Monthly Archives: April 2015

Yonder: Choosing a GP, breast cancer, patient safety, and online dating

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature. Twitter: @Dr_A_Rashid

You can download the PDF here at BJGP.org.

Choosing a GP.
The NHS constitution gives patients the right to choose the GP surgery they want to register at and to express a preference to see a particular doctor within that surgery. In a recent Australian study, researchers studied the factors that are taken into consideration when choosing a GP.1 Their online survey was filled in by 2481 adults. The most important factor was care quality, which included technical and interpersonal care as well as continuity, and the authors felt the emphasis when publicising practices should be on the manner in which care is delivered, rather than the types of care that are available. Despite the important difference that cost is not a factor in the NHS (and is in the Australian health system), the study is a useful reminder that patient priorities must be central to the way practices are designed and promoted

Breast cancer.
Advances in breast cancer treatment mean even for those with metastatic disease, there is an increasingly long period of time between diagnosis and end of life. The uncertainty of living with metastatic breast cancer and the vulnerability to physical and psychological issues while living with this diagnosis prompted a group of researchers to investigate the information and support needs of this population, interviewing 18 women in total.2 The results show that these patients deeply value relationships with health professionals, and in particular for this group, their oncologists. However, many women felt their clinicians did not appreciate the extent to which treatment side effects impact on quality of life. In addition, participants felt better supported when they had early breast cancer than following the diagnosis of metastatic disease. The authors suggest improving information provision specifically about advanced disease should therefore be a priority.

Patient safety. Vast numbers of patients are treated effectively and safely in general practice every day. However, among the complexity of consultations, prescriptions, visits, letters, and computer systems, the potential for patient safety issues is high. In recent years, there has been much focus on developing the right culture and systems to minimise the potential for harm. In a recent Globalization & Health study, a Leicester research team explored the views of health workers in low-income settings about the obstacles to ensuring patient safety.3 A total of 57 doctors, nurses, administrators, and managers from East Africa were interviewed. As is the case in high-income countries, front-line staff were able to provide valuable insights into patient safety challenges. It was particularly interesting to note that, despite the difference in material resources, key themes were remarkably similar to those in the NHS and included teamwork, professional hierarchies, and governance. This reaffirms that human factors, leadership, and culture really are central to embedding patient safety into any organisation.

Online dating. Evidence-based medicine approaches have helped to answer countless clinical questions and clarify some great mysteries of the medical world. Two clinical researchers from either side of the Atlantic Ocean recently decided to use a systematic review to find out whether there was an optimal, evidence-based approach to online dating.4 In order to do this, they searched the literature in a number of disciplines including psychology, sociology, and computer and behavioural sciences, finding 86 studies for inclusion. A desirable screen name (starting with a letter in the first half of the alphabet), an attractive still picture, and a fluent headline message are important to capture initial interest. Meanwhile, invitations to potential dates are most likely to be accepted if they contained short personalised messages addressing a trait mentioned in their profile, or extended genuine compliments. In the acknowledgements, the authors thank the potential dates who turned one of them down repeatedly and encouraged them to take this evidence-based approach!

References

1. Kenny P, De Abreu Lourenco R, Wong CY, et al. (Jan 7, 2015) Community preferences in general practice: important factors for choosing a general practitioner. Health Expect doi:10.1111/hex.12326, [Epub ahead of print].
2. Lewis S, Yee J, Kilbreath S, Willis K (2015) A qualitative study of women’s experiences of healthcare, treatment and support for metastatic breast cancer. Breast doi:10.1016/j.breast.2015.02.025, pii: S0960-9776(15)00040-5, [Epub ahead of print].
3. Aveling EL, Kayonga Y, Nega A, Dixon-Woods M (2015) Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers’ views in two African hospitals. Globalization and Health 11:6.
4. Khan KS, Chaudhry S (2015) An evidence-based approach to an ancient pursuit: systematic review on converting online contact into a first date. Evid Based Med 20(2):48–56.

BJGP Book Review: Out of Chaos Comes a Dancing Star

F1.large-2Out of Chaos Comes a Dancing Star: Notes on Professional Burnout by Chris Ellis. OpenBooks Press, 2014, PB, 95pp, £18, http://www.lastoutpost.info

This book review was written by Ami Sweetman and was in the April 2015 issue of the BJGP.

The author of this book has a fellowship and doctorate in family medicine, and from 2005 to 209 was an associate professor of family medicine at the University of the United Arab Emirates. He is now back home, semi-retired, and doing family practice in Pietermaritzburg, South Africa.

The opening quote from the philosopher Friedrich Nietzsche sets the tone, ‘Out of chaos comes a dancing star’, which in its fuller context reads: ‘One must have chaos in oneself to give birth to a dancing star.’

