RJ, et al. Risk taking in general practice: GP out-of-hours referrals to hospital. Br J Gen Pract 2009; DOI: 10.3399/bjgp09X394824.
Date: 27 Mar 2013
Topic: Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the ‘white coat’ effect?
Comments by: Una Martin, University of Birmingham, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, Birmingham, B15 2TT. E-mail: email@example.com
Roger Holder, University of Birmingham, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, Birmingham
James Hodgkinson, University of Birmingham, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, Birmingham
Richard McManus, University of Oxford, Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford
Many thanks for your comments about our recent article.1 We are happy to give a definition of ‘white-coat’ effect. This phenomenon refers to the transient rise in blood pressure triggered by a visit to the doctor’s office, caused by an alerting reaction. The difference between blood pressure measured in the clinic and on ambulatory blood pressure monitoring is usually defined as ‘white-coat’ effect whereas the clinical situation in which persistently high office blood pressure and normal ambulatory blood pressure coexist regardless of the degree of ‘white-coat’ effect is referred to as ‘white-coat’ hypertension.2,3 We agree that it would be interesting to look at the effects of medication on our findings but our study was not set up to do this. Patients on medication referred to our service are complex and usually on multiple medications. It would be impossible to identify differences from individual medication for this reason. We believe such a study would have to be done prospectively. We can confirm that detailed instructions are given to patients when they wear ambulatory monitoring and a patient diary is recorded. We agree that further analysis of the effects of comorbidity on the findings would be interesting to do. We are not able to confirm that the first blood pressure was always the highest as this was not recorded, but data collected since this study suggests that this is often the case. Finally, thank you for pointing out that the ‘no-difference’ line is above zero on Figure 2; we believe this is a publishing error.
1. Martin U, Holder R, Hodgkinson J, McManus R. Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the ‘white-coat’ effect? Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663055.
2. Verdecchia P, Angeli F, Gattobigio R. Clinical usefulness of ambulatory blood pressure monitoring. J Am Soc Nephrol 2004; 15 Suppl 1: S30–33.
3. Pickering TG, Coats A, Mallion JM, et al. Blood pressure monitoring. Task force V: white-coat hypertension. Blood Press Monit 1999; 4(6): 333–341.
Date: 25 Mar 2013
Topic: Authors’ reply to 'Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria'
Comments by: Nitin Gholap, specialist registrar, Diabetes Research Unit, University of Leicester. E-mail: firstname.lastname@example.org
Melanie Davies, professor of diabetes medicine, Diabetes Research Unit, University of Leicester
Samiul Mostafa, clinical research fellow, Diabetes Research Unit, University of Leicester
Kamlesh Khunti, professor of primary care diabetes and vascular medicine, Diabetes Research Unit, University of Leicester
We thank the authors for their interest in our article and valuable comments. First, Dr Leach disagrees with the 2-week interval for repeating HbA1c to confirm new diagnosis of diabetes in asymptomatic people with HbA1c ≥6.5% (≥48 mmol/mol).1 Dr Leach suggests instead a longer interval of 6–8 weeks for the test is more appropriate. However we disagree with Dr Leach’s suggestion. First, HbA1c already gives reflection of level of glycaemia over a period of a few weeks compared to glucose test that gives a snapshot of glycaemia at that point in time. Therefore the main idea behind repeating the HbA1c test is to rule out any lab errors in HbA1c measurement. The suggested 2-week interval is arbitrary taking into consideration any logistics of repeating the test after the first test in the primary care setting. Additionally repeating the test within 2 weeks (not after 2 weeks) preclude the possibility of a patient introducing an intervention (for example, increasing physical activity or lowering dietary glucose load) to decrease his/her glucose profile thereby affecting results of the repeat HbA1c test. Fifty per cent of the contribution to HbA1c comes from the preceding 4 weeks and therefore any longer interval would risk a change in the HbA1c result.
Second, we read with interest the data presented by Evans and colleagues from their practice.2 A similar increase in prevalence of diabetes using HbA1c compared to glucose tests was observed in our research cohort presented in an article cited as reference 4. It is known that there is discrepancy in type 2 diabetes diagnosed by HbA1c and the glucose tests, therefore the two tests may not identify the same individuals. HbA1c is a better indicator of chronic glycaemia than a glucose test. It is therefore likely that practices that switch to using HbA1c will see a sudden surge of people with diabetes diagnosis, as many individuals may have undiagnosed HbA1c levels of ≥6.5% (≥48 mmol/mol) for a while but always had negative glucose testing. HbA1c independently increases with age and it is interesting to see that the people diagnosed using the HbA1c criteria were older in their cohort. This field is evolving and in future we may gain insights into practical implications of factors such as age and ethnicity impacting on HbA1c measurement.
1. Leach M. Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria. [Letter]. Br J Gen Pract 2013; 63(610): 235.
2. Evans PH, Pereira Gray DJ, Wright C, Langley P. Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria. [Letter]. Br J Gen Pract 2013; 63(610): 235.
Date: 22 March 2013
Topic: Registrar Feedback on the article: formative assessments in medical education!
Comments by: Pete Osborne, GP Registrar, Burdwood Surgery, Wheelers Green Way, Thatcham, Berkshire. RG19 4YF UK. Email: email@example.com
Bahia Bal, Burdwood Surgery, Wheelers Green Way, Thatcham, Berkshire
I write in support of the article ‘Formative assessments in medical education’ by Dr Lakasing.1
I love my job as a GP registrar and look forward to qualification in a few months. Despite the contract wranglings, bad press, and the ever-increasing workload, I feel optimistic and enthused about the future.
I support most aspects of the ePortfolio process from the AKT and CSA exams to the Case Based Discussion and Consultation Observation Tool assessments. I think the Patient Satisfaction Questionnaires and Multi Source Feedback assessments are crucial aspects of good training, as these collate the views of the many people we are working respectively for and with.
I completely agree with Dr Lakasing about the negative impact of the requirement for writing huge volumes of reflective entries. I believe that potentially excellent GPs with the ability and energy to be involved in innovation and improvement within primary care are shackled by the need to endlessly document reflections in accordance with the curriculum. I also think that the quantity of trainee reflection must be hugely wearing for GP trainers and must put off good people from doing the job. Given the pending rise in need for GP trainers, as a profession we will need all the good people we can get.
Another problem with the ‘log entries’ is the variability of volume required across deaneries. In the London deanery, registrars do two entries per month. In Oxford and Kent, Surrey and Sussex deaneries the recommended minimum is two per week. This creates inequity of training and I would suggest that the London deanery has nearer the right balance.
The recent Francis report identified the adverse consequences of box ticking on clinical care. I would suggest that excessive box ticking has the same negative impact on training. Coerced excessive written introspection erodes professionalism and motivation. It has the potential to encourage gaming and creative writing among trainees trying to keep up in a numbers game with their peers.
Compared to my friends in other specialities such as medicine, paediatrics, and psychiatry, I feel we GP registrars have a superior training programme and I am grateful for this. The majority of the ePortfolio is good at documenting a basic level of competence. With a sensible reduction in ‘log entry’ volume and a rethink on the content and purpose of Clinical Supervisor's Report, the ePortfolio could be a fantastic aid to training. That said, what I really value in training is dedicated tutorial time with experienced GPs to talk through challenging cases and difficult scenarios. This apprenticeship-style learning and the passing on of the ‘art’ of medicine is invaluable and completely irreplaceable by the ePortfolio.
1. Lakasing E. Formative assessments in medical education: are excessive, and erode the learning and teaching experience. Br J Gen Pract 2013; 63(608): 145.
Date: 19 Mar 2013
Topic: Musculoskeletal clinical assessment and treatment services at the primary–secondary care interface: an observational study
Comments by: Robert Simpson-White FRCGP, The Old Rectory, English Bicknor, Coleford, Gloucestershire
The article by Roddy et al describes in some numerical detail the assessment of various categories of musculoskeletal ailments of 2130 patients at Stoke-on-Trent.1 It is written under the names of eight people, but it does not give their qualifications or their special expertise.
The authors claim that most patients were managed without onward referral.
They worked at ‘the interface between primary and secondary care’.
