Monthly Archives: July 2015

Yonder: Practice nurses, Ehlers-Danlos syndrome, fitness to drive, and Balint groups

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.

Practice nurses
In the UK, much like the rest of the world, a huge proportion of patients with mental health conditions are managed exclusively in primary care, with no specialist psychiatric input. Practice nurses make up a substantial part of the primary care workforce and are increasingly involved in managing long-term conditions. Traditionally, however, mental health has not often been part of their remit and training opportunities have been rare. In a recent study, a primary care mental health expert developed a programme of education designed specifically for practice nurses.1 The ‘train the trainer’ model was used to prepare 24 mental health nurses in North London to deliver the teaching. Both the practice nurses and mental health nurses felt their clinical practice would improve as a result of taking part. As we move to more integrated models of mental healthcare delivery, these collaborations could prove invaluable.

Ehler-Danlos syndrome
An inherited, lifelong connective tissue disorder characterised by joint hypermobility and a number of possible systemic features, Ehlers-Danlos syndrome (EDS) can have a significant impact on many aspects of patients’ lives. Given the complexity of the condition, frequency of chronic pain, and absence of objective physical signs, individuals with EDS are often referred for psychiatric assessment. Researchers from Sweden recently sought to identify levels of anxiety in EDS patients using postal questionnaires.2 The 250 individuals that responded had considerably higher levels of anxiety and depression than a Swedish general population group. They also had significantly lower health-related quality of life. The authors highlight that, although EDS is a lifelong condition with limited treatment options, offering more personalised interventions and acknowledging the psychosocial burden of the condition may help individuals manage their daily lives.

Fitness to drive
Driving allows people to work, socialise, and maintain self-confidence and independence. Stopping driving can have negative health and social effects, although clearly can be essential in certain circumstances such as unstable epilepsy and significant visual impairment. GPs in Ireland, like those in the UK, are expected to assess medical fitness to drive despite receiving little or no training to prepare them to do so.

A group of Irish researchers recently used postal questionnaires to survey 527 GPs about this.Although many of them felt confident in their ability to make these assessments, there was ambivalence about who should be primarily responsible to complete them. Some GP responders would consider referring for more specialist opinion if the option were to become available. Many GPs felt their skills in this area were limited and dealing with patient and family pressure and requests for legal clarifications were particularly problematic areas.
Balint Groups

Balint groups
Michael Balint, a London-based psychoanalyst, introduced seminars for GPs in the 1950s that would go on to spread across the world, helping clinicians broaden their perspectives on challenging clinical interactions through case-based presentations and discussions. In a recent review published in Patient Education and Counselling,4 Belgian researchers found that the peer-reviewed literature on Balint groups remains scarce. The research that exists, meanwhile, tends to be diversely reported and methodologically weak, although they found many rich reflective accounts and reports about the benefits they have had for individual clinicians. As studies reported effects (for example, psychosocial self-efficacy, and reduced burnout) only after long-term participation, the authors highlight the importance of organising groups for a sufficient length of time (they suggest 1–1.5 years) to allow for change. As a Balint group enthusiast, I hope this review will prompt further interest and research funding to help convince policymakers of the enormous value of these groups to healthcare professionals, and in particular, GPs.

References

1. Hardy SA, Kingsnorth R (2015) Mental health nurses can increase capability and capacity in primary care by educating practice nurses: an evaluation of an education programme in England. J Psychiatr Ment Health Nurs 22(4):270–277.
2. Berglund B, Pettersson C, Pigg M, Kristiansson P (2015) Self-reported quality of life, anxiety and depression in individuals with Ehlers-Danlos syndrome (EDS): a questionnaire study. BMC Musculoskelet Disord 16(1):89.
3. Kahvedžic A, Mcfadden R, Cummins G, et al. (2015) General practitioner attitudes and practices in medical fitness to drive in Ireland. J Transp Health 2(2):284–288.
4. Van Roy K, Vanheule S, Inslegers R (2015) Research on Balint groups: a literature review. Patient Educ Couns 98(6):685–694.

