Monthly Archives: August 2015

Going back to the start – influencing prospective medical students

JmespicforJames Pearson is an ST3 trainee in Bath and the education scholar for the year.

Suddenly you are sitting there alongside all these very intelligent people and the familiar world of sixth form seems so far away. I still remember my first day at medical school when the year group were told in our welcoming lecture that the majority of us would become GPs. I distinctly remember my reaction and that of all my peers was one of surprise and shock! How could they suggest something as absurd as that?

At that point, our exposure to medicine had mostly involved work experience in secondary care and for a few of us, some volunteering in the charity sector. Only a rare handful had managed to secure some experience in primary care. This was mainly by means of a relative or friend with suitable contacts as there are many barriers; issues with confidentiality and perceived maturity of students to name but two. Looking back, it seemed as though we were programmed from the start and had no aspiration for General Practice – we only had personal experience and tales from the media to inform us.

Consequently, I decided to set out on a quest in my role as the ST3 Bath patch Educational Scholar to try and change this locally. I also wanted to provide an excellent opportunity for GP trainees to lead and organise a placement as well as some experience in supervision. Working alongside my counterpart in the Bristol area (Dr Howse) we recruited 32 sixth formers from schools in the local area who were planning to apply to medicine in the current academic cycle. They were a shortlist of the best as determined by their application form, personal statement and teacher reference including predicted grades. We were overwhelmed by applicants and had to turn away those unless they had a realistic chance of a successful application to medical school.

By meeting them all at our carefully planned one-day preparation course, I observed their enthusiasm for medicine and it was rewarding to be able to enlighten them on topics such as ‘the role of the GP’ and ‘members of a practice team’. It was astounding to hear their views in small group work and as predicted from this and their pre-course questionnaires, their views on General Practice were misled and mistaken. It gave us the chance to set the record straight, promote our career, brief them on confidentiality and explain our expectations of prospective medical students. Overall the feedback we received at the end seemed to have a positive impact on their attitudes and all were keen to undertake the offered work experience in General Practice.

Using the demographic knowledge obtained from the application form, we were able to ensure that no student lived or went to school in the area their allocated practice was based. This had previously been one major barrier when pupils had contacted their local practice and were declined for fear of them knowing some of the patients. They were then allocated a GP trainee and left to liaise together about suitable dates as well as the format of their work experience. Further information from the pre-course questionnaires on three things the pupil wanted to get out of the experience helped trainees plan specific activities for the individual. For example, my allocated student was able to spend time with different members of the practice team and really enjoyed watching minor surgery done at the practice. She was amazed at the variety of things that were on offer and the array of opportunities available.

The first year of this project is now coming to a close and certainly each student now has a subsidiary mentor who could help them through the application process. I really hope that this has given realistic prospective medical students an insight in to primary care and we were able to overcome the barriers to gain the experience. I am not intending to suddenly convert all these students in to budding GPs but I really feel that at the moment as a profession we are not doing enough to promote our career to this group of young minded individuals where a lot of their early experiences can shape their ideas on the future.

Let’s hope that their reaction at their first day at medical school to the obligatory statement of “most people will be GPs” is different to my year group’s.

“For One Week Only” – Diagnosing high blood pressure in primary care

profile 1David Nunan is a Departmental Lecturer and Senior Researcher based in the Nuffield Department of Primary Care Health Sciences and the Centre for Evidence Based Medicine at the University of Oxford. His research interests include evidence-based medicine, cardiovascular and non-communicable disease and lifestyle medicine in primary care.

At the 44th Annual Conference of the Society for Academic Primary Care I presented results from our study to assess the diagnostic accuracy of self-monitoring blood pressure (BP) for diagnosing hypertension in primary care. Here is a synopsis of that presentation.

High blood pressure is one of the biggest underlying risk factor for cardiovascular disease (CVD) and that CVD itself is the biggest cause of premature death globally. Therefore, accurate diagnosis of high blood pressure is pretty crucial.