However, only 23% of the patients were X-rayed, no investigations were undertaken in 48% of cases, and a mere 7% were referred to ‘orthopaedics’ and 3% to ‘rheumatology’ (presumably this refers to requests for consultant opinions).
Although the team endeavoured to do their best for their patients, no evidence of benefit to them was produced. In the absence of such evidence, is there any justification for the intervention of this team between the GP and the consultant whose opinion he is seeking?
1. Roddy E, Zwierska I, Jordan KP, et al. Musculoskeletal clinical assessment and treatment services at the pimary–secondary care interface: an observational study. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663109.
Date: 19 Mar 2013
Topic: Sharing control of appointment length with patients in general practice: a qualitative study
Comments by: Robert Lambourn, GP, Wooler , Northumberland. E-mail: firstname.lastname@example.org
Joanne Richardson, ST3 GPStR, Wooler, Northumberland
Elizabeth Batley, GP, Wooler, Northumberland
Caroline Douglas, Practice Manager, Wooler, Northumberland
We read with great interest the excellent recent paper by Sampson et al1 and note their finding that doctors and patients still shared concern about the accuracy with which patients can judge their own consultation length.2,3,4
We recently examined patients’ ability to choose between ten and 20-minute appointment lengths. For one week patients were routinely asked whether they would like an appointment of 10 or 20 minutes, 10 minutes being the standard length. Appointment times were measured from the time the doctor went to fetch the patient until the patient left the consulting room.
101 consultations were studied, and of these, 91 patients requested a 10-minute consultation and 10 (10%) requested 20 minutes. Of patients choosing a consultation length of ten minutes, consultations lasted a mean of 11.24 minutes (median 11.1, minutes, range 2–33 minutes). Of patients choosing twenty minutes, consultations lasted a mean of 18.14 minutes (median 18, range 6.47–24 minutes). Our study was carried out in a single practice and conducted by researchers who were the GPs of the participating patients, and there was no attempt at blinding, so that doctor knowledge of the consultation rate could have altered the length of consultations. Nevertheless, our findings add to the evidence base that patients are capable of choosing a consultation length of either 10 or 20 minutes with a reasonable degree of accuracy.
We would also like to emphasise the difference between consultation length (ie time between patient being called/entering and leaving the consultation room) and consultation frequency (time between one patient entering and the next patient entering, or number of patients booked per hour). Reading records before a patient enters and writing up the previous patient's records takes at least two minutes. In our practice patients are booked at a rate of five per hour, which we feel equates to a consultation length of ten minutes. Our findings support previous suggestions that patients are able predict their consultation length, and suggest that only ten percent of patients request a longer consultation, and also the recent BJGP editorial questioning the appropriateness of the minute consultation.5 We also call for some consistency of definition of appointment length, as opposed to consultation frequency.
1. Sampson R, O'Rourke J, Hendry R, et al. Sharing control of appointment length with patients in general practice: a qualitative study. Br J Gen Pract 2013; DOI: 10.3399/bjgp 13X664234.
2. Harrison AT. Appointment systems: feasibility of a new approach. Br med J (Clin Res Ed) 1988; 294(6585): 1465–1466.
3. Lowenthal L, Bingham E. Length of consultation: how well do patients choose? J R Coll Gen Pract 1987; 37(304): 498–499.
4. Lambourn R. Can patients choose appointment length? Br J Gen Pract 2003; 53(497): 969–970.
5. Silverman J, Kinnersley P. Calling time on the 10-minute consultation. Br J Gen Pract 2012; 62(596): 118–119.
Date: 19 Mar 2013
Topic: Sharing control of appointment length with patients in general practice: a qualitative study
Comments by: Chris Barry FRCGP, Recently retired GP, 96 The Bramptons, Swindon, SN5 5SL. E-mail: email@example.com
I was interested to see Rod Sampson’s article;1 many years ago I read something similar, and decided to try it myself, albeit without the post-appointment interviews. We offered my patients 5, 10, 15, or 20-minute appointments; it worked very well; I was pleasantly surprised. Patients had a good idea of how much time they would need; very few requested the longer ‘slots’ so my fears of being overwhelmed proved unfounded.
We did not continue the experiment because at the time I had a policy of accepting phone calls from patients; this interrupted the consultation (although if I let the phone ring more than three times the receptionist understood that I was not going to answer) but saved having to ring back, with the problems that engendered for the patient in terms of having to stay by the phone for an unpredictable period of time. However, what happened was that for each phone call, I ran that little bit late, so if there were several calls the later patients were kept waiting for longer than I (or they) would have wished.
All this was long before QOF, but there would seem to be no reason why such a system could not work well, with an extra few minutes added on for those doctor-centred elements. Thus the patient would feel they had had a fair hearing, and the doctor would not feel pressured into trying to squeeze the QOF components into a 10-minute slot if the patient’s agenda was a long one. After all, who tells the patient that the appointment is for 10 minutes? With this system, the patient knows exactly how long they’ve got. Also, the doctor would not have in the back of his or her mind the oft-quoted fear of the patient who brings a list, surgeries would not overrun, waiting rooms would not be full of disgruntled patients; the benefits would seem considerable on both ‘sides’.
The obvious counter-argument is that surgeries would take longer, or that fewer patients would be seen. That was not the case when I tried it; Sampson’s article makes no mention of this aspect; clearly more information is needed, but in the meantime, why not try it?
1. Sampson R, O’Rourke J, Hendry R, et al. Sharing control of appointment length with patients in general practice: a qualitative study. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X664234.
Date: 4 Mar 2013
Topic: Response to ‘Not just another primary care workforce crisis’
Comments by: Dr David Berger, MBBS, MRCP, MRCGP, FRACGP, Locum DMO in Emergency Medicine, Broome Hospital, Broome, Western Australia. E-mail: firstname.lastname@example.org
Despite repeated private and public requests to clarify their position, the recent data from Morison et al and their colleagues at COGPED still fails to stratify those returning to general practice in the UK after an absence of more than 2 years.1 They refer to ‘the assessment of those returning to UK general practice after a period away from clinical practice’ and do not tell us how their extremely limited data can be stratified according to those who have been working as GPs (even though abroad) and those who have not been working at all. No-one will contest that individuals out of clinical practice completely for an extended period require assessment, and likely, a period of refreshment before returning. Some may not be suitable to return at all. However, they apply the 2-year criterion to anyone out of UK general practice, not just out of general practice. This means a GP working in general practice in, say, Australia, will be subject to the same blanket requirements for formal re-testing, a lengthy, bureaucratic, and costly process, as an individual who has not worked in clinical medicine at all. This is clearly absurd. Morison knows well cases such as that of a returning GP who had been working a few days longer than 2 years in Australia as a full-time GP and was required to undergo such formal assessment on their return to the UK, a process that lasted more than 4 months in their case. There are many others.
I have previously asked Morison and Irish to divulge the recipe of the ‘special super secret sauce’ in UK general practice, the knowledge of which apparently deteriorates over time, and which means a GP working as a GP in countries such as Australia, New Zealand, or Canada loses basic clinical competence after 2 years and then becomes unsafe to work in the UK. No such recipe has ever been forthcoming. As a GP working currently in Australia, it is clear that the standard of care and level of competence here are in many cases higher than in the UK. If the ‘special super secret sauce’ of UK general practice relates to knowledge about the QOF, CCGs, and other particularities pertinent only to the UK, then this could easily be dealt with by a short refresher course on UK procedures on top of a clinical interview and the taking up of references. It does not require pointless basic clinical reassessment lasting many months, costing large amounts of money, and delivering high levels of anguish to the individuals concerned.
1. Morison J, Irish B, Main P. Not just another primary care workforce crisis. [letter]. Br J Gen Pract 2013; 63(607): 72.