BJGP Student Writing Competition – the winner

head shotLydia Yarlott is in her final year at Oxford Medical School.

She is the winner of the 2015 BJGP Student Writing Competition themed ‘The GP in the Digital Age’ with her original article A Digital Ache.

Her tale of one GP versus the system will be horribly familiar to anyone who has done battle with the new digital bureaucracy of the NHS. It’s a rather wonderful reminder of the fundamental importance of maintaining relationships between doctors to benefit patients. The PDF version is embedded below – it needs the formatting to get the full benefit. Enjoy.

Download (DOCX, 19KB)

Yonder: prostate biopsy, childhood vaccination, oral health and medical tourism

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.

Prostate biopsy
Prostate cancer remains one of the commonest causes of cancer death in the world and as active surveillance becomes an increasingly accepted alternative to radical treatment, the use of biopsies has extended to include monitoring as well as diagnosis. Transrectal ultrasound guided biopsy (TRUS-Bx) is therefore one of the most commonly performed urological procedures in the world. In a recent qualitative study embedded in a large randomised controlled trial, researchers from Bristol sought to compare men’s experiences of these biopsies compared to the expectations they had before it.1 Although TRUS-Bx was generally well tolerated, around one-quarter of men experienced problematic side effects and anxiety. In these cases, experiences tended to deviate from the information that they had received and they, therefore, felt unprepared for elements of the procedure or its sequelae. The study findings have been used to design an updated, comprehensive, evidence-based patient information leaflet and the authors reiterate the need for detailed discussions when counselling men about this procedure.

Childhood vaccination
Childhood vaccinations are such a routine part of modern health care that it can be easy to underestimate the huge reductions in global mortality that they have led to. However, despite increases in uptake, rates remain suboptimal with vaccine-preventable diseases still a public health risk in most parts of the world. A recent systematic review identified 28 studies evaluating parental interventions developed to improve early childhood (0–5 years) vaccine uptake.2 Receiving both postal and telephone reminders was the most successful reminder-based intervention. Educational interventions, meanwhile, were most successful in lower-income countries and when conducted through discussion. As you might imagine, the precise effectiveness of interventions depended on a number of factors, including the country and levels of parental vaccine hesitancy in the target population.

Oral health
Although health-related quality of life is a well-established outcome metric in medical research, the field of oral health has lagged behind. Several measures have attempted to capture how oral health impacts on quality of life but have all been directed to older adult populations. A team of public health researchers from Yale University recently sought to develop a questionnaire addressing issues that were more relevant to young adults.3 An initial item tool that included physical, psychological, and social constructs (developed by oral health experts) was sent to 553 adult participants via an online questionnaire. Scores on the self-perception and anxiety subscale were highest in this cohort (average age of 28 years) and tooth colour appeared to be the biggest concern. The initial psychometric properties of the survey were promising, and given that 80% of questions on previous instruments related to dentures, future studies should now be better placed to measure the impact of oral conditions on all age groups.

Medical tourism
The surge of UKIP in the recent general election has brought the term medical tourism into the public vocabulary. Although the political focus has been on the use of the NHS by visitors from abroad, many patients choose to leave the UK to pursue treatments from other parts of the world. The literature in this area is growing, although studies to date have focused mainly on specific types of procedures for which patients travel, including cosmetic, dental, and fertility treatments.

In a Social Science & Medicine article, a team of researchers sought to explore why and where patients from the UK choose to travel for health care.4 They found that while distance, costs, expertise, and availability of treatment were all factors influencing the decision to travel, choice of individual provider was based on informal networks including web for a, support groups, and personal recommendations. The authors suggest that given the importance of these networks, they may be an important target for efforts aimed at regulating medical tourism. Exactly how much regulation is needed is probably the more fundamental issue politically.