The text derives from his collection of notes taken from experience, workshops, and courses on the management of stress and burnout in medical doctors, and those involved in the healing professions, although he says it applies to all professionals whether in law, business, or driving the school bus. Stress is a common theme risking progression to burnout. His work shows that understanding another person’s trials and tribulations can be a source of inspiration. Although the text has a serious undertone it sparkles with wit throughout.

Insights into some of the struggles experienced by healthcare professionals are revealed, creating an awareness of the similarity of concepts and conditions encountered by all doctors. The book offers advice and motivation to see past the common despairs of working life and provides comfort in the knowledge that you are not alone when times can get tough.

Topics included are: how we see patients, attitudes to medicine and the practice thereof, the organisation of our work, and conflicts. There are quotes from attendees at the workshops, and excerpts from ‘iconic texts’ scattered throughout the book for contemplation.

Even the list of contents is intriguing. For example; the wounded healer; long hours and no sleep; the character of the doctor; management of acute burnout; guilt and loneliness; the Mr God complex; the angry doctor; the doctor–doctor relationship; credentials needed for burnout; know thyself; and finally, the Phoenix Phenomenon.

Fundamentally the problems are of time, or rather the lack of time, overwhelming obligations, anxieties over making errors in diagnosis, the increasingly informed, uninformed, and misinformed patient, and, of course, the burgeoning administrative and management problems. There are numerous splendid quotes and example situations placed throughout the text.

I would encourage you to dive into this treasure trove of medical wisdom and take away those insights that mean the most to you personally. Although many of the concerns are the products of extreme circumstances, it’s fascinating to see how the messages relate to the NHS or similar systems all around the world, no matter how sophisticated we may think our version of health care to be. We all, save a few of us, appear to suffer stress in trying to fulfil our role.

The BJGP Student Writing Competition

A huge thanks to everyone that submitted entries to this year’s competition themed ‘The GP in the Digital Age’. We have received many wonderful entries and we are just in the final stages of judging. The people on the shortlist have now been notified by email and we will be announcing the winners next Monday.

Paracetamol, ethnic health inequalities, cerebral palsy, and pornography

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature. Twitter: @Dr_A_Rashid

You can download the PDF here at BJGP.org.

Paracetamol
A recent study from South Africa, published in Patient Education & Counselling, is titled ‘But it’s just paracetamol’ — a phrase and sentiment that most GPs will be more than familiar with. The study sought to determine whether caregivers could make informed decisions about administering over-the-counter analgesia to children.1 In particular, they sought to explore whether the information provided by paracetamol labels, inserts, and patient information leaflets was adequate. The researchers spoke to caregivers from a church mothers’ group and a sample of local pharmacists in Cape Town. Their results indicate that most caregivers found it difficult to understand the scientific information in all three mechanisms of information provision. Although patient information leaflets were deemed easiest to understand, few caregivers received these with their purchase. The authors suggest that using simpler language in text and more verbal counselling could help improve safety and literacy.

Ethnic health inequalities
Ethnic minority populations living in economically developed countries are at particularly high risk of developing obesity, diabetes, and cardiovascular disease. Improving access to health promotion interventions therefore has the potential to reduce the burden of long-term conditions and reduce ethnic health inequalities. A team of researchers from Edinburgh recently sought to explore the perspectives of health researchers and promoters working with ethnic minority populations in the areas of smoking cessation, increased physical activity, and healthy eating, to better understand the process of adapting interventions. Their interview study was published in Health Promotion International.2 Among a number of thought-provoking findings, the study highlights the important context of demographic variables such as age and sex, and how these can significantly alter the way people interpret and participate in health promotion interventions. The authors suggest that the contextual experiences surrounding ethnicity considerations shape the receptivity, durability, and continuity of these adapted interventions.

Cerebral palsy
Infantile cerebral palsy (ICP) is the commonest cause of physical disability in childhood. The birth of a child with this condition can have huge implications for a family and cause complex and changing emotions in the parents. In a recent Spanish study published in Disability & Health Journal, researchers sought to understand the experience of adjustment to a child with disability.3 A total of 24 parents of 18 children with ICP were interviewed. The most traumatic experience for these parents was the loss of the ideal child they had expected. Many spoke about how they constantly compare how life would have been if their child had not been born with ICP. The authors suggest that, whenever possible, individual sessions that encourage emotional support and normalise all loss-related feelings should be provided to parents.

Pornography
The internet has transformed pornography use and has facilitated a dramatic increase in its popularity, such that it is now a multi-billion-pound global industry. Although a vast body of evidence has established the negative effect that viewing pornography can have on beliefs and attitudes, there has been comparatively less research about whether it also influences behaviours. A US-based team of psychology researchers recently sought to explore the association between viewing pornography and engaging in potentially risky sexual behaviours (or, as they call it in the article, ‘hooking up’).4 They recruited nearly 1000 college students and used online surveys to gather data. Their results indicate that more frequent viewing of pornography is associated with a higher incidence of hooking up and a higher number of unique hook-up partners. They discuss their findings in the context of the associated literature that connects hook-ups with alcohol consumption and lack of condom use. The paper concludes that it may be worthwhile to seek out pornography consumers in order to educate them. That should be easy enough!