Date: 26 Feb 2013
Topic: Training healthcare professionals to work with interpreters: the link with patient safety
Comments by: Aarti Bansal, GP & Academic Teaching Fellow, Academic Unit of Primary Medical Care, University of Sheffield, Sam Fox House, Northern General Hospital, Herries Road, Sheffield, S5 7AU. E-mail: email@example.com
I was encouraged to see articles published on interpreted consultations in the February 2013 issue of the BJGP. Seale et al observed significant differences in the content of interpreted consultations as opposed to same-language consultations, including, fewer questions from the patient, less questioning of the patient agenda, less patient involvement in management, and a lack of humour.1 However, as the majority of the fluent English consultations were with white patients rather than with ethnic-minority patients fluent in English, it does not necessarily follow that the differences observed were as a direct result of the consultation being interpreted. Although we can assume that proficiency in English also points to a level of acculturation in ethnic-minority patients, some of the observed differences may be explained by cultural distance between the patient and provider rather than a language barrier. Cultural distance between patient and provider has been shown to challenge the delivery of patient-centred care, even where there is no language barrier.2,3 Any training on working with interpreters, therefore, also needs to incorporate diversity training that encourages examination of unconscious biases/stereotypes and enables providers to deal with the uncertainty created by cultural distance.4
In his editorial on the subject, Joe Kai points to many excellent areas of research to help improve interpreted consultations.5 These suggestions are very welcome. However, perhaps, as a first step we should prioritise implementing research linking the use of professional interpreters with patient safety. We already know that professional interpreters improve clinical care to patients with limited English to approach that of English speaking patients.6 Additionally, there are fewer problems with accuracy, confidentiality, and control when using professional interpreters as opposed to family or bilingual workers.7 Despite this, and even when interpreting services are available, healthcare professionals underuse the services of professional interpreters, tending instead to use family interpreters, bilingual workers, or ‘getting by’ without services.8 Furthermore, training healthcare professionals on how to consult effectively through interpreters not only improves skills with all kinds of interpreted consultations but more importantly increases the likelihood of using professional interpreters in future.9
Our responsibility for patient safety demands that we address the inadequate provision of training for healthcare professionals on consulting through interpreters at both undergraduate and postgraduate level.
1. Seale C, Rivas C, Kelly M. The challenge of communication in interpreted consultations in diabetes care: a mixed methods study. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663082.
2. Kai J, Beavan J, Faull C, et al. Professional uncertainty and disempowerment responding to ethnic diversity in health care: A qualitative study. PLoS Med 2007; 4(11): 1766–1775.
3. van Ryn M, Saha S. Exploring unconscious bias in disparities research and medical education. JAMA 2011; 306(9): 995–996.
4. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc 2008; 100(11): 1275–1285.
5. Kai J. Enhancing consultation with interpreters: learning more about how. Br J Gen Pract 2013; 63(607): 66–67.
6. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42(2): 727–754.
7. Leanza Y, Boivin I, Rosenberg E. Interruptions and resistance: a comparison of medical consultations with family and trained interpreters. Soc Sci Med 2010; 70(12): 1888–1895.
8. Gill PS, Beavan J, Calvert M, Freemantle N. The unmet need for interpreting provision in UK primary care. PLoS One 20113; 6(6): e20837.
9. Jacobs EA, Diamond LC, Stevak L. The importance of teaching clinicians when and how to work with interpreters. Patient Educ Couns 2010; 78(2): 149–153.
Date: 22 Feb 2013
Topic: The use of email consultation
Comments by: Hajira Dambha, ACF, University of Cambridge. Email: firstname.lastname@example.org
In this interesting editorial, Helen Atherton discusses the use of emails for consulting with patients.1 The consultation is at the core of general practice. With the patient in front of us in the consulting room, we are able to interact and engage with them, develop a rapport, and nurture the doctor–patient relationship. We have the opportunity to get to know our patients along with their families on an individual and personal level. Face-to-face, we also learn about our patients from their non-verbal cues, demeanor, and attire. This assists us in understanding our patients and their needs as a whole, beyond their health needs. When I signed up to GP training, I did so because I was excited about this idea of delivering a personal and holistic service.
A few lines in some form of email consultation seems incomplete, impersonal, and lacks the patient-centeredness, family-centeredness, and holism that GPs are encouraged to aspire towards.2
1. Atherton H. Use of email for consulting with patients in general practice. Br J Gen Pract 2013; 63(608): 118–119.
2. Goodwin N, Dixon A, Poole T, et al. Improving the quality of care in general practice. Report of an independent inquiry commissioned by The King’s Fund. London: The King’s Fund, 2011.
Date: 21 Feb 2013
Topic: The RCGP tie
Comments by: Bashir Qureshi, FRCGP. Email: email@example.com
I know by first hand experience, having served as a member of Council over four terms, that our College does take note of world opinion and is a progressive organisation. Once upon a time, our Council was going to adopt an owl as the College’s insignia. The idea was dropped but the owl was retained on the College tie. I asked Late Dr Bill Styles, then Honorary Secretary, the reason. He told me ‘it was due to you’ and explained that I had written in an article on transcultural medicine in 1983, that the owl is a symbol of wisdom in the West, because it remains awake observing everything around it all night, and does not make any noise, but that in the East an owl is a symbol of foolishness because it is awake at night when everyone is asleep and no one is around to feed it. It sleeps all day. To be called ‘an owl’ is a term of abuse and can be very offensive. Moreover, it is a symbol of ‘bad luck’ and it is not a good omen for an Eastern patient. When ill, an owl is the last thing they would want to see.
No wonder, even now-a-days working as a GP, I wear my College life-fellow tie, with an owl, only in predominantly English areas of London, such as Richmond, but wear a different tie, with a scale (I am a Libra sign), in multicultural areas. I wonder what the other readers or College members do.
Date: 20 Feb 2013
Topic: Treatment intensification in type 2 diabetes mellitus and obesity
Comments by: Agnieszka Zawiejska, MD, PhD, Medical Research Fellow, Weight Management Services, Heart of England NHS Foundation Trust, and Centre for Endocrinology and Metabolism and NIHR Birmingham and Black Country CLAHRC, University of Birmingham
Jane McAleese, RN, Diabetes Specialist Nurse, Weight Management Services, Heart of England NHS Foundation Trust, and Centre for Endocrinology and Metabolism and NIHR Birmingham andBlack Country CLAHRC, University of Birmingham, Weight Management Services, Heart of England NHS Foundation Trust, and Centre for Endocrinology and Metabolism and NIHR Birmingham and Black Country CLAHRC, University of Birmingham
Prasad Yemparala, MD, MRCP, Consultant in Diabetes and Bariatric Physician, Weight Management Services, Heart of England NHS Foundation Trust, and Centre for Endocrinology and Metabolism and NIHR Birmingham and Black Country CLAHRC, University of Birmingham
Shahrad Taheri, MB BS, PhD, FRCP, Consultant in Diabetes and Bariatric Lead, Weight Management Services, Heart of England NHS Foundation Trust, and Centre for Endocrinology and Metabolism and NIHR Birmingham and Black Country CLAHRC, University of Birmingham. Email: firstname.lastname@example.org
As Dr Pierce’s editorial points out,1 there is increasing evidence from bariatric surgery and intensive weight-loss approaches that it is possible to significantly improve type 2 diabetes (T2D) to the point of remission in some individuals. Thus there is a need to rethink the current approach to diabetes management. Pursuing glycaemic control in T2D has resulted in treatment intensification, including insulin initiation. This approach, however, commonly results in weight gain. We describe two cases questioning the inevitability of beta-cell failure in T2D, and highlight the need for judicious treatment intensification.
A 65-year-old female with T2D, dyslipidaemia, hypertension, and obstructive sleep apnoea, attended our specialist weight management clinic. She was wheelchair-bound, weighed 148.8Kg (BMI:62.7Kg/m2), and her HbA1c was 9.3% (78mmol/mol). She was taking metformin, insulin glargine [80IUod], and prandial insulin treatment was planned. Instead of insulin intensification, a GLP-1 analogue (GLP-A) was added off-label, and basal insulin halved. She presented for follow-up with reduced body weight and improved glycaemia; insulin was further decreased until full withdrawal 10 months later. After a year of GLP-A, she weighed 112.0Kg (BMI:47.3Kg/m2), and was insulin-free with well-controlled diabetes. She was mobilising with much-improved quality of life.