References

1. Wade J, Rosario DJ, Howson J, et al. (2015) Role of information in preparing men for transrectal ultrasound guided prostate biopsy: a qualitative study embedded in the ProtecT trial. BMC Health Serv Res 28(15):80.
2. Harvey H, Reissland N, Mason J (2015) Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: a systematic review and meta-analysis. Vaccine 33(25):2862–2880, doi:10.1016/j.vaccine.2015.04.085.
3. Daneshvar M, Devji TF, Davis AB, White MA (Apr 17, 2015) Oral health related quality of life: a novel metric targeted to young adults. J Public Health Dent doi:10.1111/jphd.12099, [Epub ahead of print].
4. Hanefeld J, Lunt N, Smith R, Horsfall D (2015) Why do medical tourists travel to where they do? The role of networks in determining medical travel. Soc Sci Med 124:356–363.

RATs: Quality not Quantity

image1Joe Anthony is a history graduate currently in his fourth year studying medicine at the University of Manchester. He was joint second in the BJGP Student Writing Competition which had the theme The GP in the Digital Age. Joe’s article took us straight into how technology has an impact on two key topics for any GP: quality and continuity.

Talk to any politician and they will tell you that the problem is one of access. ‘GPs should be working 7 days a week’, ‘more appointment-slots should be available’, ‘better access equals a better service’, they yell from their soapboxes. And with a growing population, which has ever-increasing expectations of what the NHS should do for them, you might be forgiven for thinking that the problem is simply one of quantity.

This attitude is evident in the government’s recent approach to improving general practice. Development of effective telehealth in the UK has been a priority, with CCGs rolling out these services thanks to heavy financial backing. Telephone consultations were once the purported solution; increasing ease of access and therefore the quantity of consultations available was the goal, however, the results were far from satisfactory as the increased access simply led to greater demand. The telephone slots were used but those same patients too often still required a traditional consultation, hence the ESTEEM trial’s conclusion that telephone consultations were not cost-effective.1

CCGs are therefore turning to the next step in telecommunications and video consultations using Skype are now widely available. These continued attempts to pursue telehealth seem to ignore the lessons learnt on the telephone. Telehealth provides consultations at the click of a button, day or night, decreasing overheads for premises, administration staff, and the like. The goal is an increased number of consultations at low cost but as these services are not proving economical and have not tackled the previous issue of patients requiring a repeated consultation, what purpose do they serve?2

The digital age is, however, supplying technologies that are resulting in palpable improvements to health services. While telehealth receives the headlines and funding, the comparatively humdrum integration of Risk Assessment Tools (RATs) is leading to faster and safer consultations. In broad terms, this utilisation of software to carry out important analysis of patient data can and does save GPs valuable time, which can be better spent elsewhere in the consultation.

The growing numbers of RATs available to GPs are small steps that can make a big difference to patients. ECLIPSE (Education & Cost-analysis Leading to Improved Prescribing Safety & Efficiency) is just one example of such a tool. The software analyses data on practice systems and uses algorithms to detect long-term trends in clinical entries, prescribing, and pathology results. ECLIPSE identifies patients who are overdue for monitoring tests or being put at risk by their medications and presents these findings via a traffic light system of alerts, with the aim being to prevent unnecessary hospitalisations. For example, a full blood count shows a haemoglobin of 13.5 g/dL, a rushed GP sees a normal result but ECLIPSE sees the bigger picture. This patient is on an NSAID and their haemoglobin was 16.0 g/dL 2 months ago, an ODG is ordered, a peptic ulcer is detected, and an outcome improved.

ECLIPSE has already been rolled out by several CCGs and more RATs are being added; for example, Nottingham’s QCancer® score and Professor Willie Hamilton’s cancer prediction tools which aim to tackle an identified weakness of the NHS — early cancer diagnosis.3,4 This is not the story of a digital panacea, rather of incremental improvements that have the potential to improve general practice, and thus patient outcomes.

Talk to any GP and they will tell you the problem is not one of access. They will tell you the focus should not be on quantity but on quality. They will emphasise the importance of continuity of care and a safe and efficient service. RATs are helping to provide that service.