References

1. Bennin F, Rother A (2015) ‘But it’s just paracetamol’: caregivers’ ability to administer over-the-counter painkillers to children with the information provided. Patient Educ Couns 98(3):331–337.
2. Liu J, Davidson E, Bhopal R, et al. (2015) Adapting health promotion interventions for ethnic minority groups: a qualitative study. Health Promot Int pii:dau105, [Epub ahead of print].
3. Fernandez-Alcantra, García-Caro MP, Laynez-Rubio C, et al. (2015) Feelings of loss in parents of children with infantile cerebral palsy. Disabil Health J 8(1):93–101.
4. Braithwaite SR, Coulson G, Keddington K, Fincham FD (2015) The influence of pornography on sexual scripts and hooking up among emerging adults in college. Arch Sex Behav 44(1):111–123.

Essential law for GPs: if CPR would be futile what do I tell my patient?

IMG_9619 copyAdam Sandell is a GP in Cumbria, and a barrister at Matrix Chambers.

If CPR would be futile, do I have to tell my patient about a decision not to attempt it?

The busy-doctor answer: Normally, yes.

In more detail: Mr Bloggs has end-stage COPD. He knows he’s unwell. But he’s an anxious man with an anxious family. He hasn’t asked you about prognosis. And he’s deteriorating. Forward planning seems wise: indeed, the General Medical Council says that, when patients become clinically unstable and there’s a foreseeable risk of arrest, a judgment about the likely benefits, burdens and risks of CPR should be made as early as possible.

You reckon CPR would be futile, so a decision not to attempt cardiopulmonary resuscitation (‘DNACPR’) looks right. Were Mr Bloggs to arrest, pummelling his chest in the back of an ambulance to nowhere will do no-one any good.

So surely there’s no need to cause him further distress by discussing this with him? It’s futile, so isn’t it as relevant as discussing whether you’re going to certify him fit to climb Kilimanjaro?

Not so, said the Court of Appeal last year in a case called Tracey. Mrs Tracey had lung cancer and was on a ventilator following a road accident. An intensivist completed a DNACPR form without discussing it with Mrs Tracey (who was apparently conscious and communicating at the time) or her family.

A horrified daughter found out about the DNACPR decision. Mrs Tracey asked that it be withdrawn, and it was. Then she deteriorated. At that point she said she didn’t want to discuss resuscitation. In conjunction with her family, a second DNACPR decision was made. Mrs Tracey died two days later.

The case was about the first DNACPR decision. Mrs Tracey’s husband said that his wife should have been consulted and told about it. And, if she wasn’t willing or able to be involved, members of her family should have been consulted.

The Court of Appeal agreed with Mr Tracey: DNACPR decisions are just too important, said Lord Dyson. “There should be a presumption in favour of patient involvement. There need to be convincing reasons not to involve the patient”.

One persuasive justification for expecting us normally to involve patients, even if CPR would be futile, was this: if you don’t tell your patient that you’ve made a DNACPR decision on the basis that CPR would be futile, you deny her the opportunity to seek a second opinion about whether it would be futile. I’d venture that most of us have, at some point, been wrong about things like the prospects of successful resuscitation.

A presumption in favour of patient involvement: that means you have to have good reasons not to discuss it. (And you’d be wise to document those reasons.)

One good reason not to discuss it would be if doing so would cause the patient physical or psychological harm. But harm is more than distress. Many patients may find involvement in this decision distressing, said the Court of Appeal, but that’s not enough of a reason to deny them the opportunity. (Perhaps ask yourself: is it my own discomfort that’s making reluctant to raise this?) However, if you conscientiously consider whether to discuss CPR with your patient, the courts will be slow to second-guess you.

When CPR won’t work, patients can’t require you to provide it. But they are normally entitled to know that you’ve decided not to. And, if your patient disagrees, the GMC would have you explain the options of seeking a second opinion and of getting legal representation.

The GMC’s current end-of-life guidance says this about DNACPR decisions when CPR would be futile:

“You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.”

Following Tracey, that’s a little misleading: your suspicion that Mr Bloggs may find involvement in this decision ‘burdensome’ probably doesn’t justify keeping him in the dark about it. But you’ll approach this sensitively. And if Mr Bloggs makes it clear that this isn’t a conversation he wants to have, get his permission to discuss it with those close to him.

This is one of several recent cases on patient autonomy in which the normally conservative higher courts are a little ahead of some corners of the medical profession. Those in fellowship with tabloid rants about human rights ‘gone mad’ will take succour from the knowledge that this case was brought under the Human Rights Act.