A 50-year-old female with T2D for 10 years, dyslipidemia, fatty liver, and hypertension had been on premixed insulin for 8 years with poor glycaemia and increasing body weight. Her body weight was 92Kg (BMI:37.8Kg/m2) and HbA1c of 8.9% (74mmol/mol). She was taking 48IU of premixed insulin bd, and metformin 850mg tds. The insulin dose was reduced, and a GLP-A added off-label. After 4 months, she weighted 82.5Kg (BMI:33.8Kg/m2) and HbA1c was 5.9%(41mmol/mol). Insulin was eventually stopped. She remained on the GLP-A and metformin. After 8 months, she weighed 72.4Kg (BMI:29.5Kg/m2); HbA1c was 6.1% (43mmol/mol).
Intensive glycaemic control in T2D is driven by pursuit of preventing vascular complications and the belief that beta-cell failure in T2D is inevitable. Treatment intensification, however, often results in relative hypoglycaemia (where the patient is symptomatic of lower glucose without blood glucose in the hypoglycaemic range), snacking, weight gain-hyperglycaemia, insulin dose escalation, further relative hypoglycaemia, repeat snacking, and still poor glycaemic control. The vicious cycle of weight gain and poor glycaemia can result in greater reliance on expensive bariatric surgery.
Our cases demonstrate that beta-cell failure is not inevitable, even in patients with up to 10 years of T2D. In some patients, insulin is initiated too early with increased weight gain. Insulin is important in modern T2D care, but evidence is accumulating that it should be used more prudently, having ensured that patients have had access to adequate lifestyle/dietary support. The focus of T2D management also needs to shift to give patients the opportunity to reverse their diabetes.
1. Pierce M. Type 2 diabetes: prevention and cure? Br J Gen Pract 2013; 63(607): 60–61.
Dr Shahrad Taheri has received funding from the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme. The views expressed in this publication are not necessarily those of the NIHR, the Department of Health, NHS Partner Trusts, University of Birmingham or the CLAHRC-BBC Theme 8 Steering Group. Dr Agnieszka Zawiejska was funded as a Lilly European Diabetes Fellowship.
Dr Taheri has received research and educational funding from Novo Nordisk and Lilly.
Date: 19 Feb 2013
Topic: Chronic pruritus
Comments by: Dr Nina Putnis FY2 Worthing Hospital, Flat 2, 9–10 York Place, Brighton BN14GU. E-mail: email@example.com
Despite the myriad causes behind chronic pruritus, it is important not to miss the rarer, and potentially life-threatening systemic diagnoses. This includes, in the case of my friend, a previously well and itch-free 27-year-old secondary teacher, a diagnosis of Hodgkin's Lymphoma. This conclusion was reached 10 months after the emergence of the intractable itch, and found only after numerous disheartening GP appointments and a dead-end dermatology referral, where of course no diagnosis was found. This finding was not fed back to the original GP, who may have hopefully thought about looking into alternate causes, especially taking into account the severity of her symptoms, refractory to any offered medication. Yet still did the penny not drop when her cervical lymphadenopathy became apparent and no haematology referral was forthcoming. There was henceforth a period of investigation into a potential tuberculosis infection, despite the absence of any other mycobacterial features, no appropriate history, and a BCG vaccination. There were then still months of delay.
Lymphoma needs to be considered in any sudden onset new widespread pruritus without any dermatological features, especially after the discovery of lymphadenopathy. This could have saved my friend months of pointless investigation into tuberculosis and brought forward her diagnosis potentially by 6 months, curtailing the expansion of her cancer and sparing her 6 months of being ignored by doctors who she did not feel were listening, and were increasingly disbelieving of her symptoms. This outlines a basic failure in communication with a very distressed patient who knew from the outset that there was something amiss and of communication between medical professionals. This should function as a valid learning point, and is pertinent in primary care, but yet also in other specialties. My friend was seen by multiple GPs, dermatologists, and infectious disease professionals, but yet was sent away without the appropriate further investigation almost every time.
It is now her that must deal with the consequences of a missed diagnosis, both physically and emotionally. Her trust in her doctors has been irreconcilably lost, at a time when she most needs to feel supported. Itch in lymphoma is known to be severe, extremely distressing, with a large burden on quality of life.
Date: 18 Feb 2013
Topic: Inter-arm blood pressure differences compare with ambulatory monitoring: a manifestation of the ‘white-coat’ effect?
Comments by: Rosa M Nieuwenhuize, Department of general practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
Judith JP Geuze, Department of general practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
Alyt Oppewal, Department of general practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. Email: firstname.lastname@example.org
With interest we read the article of Martin et al,1 that discussed the use of ambulatory blood pressure monitoring to better understand the clinical significance of inter-arm differences in blood pressure. We agree it is important to evaluate the diagnostic possibilities for hypertension, especially since it was shown that only half of the time GPs adhere to the guideline of subsequent blood pressure measurements.2
The authors state that the ‘white-coat’ effect is probably responsible for the inter-arm differences found in office readings. However, we have some concerns regarding this conclusion. First, a definition of the ‘white-coat’ effect is not provided by the authors. This is essential for understanding the conclusions drawn in this article. Second, the authors included both patients with a new diagnosis of hypertension as well as patients with already existing hypertension but with failure of treatment, drug intolerance, and/or in need of further investigation of underlying causes. Nevertheless, in the data analysis, these two groups were taken together. We think it is necessary to analyse these groups separately, because Pickering et al3 described a diminishing effect of antihypertensive medication on the ‘white-coat’ effect. This may also have an effect on the inter-arm differences in blood pressure in the patients with already existing hypertension. This difference even depends on which antihypertensive medication the patient is taking.3 However no information on the patients’ medication was reported. Furthermore, daytime activities have an effect on ambulatory blood pressure measurements. No information was provided as to whether the patients received instructions on how to spend their day while being monitored.
The authors collected quite some risk factors that are interesting in the context of hypertension. However, the authors did not analyse if any of these factors affected the outcome. If this was the case, it is relevant to correct for these factors in the analysis of the data.
In the results section, information is lacking on whether the first blood pressure was always the highest. If not, this could contradict the authors’ explanation of the ‘white-coat’ effect.
Finally, Figure 2 contains a Bland-Altman plot in which the ‘no-difference’ line is above zero. Is this a mistake or is there a reason?
1. Martin U, Holder R, Hodgkinson J, McManus R. Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the ‘white-coat’ effect? Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663055.
2. Heneghan C, Perera R, Mant D, Glasziou P. Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence. Br J Gen Pract 2007; 57(545): 948–952.
3. Pickering TG, Gerin W, Schwartz AR. What is the white-coat effect and how should it be measured? Blood Press Monit 2002; 7(6): 293–300.
Date: 11 Feb 2013
Topic: Self monitoring
Comments by: Chris Gunstone, GP, 36 Holly Street, Burton Upon Trent, Staffs, DE15 9ET. E-mail: email@example.com
It seems that institutionalised paternalism is alive and kicking in the NHS. The principle of long-term condition care is that patients become responsible for their own health.
Improved technology has meant that home monitoring becomes increasingly possible. However rather than encourage this we seem to have an institutional need to maintain dependence. For instance, there is evidence that patient monitoring and dosing of warfarin is probably safer and probably provides no worse INR control than dragging patients back to clinic.1 NICE however does not recommend this.2
Blood pressure monitors are becoming cheaper. We are encouraged to use them as a means of diagnosing hypertension. Although the Quality and Outcomes Framework documents do not expressly state that the practice is responsible for checking patient blood pressures, the implication is that the patient will be seen every 6 months and a blood pressure recorded. Is this necessary? If we treat patients as responsible adults, surely there is no reason why a patient should not be advised to monitor their blood pressure every 3–6 months, and contact the practice if the blood pressure falls out of defined ranges. Does the practice need to record the blood pressure? Does the patient need to attend the surgery if all is well controlled? If so, how often? Every 3–5 years?
In an NHS where resources are increasingly scarce, the importance of people taking responsibility for their own health seems a priority. I wonder if, as health professionals, we are ready for this.
1. Heneghan C, Ward A, Perera R, et al. Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet 2012; 379(9813): 322–334.
2. National Institute for Health and Clinical Excellence. Venous thromboembolic diseases. Clinical guidance 144. London: NICE, 2012.