REFERENCES

1. Campbell JL, Fletcher E, Britten N, et al. (2014) Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet 384(9957):1859–1868.

2. Henderson C, Knapp M, Fernandez JL, et al. (2013) Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ 346:f1035.

3. Rubin G, Vedsted P, Emery J (2011) Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract doi:10.3399/bjgp11X572283.

4. Hamilton W, Green T, Martins T, et al. (2013) Evaluation of risk assessment tools for suspected cancer in general practice: a cohort study. Br J Gen Pract doi:10.3399/bjgp13X660751.

The Technophobe’s Guide to the Digital Age

R.VarleyRebecca Varley trained at Lancaster Medical School and is on the brink of being an FY1 based at Manchester Royal Infirmary. She was joint second place in the BJGP Student Writing Competition which had the theme ‘The GP in the Digital Age’. We liked her warm, personal counter-perspective on how we approach technology.

Douglas Adams had it right. In his Hitchhiker’s Guide to the Galaxy series he perfectly encapsulates the way I feel about technology. I am one of those poor Earthlings who “still thinks digital watches are a pretty neat idea,” and wonders why no one has noticed that technology is only making life more complicated? Adams’ infamous Nutrimatic-Drinks-Dispenser “invariably delivers a liquid that is almost, but not quite, entirely unlike tea.”1 And isn’t it true? Machines can’t even get tea right.

When the best part of technology is the “sense of achievement you get from getting it to work at all,” something is wrong.2 Despite having been born slap-bang in the middle of the digital age, I am dismayed to find myself a ‘technophobe.’ But when I look around at my colleagues-to-be, I don’t believe I’m alone.

On every GP placement I have heard doctors bemoaning technology day in and day out. And why not, when all the patient notes spontaneously decide to reboot mid-surgery, when the electronic prescribing program takes itself out for a few hours, or when a glitch renames every patient in the system ‘George’ (alright that one didn’t happen, although I bet it could). It causes chaos.

But technology is a wonderful thing. We should be exalting it, not quivering at the byzantine complexity of decrypting our own passwords. For goodness sake, people are printing pelvises; it’s simply marvellous!

It’s true, hospitals see the most dramatic breakthroughs — whereas on some of my GP placements I’d have been lucky to see a pulse oximeter — but even without the flashiest gadgets, over time, technology has changed the job of the GP in a subtle yet profound way. And the more I think about it, the more I am won over.

Gone are the dark days of paternalism where patients unassumingly followed advice. More and more, patients are feeling empowered by knowledge from the web. ‘Cyberchondriacs,’ as some are affectionately nicknamed, are developing increasingly unusual diseases and I think it’s fun to be kept on our toes; having to explain why it’s unlikely to be an amoebic liver abscess and more likely to be gallstones to someone who is alarmingly well informed. But all joking aside, technology is helping people to take responsibility for their health, which is fantastic news for everyone.

The development of health applications and online symptom checkers is part of this new age of patient empowerment. Of course they are currently far from perfect but their potential is incredible. Apps are being designed to make long-term conditions, such as diabetes, easier to manage at home, and apps that aim to improve diet and fitness could play an enormous role in the fight against obesity, a costly and growing concern.

I have come to realise that ‘technology’ is so much more than erratic computer systems and so what if I can’t run HTML backwards while simultaneously lowering cholesterol? We all have our strengths and computers aren’t mine: that doesn’t mean I should condemn all technology and run from it terrified. Technology was never the problem, I was.

My GP placements have helped me to see technology for what it really is and for that I am incredibly grateful. Even though I may never know what ‘the cloud’ is, and I am still waiting for that perfect cup of tea, I am embracing technology at last and am happy I will be a doctor in a digital world. So for anyone out there who has ever felt like me, keep going, we’ll get through it.

REFERENCES

Improving GP recruitment: a medical student perspective

photoNabila Rehnnuma is a first year graduate-entry medical student at Cambridge University.