Current NICE guidance advocates suspecting hypertension if clinic blood pressure is 140/90 mmHg or greater on 2-3 occasions over a period of weeks to months. If there is a suspicion then the patient should be offered ambulatory blood pressure monitoring which collects the average blood pressure taken over 24 hours using a special electronic monitor that automatically takes measurements 2 to 3 times an hour (1 per hour at night – more than this would be unkind). This is currently considered the “gold” or reference standard for diagnosing high blood pressure. However, not everybody can tolerate this intense level of monitoring.  In these cases the guidance advocates home blood pressure monitoring.

Nearly one third to two-thirds of people with suspected high blood pressure already monitor their own blood pressure with an electronic device readily available in their local pharmacy.

But how long should you take home BP measurements to make a diagnosis of hypertension?

Current guidelines for self-monitoring to diagnose high blood pressure state that people should take 2 measurements in the morning and 2 in the evening for 7 days. Doctors should then take an average of all the measurements except those taken on the first day. This is because there is some evidence that self-monitored blood pressure measurements taken on day 1 are often higher than subsequent days due to anxiety or unfamiliarity with the device. The average is then used to determine if someone has high blood pressure or not.

However, the evidence for these recommendations isn’t particularly strong, and no one has assessed what effect these recommendations have on the ability to detect if a person has high blood pressure or not.

Therefore, we conducted a diagnostic accuracy study to find out. This sort of study basically looks at how well a new/alternative test or measurement identifies if a person (usually a patient) does or does not have a particular disease or health condition. Simply put, it’s the way health professionals ask “does the test work?” (it’s actually a little more nuanced than this – anyone interested can follow up here).

Our study set out to look at how current recommendations for self-monitoring impact on its accuracy for diagnosing high blood pressure. We also wanted to look at if using more or less readings from self-monitoring would have an impact on diagnostic accuracy and whether self-monitoring performed in the GP surgery would be better at identifying people with high blood pressure than readings taken by the GP

So what did we do?

Figure 1 illustrates our study protocol. Patients had their blood pressure measured by their GP (or nurse). They then performed 6 self-monitoring readings in their GP surgery. We then asked patients to self-monitor their blood pressure (according to current guidelines) at home or work for 28 days. This was followed by a 24 hour ambulatory recording.

Figure 1.
hybetfig1

For each patient, we used the average daytime readings from the 24-hour ambulatory recording to diagnose high blood pressure. We then compared the average blood pressure from self-monitored readings taken over 7 days (discarding day 1 readings as per guideline recommendations).

So what did we find?

As expected, compared with measures taken by a doctor (or nurse) in a GP surgery, the average of 7 days readings taken by patients at home (or work) using an electronic monitor was more accurate at identifying whether someone had high blood pressure or not (see Figure 2).

hybetfig2

Figure 2. Sensitivity = for every 100 patients, the values in this row represent the number of patients who actually have hypertension that will be correctly identified by each test (e.g. first column = 95 out of 100 patients who have hypertension will be correctly identified as having hypertension when GPs take the readings). Specificity = for every 100 patients, the values represent the number of patients who do not have hypertension that will be correctly identified by each test (e.g. only 7 out of 100 patients who do not have hypertension will be correctly identified as not having hypertension by the GP).

OK, so not exactly a groundbreaking finding there then. However, when we looked at whether adding more or less readings affected the accuracy of self monitoring (we expected an improvement), we found that the best accuracy came from the first 5 days of self-monitoring.

Increasing the number of readings beyond day 5 (i.e. 20 readings) had surprisingly little effect on the ability to correctly identify high blood pressure or not. The was due to the fact that self-monitoring readings produced on average a higher (around 7 mm Hg) blood pressure when compared with 24 ambulatory monitoring.

Finally, we found that including self-monitored readings taken on day 1 to calculate the average blood pressure had no effect on the ability to detect high blood pressure or not (see Figure 3).