Date: 5 Feb 2013
Comments by: Ronald NC Douglas, FRCGP, 31 Burnhead Road, Glasgow G43 2SU. E-mail: firstname.lastname@example.org
As a retired GP I have read the recent article by Dr Clare Gerada and the subsequent responses with great interest.1 I well recall practising before and after the passage of Lord Steele's Act. We were at that time assured that two doctors would have to agree that proceeding with the pregnancy would constitute a greater risk to the life and health of the patient than termination. We all know now that this has become de facto ‘Abortion on Demand’.
The parallel with the current proposals is striking. I greatly fear this would be the start of a slippery slope leading to older patients feeling it was their duty to ask for euthanasia in order to relieve the perceived burden they caused their relatives and/or the State. Politicians might well see this as a solution to the cost of an ageing population.
Of course the profession must oppose this development. Who else is going to be obliged to carry out the killing? Clearly the right course for a civilised society is optimal terminal/palliative care.
1. Gerada C. The case for neutrality on assisted dying — a personal view. Br J Gen Pract 2012; 62(605): 650.
Date: 4 Feb 2012
Topic: Doubling the incidence of Type 2 Diabetes?
Comments by: Philip H Evans, Senior GP Partner and Lead Researcher, St Leonard’s Research Practice, Athelstan Road, Exeter, Devon, EX1 1SB. E-mail: email@example.com
Denis J Pereira Gray, Research Consultant, St Leonard’s Research Practice, Athelstan Road, Exeter, Devon, EX1 1SB
Christine Wright, Health Services Researcher, St Leonard’s Research Practice, Athelstan Road, Exeter, Devon, EX1 1SB
Peter Langley, Research Assistant, St Leonard’s Research Practice, Athelstan Road, Exeter, Devon, EX1 1SB
We read with interest Gholap et al’s article on the diagnosis of type 2 diabetes mellitus (T2DM) using the new HbA1c criteria.1 We have been studying the diagnosis of T2DM in our general practice for several years.2
The diagnostic criteria for T2DM have long been set by the World Health Organization (WHO) and national guidelines. In 2011, WHO changed the diagnostic criterion to include an HbA1c level of 48 mmol/mol (on two occasions if asymptomatic).3 The impact of this change has been debated,4 but not demonstrated in clinical practice. However, it does make it easier for GPs to arrange blood testing for people for whom fasting is practically difficult, and hence may increase the incidence of diabetes.
We have tracked the incidence of T2DM since our practice adopted the changed diagnostic criterion in November 2011. There were 23 new diagnoses in the last 9 months using the old criteria (61% detected by screening) compared with 59 in the same 9 months of the following year using the new criterion (73% by screening). Thus the incidence rate increased from 2.95 to 7.46 per thousand (chi-square = 15.32; P<0.001). This was a 2.5 fold increase in T2DM within the first year of using the new criterion.
The characteristics of patients diagnosed with type 2 diabetes in each of the time periods are summarised in Table 1 (available from the authors). Patients diagnosed after the change in diagnostic criterion were, on average, 9 years older (P = 0.03) but were similar in terms of their gender, HbA1c, and body mass index at diagnosis.
This preliminary report appears to demonstrate a major increase in the incidence of diabetes using the new HbA1c criterion. This increase may be due to differing groups of patients being identified but may also be due to instances where patients with previous elevations of their HbA1c, but with normal blood glucose measurements, are now being retested and diagnosed. The implications are profound as diabetes currently takes 10% of all NHS hospital costs and 20% of all hospital beds.5
This may be a major advance enabling general practice to ‘break into the iceberg’ of undetected diabetes, or a new group of people with diabetes may be emerging. The clinical impression of one of us (PHE) is that more people are now being diagnosed with T2DM with substantial comorbidity, both physical and mental. We look forward to comparing diagnosis rates with colleagues.
1. Gholap NN, Davies MJ, Mostafa SA, Khunti K. Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663244.
2. Evans PH, Langley P, Pereira Gray D. Diagnosing type 2 diabetes before patients complain of diabetic symptoms—clinical opportunistic screening in a single general practice. Fam Pract 2008; 25(5): 376–381.
3. World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus: abbreviated report of a WHO consultation. Geneva: WHO, 2011.
4. Mostafa SA, Khunti K, Srinivasan BT, et al. The potential impact and optimal cut-points of using glycated haemoglobin, HbA1c, to detect people with impaired glucose regulation in a UK multi-ethnic cohort. Diabetes Res Clin Pract 2010; 90(1): 100–108.
5. Alberti G, Gerada C, Hadley-Brown M, et al. Diabetes: ‘we must act now’. The Times 2012; June 12: http://www.thetimes.co.uk/tto/opinion/letters/article3442389.ece
Date: 4 Feb 2013
Topic: Response to’ Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review’
Comments by: Peter Ward, GP, Central Gateshead Medical Group, Gateshead Health Centre, Gateshead, NE8 1NB. E-mail: firstname.lastname@example.org
Connelly et al believe patients with dementia are receiving less medical intervention than they should with regard to cardiovascular disease.1 They interpret their findings of less medical activity and prescribing as evidence of this.
I struggle personally with the issues around preventative treatment in those with dementia. My suspicion that is many GP’s do and I don't believe the issues are as clear-cut as the authors imply. First, there are barriers to some forms of disease monitoring; how to test for sensory neuropathy in someone you can't communicate with? How to take blood from patients who won’t allow it? How to retinal screen a person who can’t co-operate?
Second, disease-specific guidelines come unstuck in patients with multiple pathologies. NICE is thinking about how best to get around this.2 Guidelines inform clinical decisions but are not there to be slavishly followed. Third, we should consider the ethics of aggressive risk-factor management, particularly the issue of consent.
98% of those who take aspirin after a stroke or heart attack do not benefit,3 96% of MI sufferers do not benefit from taking statins, and 10% are harmed (muscle damage).4,5 Who can tell what the NNT for hypertensive treatment is in an 83-year-old bed bound patient with Alzheimers, arthritis, and chronic obstructive pulmonary disease? Preventative treatments are marginal, many patients who understand the issues decline them. How to discuss the potential benefit and risks of introducing an eighth (or ninth or tenth?) tablet because the blood pressure is 156/91 or cholesterol 5.3? Can a GP have a meaningful discussion about the likelihood of individual benefit in many dementia patients, and is it right to assume consent to monitoring and treatments if the patient cannot participate in the decision?
Many of my older patients are not interested in the extremely small longevity gains from intensive cardiovascular disease risk management and it would be a bold assumption that patients suffering dementia do consent to it. Patients can usually choose whether to attend chronic disease management clinics. Are we to force it on those with dementia? There is an argument that ethically, preventative cardiovascular disease treatment should not proceed in those who cannot consent.
1. Connolly A, Campbell S, Gaehl E, et al. Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review. Br J Gen Pract 2013; 10.3399/bjgp13X663046.
3. Antithrombotic Trialists' (ATT) Collaboration, Baigent C , Blackwell L , Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373(9678): 1849–1860.
4. Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005; 366(9493): 1267–1278.
5. Thavendiranathan P, Bagai A, Brookhart MA, Choudhry NK. Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166(21): 2307–2313.
Date: 31 Jan 2013
Comments by: Mick Leach FRCGP, 28 Kings Road, Harrogate, HG1 5JP. E-mail: Mick.Leach@gp-b82013.nhs.uk
Topic: Response to ‘Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria’
In the February 2013 issue of the BJGP there are several interesting and useful articles about aspects of diabetes, but I would like to question just one aspect stated in the Clinical Intelligence article by Gholap and colleagues.1
Basing diagnosis on an HbA1c result has significant advantages, which are outlined in the article. They say that the HbA1c level reflects average glucose levels over the preceding 6–8 weeks (later giving the clinical situations in which that may not be the case). And they say that in a patient without symptoms any ‘diagnostic’ level test result needs to be repeated, or supported by another kind of test, to confirm a diagnosis with such important long-term implications. So-far-so-good. But I think it is incorrect to say that you can use an HbA1c level repeated just 2 weeks later. At this point the test result will largely cover exactly the same time period as the first, and thus it will confirm that the first test result was accurate. In order for it truly to be a ‘second test’ one needs to delay repeating HbA1c for at least 6–8 weeks, so that the result reflects a different time period. This is a disadvantage of relying on HbA1c.