A funding crisis, increasing workload, falling real income and continuing negative media press, these are just a few of the reasons why general practice is decreasing in its level of popularity amongst medical students.1 This problem is further exacerbated by medical schools, which have cultivated a culture where general practice is seen as the “second-choice”. This is despite the fact that general practice can be one of the most challenging and equally rewarding professions. Headlines describing the rising patient expectations, reduced resources and poor staffing levels further dissuades potential general gractitioners, with more than 400 GP trainee posts left vacant in 2014.2 This diverges from governments’ current plans which have stipulated that Health Education England should ensure that, by 2015, half of all medical students are to become GPs.1 Therefore, the question remains, how do we meet this target? And more importantly, how do we make the role of a general practitioner more appealing to the current medical student?

One of the important determining factors behind medical students’ career preferences tend to be their attitudes towards the medical specialities.3 Experiences at medical school tend to dictate an individual’s attitude, with attitude being one of the most important driving forces. Positive previous experiences on placement stood as one of the greatest influences affecting medical students’ career choices, according to a study carried out on medical students, trainees and practicing physicians regarding the factors which influence career preferences.4 Therefore one of the potential strategies medical schools can employ is to increase exposure to primary care experiences during the early years of medical school and emphasise primary care experiences during training years. Medical schools should allocate more funding towards GP delivered in the community. Increasing exposure enables medical students to be exposed to positive role models, such as Dr Weatherburn5, an Academic Fellow in General Practice in the University of Dundee, whom is able to “lead by example”, and illustrate why a career in GP is so rewarding. By providing high quality career’s advice regarding the flexibility and variety of avenues that a GP career can take, it enables a re-focus on why such a career still remains a good career choice.

Another means to curb the current decline in primary care, is to improve satisfaction among family physicians.4 As previously mentioned, it is positive experiences on placement which to some extent dictate a medical student’s career preferences. However, in order for the experience to be positive, current physicians must be content with their career and current lifestyle. One means to achieve this is to enable a greater employer focus on retaining and investing in their current staff.6 This can be via commissioning education and training opportunities to train and develop current staff, and attract the future workforce. Financial incentives such as the ‘golden handshake’, where GPs are offered higher salaries for working in rural areas, as well as greater flexibility in working hours are other means to retain the current GP workforce. If the government is able to reduce the pressure on GPs and invest in the future of general practice2, particularly in their training and education, this can attract potential medical students into the profession.

The final means suggested to attract the future GP workforce, is the opportunity to be able to vary career direction or combine careers.7 Offering clinicians the opportunity to combine a specialism with generalism may be another mechanism to attract more general practitioners needed to cater for large scale shifts from secondary care. This is where general practitioners are able to gain experience and qualifications in a field of particular interest to them, such as psychiatry or dermatology. Given recruitment problems often reside in the fact that students seek to train in fields where employment opportunities align with career preference, as opposed to service needs, dual training opportunities provide an appropriate means to accommodate for this. Therefore if students are able to combine career and training opportunities, this might be attractive to some doctors whom may not primarily consider general practice.

These are just a few of the means to attract the next generation of General Practitioners. However, it appears that what matters most to current medical students is personal interests. Could they see themselves as a GPs and more importantly what is the greatest factor that can sway their vote?

Links

1. http://careers.bmj.com/careers/advice/view-article.html?id=20017562

2. http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/gps-feel-undervalued-and-angry/20008701.article

3. http://www.academia.edu/4775633/Career_preferences_of_medical_students_influence_of_a_new_four-week_attachment_in_general_practice

4. http://www.bcmj.org/article/factors-influencing-career-choices-made-medical-students-residents-and-practising-physicians

5. http://www.bmj.com/content/349/bmj.g6245/rr/786933

6. http://hee.nhs.uk/wp-content/blogs.dir/321/files/2014/12/HEE-investing-in-people-20151.pdf

7. http://careers.bmj.com/careers/advice/view-article.html?id=20018623