Figure 3.

hybetfig3

Our study showed that home monitoring is best used as a test to rule out hypertension (for those interested, the techy bits about how we determined this can be found here) and that doctors can just as accurately identify patients without hypertension from 5 days of self-monitoring. There’s also no need to worry about excluding readings taken on the first day.

 So what does this mean in clinical practice?

One of the GP practices involved in our study has adopted this new regime for diagnosing hypertension and has noted significantly shorter waiting times for home-monitoring assessments and quicker diagnostic decisions. We anticipate that our findings and impact cases will be used to underpin updates of current NICE Hypertension guidelines.

 

Reference

Nunan, D., Thompson, M., Heneghan, C. J., Perera, R., McManus, R. J., & Ward, A. (2015). Accuracy of self-monitored blood pressure for diagnosing hypertension in primary care. J Hypertens, 33(4), 755-762; discussion 762. doi: 10.1097/hjh.0000000000000489

 Declaration of interest

This project was part of an independent research project commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-0407–10347). The views expressed in here are those of the author and not necessarily of the NHS, the NIHR or the Department of Health.

Anyone wanting but unable to access our paper please email me for a copy at david.nunan@phc.ox.ac.uk

The Locum: Assassin of Independent Contractor Status

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

In the June issue of the BJGP there was a debate as to whether GPs should maintain their status as independent contractors. To me this seemed like a macrocosm of the decision that all newly qualified GPs have to make when it comes to finding a job.

Since the new contract for general practice it seems to have become the norm for a new GP to take a salaried job which provides stable employment and predictable pay without the burden of extra responsibilities born by partners. Generally this is considered a stepping stone to partnership.

But the status quo is being upset by the increasing popularity of locuming. Dr Larry Locum seems to be the man who has his cake but eats yours. Advocates of this way of working describe it as a Nirvana of convenient working hours, minimal responsibility and good pay. The appeal is obvious and, as the pay for salaried roles gets squeezed, the appeal is growing. Although this life has potential to be unstable many of my cohort feel that this is more than offset by the flexibility and the remuneration.

Whilst many still see a period of doing locums as a prelude to seeking permanent employment there is a growing number of GPs who feel no compulsion to take either a salaried role or a partnership after years of enjoying locum life. Interestingly, medical chambers are also filling up with GPs who have been partners but now wish to locum.

Could this way of working pose an existential threat to the partnership model?

Without wishing to sound mercenary, a big part of the problem is pay and, in particular, the complexity and opaqueness of partner pay. Ask a salaried doctor how much they get paid and they can tell you their pay per session. Ask a locum and they can tell you the going rate. But ask a partner and their eyes glaze over and they start talking in tongues, using phrases like ‘notional rent’, ‘local enhanced services’ and, of course, the ‘QOF’. Meeting the shifting targets of the QOF alone seems as fiendish as a battle of wits with Professor Moriarty. This complexity, combined with the fact that partners often seem to work harder and bear more responsibility than their colleagues, makes partnership seem daunting and uncertain.

Clearly there are less tangible rewards in partnership. People talk of the ability to guide your practice in the direction you wish it to go, or the emotional satisfaction of nurturing your own business but, to the uninitiated, these rewards can seem fairly trifling compared to the possibility of losing your house if things go really wrong.

Compared to becoming a locum, where the pay can be closer to that of a partner, becoming a salaried GP is increasingly seen as an under rewarded role and yet it is still the predominant job type on offer in the jobs market. Whilst many practices seek to employ salaried doctors the logical choice from the perspective of a GP registrar is between seeking one of the few available partnerships or doing locums, or at least having time free in the week in which to do locums on top of a part-time salaried role.

This tension between the demands of new GPs and the supply from practices is in danger of making the locum role the norm with the attendant possibility of sleep walking the partnership model of general practice out of existence. Without partnerships the debate over the independent contractor status of GPs will be moot, it will simply cease to exist.