1. Gholap NN, Davies MJ, Mostafa SA, Khunti K. Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria.
Br J Gen Pract 2013; DOI: 10.3399/bjgp13X663244.
Date: 30 Jan 2013
Topic: Response to ‘Enhancing consultations with interpreters: learning more about how’
Comments by: Jane Hunt, GP, Hounslow. E-mail: email@example.com GP, Helen Bamber Foundation, 5 Museum House, 25 Museum St, London, WC1A 1JT
I am a GP who has worked for 15 years in inner-city London. I also work at the Helen Bamber Foundation for victims of cruelty. This is a non-NHS role and one of my duties is to liaise with our patients own GPs ensuring that they have access to good quality health care. Our patients are often extremely traumatised victims of torture and trafficking from all over the world and struggle to tell their own stories even in their own language.
I am finding it increasingly difficult to find practices that will agree to any form of translating service. More and more are insisting that patients bring their own translators with them. As Professor Kai states, relatives and friends translating is common, but not ideal, and adds many challenges.1 This is even more difficult for our patients who are often socially isolated, and, if not, would find it impossible to tell parts of their horrific stories via other family members or friends.
In my own practice I have always used a telephone translating service and, while recognising the fact that this is also not ideal and can be very frustrating, it is far preferable to no translating service at all.
While agreeing with Professor Kai’s editorial comments regarding empowering all involved to enhance translated conversations, I feel that there is first a more basic need in ensuring that all practices recognise that withholding the use of translating services is not an option no matter the financial constraints we all find ourselves under.
1. Kai J. Enhancing consultations with interpreters: learning more about how. Br J Gen Pact 2012; 63(607): 66–67.
Date: 23 Jan 2013
Topic: Asking the shisha question
Comments by: David Rawaf, St George’s, University of London. E-mail: firstname.lastname@example.org
Abdelaziz Elgindi, St George’s, University of London
Sajjaad Ismail, St George’s, University of London
Pippa Oakeshott, St George’s, University of London
In an excellent editorial, Jawad and colleagues1 highlighted the need for increased awareness of the prevalence and health effects of shisha pipe smoking. By not asking about shisha use, GPs may be missing the opportunity to give smoking cessation advice.
In each of the past 3 years, a St George’s medical student has conducted a research project on shisha pipe smoking. In the first survey conducted in 2010, Sajjaad Ismail gave a questionnaire to consecutive shisha café attenders in Manchester. The response rate was 85% (202/237). We found that 40% (95/237) of responders did not know the constituents of shisha, 52% (123/237) were unaware of the health risks, and 40% (95/237) would not tell their doctor about shisha if asked about smoking.
A similar survey by Abdelaziz Elgindi of 103 shisha café attenders in London in 2011 (response rate 94%, 103/110) found that of the 42 responders who also smoked cigarettes, 89% (34/38) reported that smoking shisha relieved the cravings they had for cigarettes compared with only 52% (22/42) who said that cigarettes relieved the cravings they had for shisha (P = 0.001). A head of shisha is estimated to contain around 10 times as much nicotine as one cigarette.2
Most recently in 2012 David Rawaf conducted an online survey of medical students at St George’s, London, with a response rate of 62% (137/222), of which, 65% (89) were white, 11% (15) Middle Eastern, 10% (14) Indian, 7% (10) Pakistani, with the rest Bangladeshi, black, Chinese, and others. It was found that 79.4% (43) have smoked a shisha pipe before, of which the majority are white (58%, or 25). However, only 12 students were ‘regular’ shisha smokers (more than once a week), out of those, three smoked cigarettes. Of the regular smokers, six were Pakistani, four were Indian, and one each of black and white origin. The majority of responders (79%, or 108) did not smoke cigarettes, with 77% (83) having smoked a shisha pipe once. As an aside, it was discovered that medical students had a good understanding of the constituents and health risks of shisha, and most (85%, or 116) felt that clinicians should ask about shisha smoking.
As can be seen, shisha smokers are from varying backgrounds, so it is indeed a culture-wide trend, especially among students. However, the dangers are not fully understood by the public, and it is on the shoulders of current and future clinicians to raise awareness.
We agree with Jawad and colleagues that GPs, particularly those working in areas with many ethnic-minority patients, should consider ‘asking the shisha question’.
1. Jawad M, Khaki H, Hamilton F. Shisha guidance for GPs: eliciting the hidden history. Br J Gen Pract 2012; 62(595): 66–67.
2. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, ‘tar’, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol 2005; 43(5): 655–661.
Date: 28 Jan 2013
Comments by: Dr Taz Syed, The Pall Mall Surgery, 918 London Road, Leigh-on-Sea, Essex, SS9 3NG. E-mail: email@example.com
The advent of the PHQ-9 has changed depression assessment in primary care in the UK. The 9th question always troubles me when I look at the record of the consultation. The question asks whether the patient has thoughts that they would be better off dead or hurting themselves in some way in the last 2 weeks. When this question scores positively (that is, scores 1, 2, or 3), a GP must further assess and clearly document the patient’s suicide risk in that consultation record. This can often be missed in the complexities of the consultation.
We are under enormous time pressure, but this is always necessary. It worries me that the form filling would be considered to suffice.
Date: 20 Jan 2013
Topic: Response to ‘Primary Health Care: What role for occupational health?’
Comments by: Dr Debbie Cohen, OBE, MD, FRCGP, FFOM, FRCP, Senior Medical Research Fellow, Cardiff University. E-mail: firstname.lastname@example.org
Dame Carol Black, DBE, FRCP, FMedSci, Expert Adviser on Health and Work to Department of Health.
We were interested to see the editorial by Buijs et al on primary health care: the role for occupational health?1 It is clear that there is now a growing momentum across Europe to improve physicians’ awareness of the importance of work as a contributory factor towards health and wellbeing.
Following the Black review in 2008, the UK Government response, and the introduction of the new fit note there has been an important shift in attitudes among health professionals in the UK. A proactive approach and carefully designed programme of work, we believe, has been central to this shift.
The programme consists of collaboration across general practice, occupational health, and employers, providing a range of training materials to suit all learning styles. The training highlights the evidence base about the benefits of work as well as providing useful resources and strategies for GPs and other healthcare professionals when managing the work and health consultation. More than 3500 GPs across the UK have now attended face-to-face training run by the RCGP and many have downloaded e-Learning resources. All the resources, training, and information sit within one website created as part of this initiative in collaboration with UK and Welsh Government called Healthy Working UK.2 The next stage in this work is to embed the resources into specialist training and appraisal and work is being undertaken in collaboration with the RCGP in the UK to see how this may be achieved. Resources and ‘champions’ across all medical schools in the UK have also been developed and support the undergraduate curriculum. Further resources are also being developed to support key messages across all medical specialties. We believe that this work alongside the new fit note (and the launch of the electronic fit note in July this year) will support physicians in the UK to embed ‘health and work’ into their clinical management.
1. Buijs P, Gunnyeon B, van Weel C. Primary health care: what role for occupational health? Br J Gen Pract 2012; 62(605): 623–624.
2. Health working UK. www.healthyworkinguk.co.uk
Date: 19 Jan 2013
Topic: Diabetes is on the rise, so why are we not bothered?
Comments by: Asadullah Naqvi, Final Year Medical Student, Barts and The London. The Royal Docks Medial Practice, Newham. E-mail: email@example.com
In regards to the article ‘Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria’, Nitin N Gholap et al, state that ‘routine screening to identify high-risk individuals is important to improve outcomes. Availability of a simple, accessible, and reliable diagnostic test is crucial’.1 Gholap et al furthermore explain the benefits of the HbA1c testing compared to the glucose-based test and how outcomes and complications can be improved.
To further add to Nitin N Ghopal et al study, we conducted an audit that was carried out at The Royal Docks Medical Practice in 2012, in the Borough of Newham, London. The aim was to improve patient compliance in taking the HbA1c tests, that would in turn improve the outcomes and reduce the complications of diabetes and in turn reduce the costs to the NHS.
A list of 54 patients with an HbA1c above 9% in the first cycle of the audit, and 52 patients in the second cycle of the audit were used. In the first cycle (Method A), we posted out blood request forms to all 54 patients, information regarding the times and location of the blood test, and a universal cover letter explaining what the blood test was for.
In the second cycle (Method B), which was employed 3 months after the first cycle, 52 patients were contacted to come to the surgery to discuss their diabetes and book a blood test, this would mean patients would have to make two trips, one to the surgery, and in most cases another to the blood centre on a separate day. As oppose to the Method A that required one trip, only to the blood centre.
Patient compliance was improved by 57.4%, and 24.07% of patients had an improved HbA1c below 9% with Method A. With Method B, patient compliance improved by 32.7%, and 7.7% of patients had an improved HbA1c below 9%. Therefore the key advantages of using Method A is that most importantly 25% of patients had a reduced HbA1c and 55% improved in compliance. It will help to contain the growing costs for the Clinical commissioning groups that go live to manage the local health budgets from 1 April 2013. Method A can also be used throughout the UK and for other types of routine blood tests. Furthermore it saves the NHS money through reduced hospital admissions of diabetic emergencies and saves GPs money via less referrals. It will benefit GPs by improvement in Quality and Outcomes Framework scores. Improvement in compliance will mean patients will need to take less time off work, therefore less health related work absence.
1. Gholap NN, Davies MJ, Mostafa SA, K Kamlesh. Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria. Br J Gen Pract 2012; DOI: 10.3399/bjgp13X663244.
Date: 19 Jan 2013
Topic: Response to ‘Symptoms and risk factors to identify men with suspected cancer in primary care’
Comments by: David Church, GP, Machynlleth. E-mail: firstname.lastname@example.org
While the article ‘Symptoms and risk factors to identify men with suspected cancer in primary care’1 was quite interesting academically, I do not see how the algorithm could be of use to me in practice.
The problem is that while the risk factors can be identified from our computer records of patients, the overall risk covers a heterogenous group of diagnoses, not a single one, and we are not given an intervention that has a known beneficial influence on the risk outcome.
Unlike perhaps screening patients at high risk of diabetes for raised sugar or HbA1C levels, leading to a unique diagnosis, or even using the Qrisk scores to adjust and inform management of blood pressure, lipid levels, body mass index, smoking in patients with high risk of CVD, but for a generally raised ‘risk of cancer’ we do not have a suitable single screening test, because cancer could originate in different ways in so many different tissues, and besides the standard and universal advice regarding diet, lifestyle, smoking, and exercise that we would hand out universally regardless of ‘cancer risk’ level, we don’t at present have anything extra to offer the patients with a high score.
What we can do by telling them they have a high score is increase their anxiety levels, increase their attendance for insignificant symptoms in systems unrelated to where their own cancer actually is. Higher levels of anxiety are in fact associated with cancer causation, so that is not good for a start.
Second, we may increase the ‘cry wolf’ effect to the extent that when they do present a symptom of their own cancer, the GP may be so inured to their frequent anxious presentations that we under investigate and falsely reassure. No, the time is not right yet to let it be known that we can estimate future risks of ‘cancer’ generically. It will raise expectations and claims for negligence and diagnostic delays.
Knowing the risk is higher will not indicate which body part should be investigated or screened for cancer, so is not as yet of any practical use. I am afraid the algorithm, as presented, signally fails to satisfy the established criteria for a good screening test. It should be clearly reported to the public that it is not of use clinically and only of academic interest for research, and not any predictive usefulness in a diagnostic manner. Otherwise it will just cause ill health, harm by over-investigation, and excess sue age.
1. Hippisley-Cox, Coupland C. Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X660724.
Date: 14 Jan 2013
Topic: Response to Wilfred Treasure Letter
Comments by: Julia Hippisley-Cox, University of Nottingham, Division of Primary Care, 13th Floor, Tower Building, Nottingham, NG2 7RD. E-mail: email@example.com
Carol Coupland, University of Nottingham, Division of Primary Care, School of Community Health Sciences, Nottingham.
Thank you for the opportunity to respond to Dr Wilfred Treasure’s letter1 regarding our two papers.2,3 The QCancer® algorithms are an evolving set of risk algorithms to quantify the risk of a previously undetected cancer. They are intended to support clinical decision making and we are currently carrying out a pilot to inform how best to implement them. The algorithms currently combine multiple risk factors and symptoms to give a global risk of cancer and risks of individual cancer types. Dr Treasure is correct in saying that the QCancer algorithms do not currently include results of clinical examinations; it’s possible these could be added in a future version of the tool should the relevant data be coded in the clinical record. However, as we say in the paper, QCancer is intended for use in a primary healthcare setting to help doctors assess which patients to send for investigations such as colonoscopy. Therefore the tool does not include the results of colonoscopy or other diagnostic tests as that is not the purpose of the tool.
In response to Dr Treasure’s second point we agree that the predictive values are based on data recorded during general practice consultations. The information on the QCancer website states the following ‘This website is primarily intended for doctors and nurses working in general practice and for academics who are interest in the underlying research. Patients are welcome to read this information and use the calculator together with their doctor so that any symptoms or concerns can be addressed within a healthcare setting. All medical decisions need to be taken by a patient in consultation with their doctor. QCancer works out the risk of a patient having a current but as yet undiagnosed cancer-taking account of their risk factors and current symptoms. It does not give a diagnosis of cancer, but a risk’.
The paper offers possibilities on how QCancer can be implemented into clinical settings as Dr Treasure points out. The paper is not a detailed guide on the implementation but does offer several possibilities including the use of structured templates. Such templates are already commonly used to assist in data entry across a wide range of clinical areas including risk-assessment tools and their use is likely to improve the ascertainment and recording of positive and negative symptoms over time. This will enhance both the medical record in its primary purpose but also future updates of the QCancer tool.
1. Treasure W. Symptoms and risk factors to identify people with suspected cancer in primary care. Br J Gen Pract 2013; 63(608): 125.
2. Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X660724.
3. Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X660733.
Date: 13 Jan 2013
Topic: Problems with hypertension guidelines
Comments by: Michael Kennedy, Woods Surgery, Clane, Co Kildare, Ireland. E-mail: firstname.lastname@example.org
Congratulations to Schofield et al1 on their thought-provoking paper looking at hypertension and ethnicity. Three points occur. How useful are NICE guidelines, and in terms of an ethnic population, how accurate are they? Also in an era of austerity could they be harmful to patient care? Adherence to NICE recommendations was relatively low in the inner-city population studied. No evidence was found of significantly poorer control in patients on any of the ‘incorrect’ treatments. In 20062 and 20112 the National Institute for Health and Clinical Excellence (NICE) has stratification of antihypertensives. Other contemporaneous guidelines disagree. The 2007 and 20093 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) concluded all diuretics, ACE inhibitors, calcium antagonists, angiotensin ii receptor blockers (ARB), and beta-blockers were suitable for the initiation of and maintenance of antihypertensive treatment. ESH argued the traditional ranking of drugs into first, second, third, and subsequent choice with an average patient as reference has little scientific justification.
The American Joint National Committee 7 (JNC) (2003) soon to be superseded by JNC 8 concluded that thiazide diuretics were unsurpassed in preventing the cardiovascular complications of hypertension. Australian 2010 guidelines contradicted NICE arguing that in uncomplicated hypertension ACE inhibitors, dihydroperidone calcium channel blockers were equally effective as a first-line treatment. The World Health Organization (WHO) in 2007 published a document offering a further variation. Given that non-adherence made no difference to blood pressure control and the differing opinions of other authorities, how useful are the current NICE guidelines?
The area of ethnicity is interesting in blood pressure guidelines. Schofield points out that lower renin levels in young black people reduce the response to ACE inhibitors. This is well known. Studies have traditionally neglected both ethnic minorities, and that 50% of the population who happen to be female. The ALLHAT4 study was correctly praised for having ratios of 47% female, 35% black American, and 19% Hispanic. ALLHAT provided part of the justification for NICE’s recommendation for thiazide diuretics if calcium channel blockers were ineffective for black people of African–Caribbean descent of any age. But ALLHAT looked at patients of 55 years or older, the mean age was 67 years. It provided no evidence for those under 55 years. It didn’t look at black British people. Johnson observed that many black British people may belong to what is now viewed as an emergent ‘mixed’ origin population of the UK that can be genetically significantly different from black Americans. The evidence for NICE guidelines in ethnic minorities I would argue is weak and may answer Schofield’s question as to why GPs and patients in this study opted for alternative treatment regimes.
Majeed’s5 editorial noted that general practices in England could face reductions of 20% in their annual budgets. Is it only a matter of time before prescribing is limited? Could this be based on guidelines with a weak evidence base?
1. Schofield P, Baawuah F, Seed P, Ashworth M. Managing hypertension in general practice: a cross-sectional study of treatment and ethnicity. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X656847.
2. National Institute for Health and clinical Excellence. Hypertension: clinical management of primary hypertension in adults (update). Clinical guideline 127. London: NICE, 2011.
3. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009; 27(11): 2121–2158.
4. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 228(23): 2981–2994.
5. Majeed A, Salman R, De Maeseneer J. Primary care in England: coping with financial austerity. Br J Gen Pract 2012; 10.3399/bjgp12X659150.
Date: 7 Jan 2013
Topic: Response to ‘Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm’
Comments by: Wilfrid Treasure, Whalsay Health Centre, Symbister, Whalsay, Shetland, ZE2 9AE. E-mail: email@example.com
Julia Hippisley-Cox and her team have made great progress in their continuing process of helping GPs estimate a patient’s risk of cancer.1,2 I do suggest caution in the use of their current QCancer® risk calculators3,4 for three reasons though.
First, the risk calculators don’t as yet include important data such as the doctor’s clinical examination findings or recent negative results of screening by mammography, cervical smears, and colonoscopy.
Second, predictive values of symptoms, signs, and test results (indicants) depend on the context in which the data were collected.5 Predictive values for indicants in the QCancer® risk calculators were derived and validated using coded data recorded during general practice consultations. These predictive values therefore don’t necessarily apply to data recorded by patients themselves or by doctors on checklists, nor to uncoded indicants. This isn’t made clear to members of the public visiting the QCancer website who are told: ‘You can use this calculator to work out your risk of having a cancer as yet undiagnosed by answering some simple questions’.3,4 Nor is it made clear to doctors who are told that ‘the template would then help structured data entry of other related symptoms including significant negative findings and the results generated automatically’.1,2
Third, a digital risk score replacing or accompanying the traditional analogue clinical note will have unpredictable, perhaps undesirable, consequences. Diagnosis and risk assessment are improved by looking at the clinical information available from different angles. These calculators provide an additional perspective. How clear a view they give us is questionable.
1. Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X660724.
2. Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X660733.
3. QCancer-2013-male. http://www.qcancer.org/male/index.php (accessed 5 Feb 2013).
4. QCancer-2013-female. http://www.qcancer.org/female/index.php (accessed 5 Feb 2013).
5. Treasure W. Diagnosis and risk management in primary care: words that count, numbers that speak. Milton Keynes: Radcliffe Publishing, 2011.
Date: 6 Jan 2013
Topic: The use of written material in consultations
Comments by: Dr Shoba Poduval, Salaried GP, The Ritchie Street Practice, London, N1. E-mail: firstname.lastname@example.org
The November and December issues of the BJGP have featured interesting studies on the use of written information in consultations. First the University College London study1 in the November issue described patients’ experiences of presenting health information from the internet in GP consultations. Then in the December issue a Dutch study2 reported the effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections.
The findings of these studies are important as they affect the way all of us consult. While it is reassuring that patients prefer information from a physician than a written resource, and I agree that there is no substitute for effective individualised face-to-face communication, I worry that these results dismiss the role of written information and potentially conflict with the growing interest in telemedicine. I will continue to be an advocate for patient education and the use of written resources as a supporting tool. Good communication-skills training needs to remain high on the GP training agenda, but with the inclusion of how to acknowledge the information presented by patients and how to use written information to enhance our explanations rather than replace them. With patient satisfaction surveys becoming an integral part of the revalidation process, further research into this area will no doubt be important for improving patient care and successful professional development.
Developments in telemedicine are likely to increase in the future due to its potential to be more cost effective than more traditional models of care. I expect telemedicine to be challenging due to the need to make treatment decisions remotely. As anyone who has experience in telephone triage will appreciate, the use of careful history taking, safety netting, and good record keeping is likely to be even more important in an electronic setting. And if we have evidence that patients prefer face-to-face explanations, should we be directing our research in telemedicine into where it will be most effectively used? Are there situations such as chronic disease management and routine outpatient follow-up where telemedicine would be more relevant? I look forward to developments in the use of technology in health care but hope that patient preferences and the clinical challenges are fully appreciated when telemedicine is more extensively introduced.
1. Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X658250.
2. van der Velden AW, Pijpers EJ, Kuyvenhoven MM, et al. Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X659268.
Date: 2 Jan 2013
Topic: Response to ‘Outside the Box: Proactive care: the patient's right to choose’
Comments by: Paul Pharoah, Professor of Cancer Epidemiology Departments of Oncology and Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge, CB1 8RN. E-mail: email@example.com
Greenhalgh asks ‘If it’s ethical for someone to decline an offer of an opportunistic check or an invitation to screening, surely it is also ethical for a patient to ask not to receive such offers in the first place?’.1 First, whether or not a patient should be allowed to ask not to receive offers of opportunistic screening is hardly an ethical one. It is clearly ethical for a patient to make such a request.
The real ethical issue relates to the targets of the Quality and Outcomes Framework that are related to uptake. The evidence that any of these opportunistic tests have net benefits either for an individual (informs the individual decision whether to opt to take up the test or not) or for a population (should the test be offered by the NHS or not) is scanty at best. It is thus entirely rational and reasonable for a person (not a patient) to choose not to have the test. It then becomes unethical for uptake of that test to be a criterion by which quality is measured as it creates conflict of interest in the clinician which is clearly counter to the concept of informed patient choice and decision making. The only reasonable target in such a situation would be the proportion of patients making a decision (yes or no) based on informed consent. That the NHS persists in having targets for uptake of tests of debatable value to the population or to the individual is simply unethical.
1. Greenhalgh T. Outside the Box: Proactive care: the patient’s right to choose. Br J Gen Pract 2012; 63(606): 37.
Date: 1 Jan 2013
Topic: Response to ‘Outside the Box: Proactive care: the patients’ right to choose’
Comments by: Zain Bamber, GP Locum, Harrow, London. E-mail: firstname.lastname@example.org
Professor Greenhalgh makes a valid point about the pitfalls of opportunistic screening in general practice.1 There will always be patients who find opportunistic health checks intrusive and entirely superfluous to their consultation with their GP. However, as Dr Greenhalgh points out herself, proactive care of this kind is often based on robust evidence and contributes significantly to practice income too. Allowing patients to entirely opt out of participating in these health checks could therefore have serious long-term clinical and cost implications.
There are also practical problems in implementing any ‘opt-out’ systems. Presumably any decision to opt out of routine health checks would have to be based on informed consent. But such informed consent would surely have to be regained at fairly regular intervals in order be ethical and fair. If a 50-year-old woman, for example, opts out of ever receiving letters inviting her for annual blood pressure or urine-dip screening, is it ethical to regard this consent as indefinite and not re-offer the screening as she ages, her cardiovascular risks increase, or if her social circumstances/medical comorbidities change?
There are also other advantages in sending ‘unsolicited mail’ to our patients that Dr Greenhalgh overlooks. For example, such offers of screening, even if they are declined, can serve to remind infrequent attenders of the existence of their GP and encourage attendance for other problems.
Dr Greenhalgh refers to a few of her patients ‘who have negative attitudes towards proactive care’ and one patient in particular who felt that ‘her biometric data in the absence of symptoms are none of anyone’s business’.1 Surely it is our role as primary care clinicians to challenge attitudes of this sort and, so far as it is reasonable, encourage all patients to participate willingly and actively in taking responsibility for their long-term health, rather than allowing a select few to opt out of health checks on a default basis.
1. Greenhalgh T. Outside the Box: Proactive care: the patients’ right to choose. Br J Gen Pract 2013; 63(606): 37.
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