Monthly Archives: January 2016

Been there, done that, bought the T-shirt

Screen Shot 2016-01-28 at 13.44.05Simon Morgan is a GP and medical educator from Newcastle, NSW, Australia. He spends his spare time writing and playing the ukulele.

Can I take a photo?
Recently, I was in Heathrow Airport when an anonymous traveller approached me and asked ‘Do you mind if I take a photo of your t-shirt?’ I replied ‘Which one?’, thinking of my collection of much-loved, short-sleeved casual cotton tops back in Australia (Tin Tin in Vietnam is a particular favourite).
Looking somewhat nonplussed, she replied ‘Sorry, I meant the one you’re wearing’. I was clad in a black t-shirt with the words ‘I AM UNCONSCIOUSLY INCOMPETENT’ on the front. (I had deliberately worn it for the long-haul flight from Sydney to London so that I wouldn’t be mistaken for the pilot at any point. It appeared to work.) I said ‘Sure, but do you mind if I leave it on?’ I think at that point she regretted initiating contact.

Small world
Actually, that story isn’t entirely true. A woman did ask to take a photo of my t-shirt in Heathrow, and it was that t-shirt, but the rest of the dialogue was fabricated. That said, the real story was pretty noteworthy in its own right. After I actually responded in a far less cryptic manner than described above, the woman explained ‘It’s just that I use that expression in my student teaching all the time’.
I detected a stirring of recognition in my gut (it was either that or the indeterminate airline dessert I had foolishly eaten a few hours previously), and asked ‘Tell me, were you a keynote speaker at a medical education conference in Australia about 12 months ago? I think I know you!’.
She had, and I did — she was an academic from Canada who had given a plenary session on faculty development at a pre- vocational medical education conference in my home town.
Even though I had just spent 24 hours half-circumnavigating the globe, I said, without a hint of irony, ‘Small world!’. She took the photo and disappeared into the food hall.

Unknown unknowns
A colleague had purchased the catalytic t-shirt through the Internet a couple of years previously for the very same reason as my airport acquaintance. As part of a GP Trainer professional development session on the use of random case analysis as a formative assessment tool, we would discuss the concept of ‘unknown unknowns’, colloquially known as ‘Rumsfeldisms’.
Every good educational session needs a framework from which to hang its hat, and ours was the so-called ‘Johari Window’, the two-by-two table of knowns and unknowns.1
The Johari Window is essentially a communication model used to improve understanding between individuals.2

The origin of the word Johari is worth a mention. I initially thought it was named after a city in India, say, where the idea had been developed, equivalent to the Dayton Peace Accords or the Melbourne Manifesto. It is, however, an amalgamation of the first syllable of the Christian names of its two inventors, Joe and Harry.
As an aside, two medical education colleagues of mine, Wanda and Kerry, were considering the same idea for naming a feedback model they had developed, but I managed to talk them out of it.

Memorably uninstructive
So, we worked up a little skit as part of our presentation where my co-presenter would ask me how I thought the workshop was running and, as he revealed my apparent ‘unconscious incompetence’ about a supposedly disengaged group of participants at the back of the room, we would both unbutton our shirts to reveal the catchphrase t-shirts underneath. It always got a laugh.
On reflection, we may not have taught them anything, but at least we were memorably uninstructive. I mean, who wants to be unmemorably instructive! Or worse still, unmemorably uninstructive?

An effective communication tool
So there seems to be accumulating evidence that the humble t-shirt is effective as a communication tool. So much so, that I am thinking of marketing my own line of consultation-themed t-shirts. How about ‘I’m not ignoring you, this is a diagnostic pause’. Or, for those undergraduate placements, ‘I’m with student’. Imagine the effect of wearing a fluoroscent t-shirt emblazoned with the words ‘Diagnosis or bust!’, or a pastel V-neck stating ‘That sounds really troubling’. But my personal favourite, and I reckon my potential best seller, would be ‘I am comfortably uncertain’.


1. Halpern H. Supervision and the Johari window: a framework for asking questions. Educ Prim Care 2009: 20(1): 10–14.
2. MindTools. The Johari Window. Using self- discovery and communication to build trust. JohariWindow.htm (accessed 23 Dec 2015).

Top 10 most read BJGP research articles published in 2015

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from

1. Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire.

Parental perceptions and clinical definitions of child obesity are known to diverge; however, the extent of the discrepancy has not been documented. This study characterises parental classifications of obesity and identifies sociodemographic characteristics that predict misclassification. Also, BMI centile cut-offs for weight status are established as derived from parental perceptions.

2. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis.

This current review looks at management of non-malignant chronic pain as a whole, includes only randomised controlled trials, and uniquely focuses on humanistic outcomes such as pain acceptance and perceived pain control. These are of particular relevance with this self-help technique, as well as clinical and economic outcomes.

3. Help seeking for cancer ‘alarm’ symptoms: a qualitative interview study of primary care patients in the UK.

The Model of Pathways to Treatment highlights the importance of understanding patient appraisal and decision-to-consult processes for improving earlier diagnosis. Little is known about how people make decisions about visiting their GP for potential cancer symptoms in everyday life, without a researcher-imposed cancer perspective. This is the first qualitative, community-based study to assess how people respond to cancer ‘alarm’ symptoms outside of the cancer context. The results not only highlighted the importance of people’s interpretations of symptoms, but also their sense that they had to limit their demands for GP advice, both to preserve their self-image and to avoid uncomfortable interactions with the GP if they were seen as time wasters. The findings highlight potential avenues to promote prompt help seeking.

4. Simplified sleep restriction for insomnia in general practice: a randomised controlled trial.

Insomnia is a common health problem seen in general practice. Cognitive behavioural therapy for insomnia (CBT-I) is effective but its use has been limited by the time and expense required for delivery. Sleep restriction, or restricting the time in bed, is one component of CBT-I. This trial found that simplified sleep restriction advice, delivered in two GP consultations, is a practical, effective intervention for chronic primary insomnia.

5. Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population.

Cannabis smoking is associated with increased respiratory symptoms, but evidence of adverse effects on lung function is sparse. This study provides the first UK data on the impact of cannabis smoking on the prevalence of respiratory symptoms and chronic obstructive pulmonary disease in a general practice population. Although many adverse effects appeared attributable to tobacco, evidence of some additional adverse effects of cannabis was found.

6. Physician associates and GPs in primary care: a comparison.

Physician associates (previously known as physician assistants) are a new professional group in UK general practice, and evidence is required on their outcomes and costs. For patients attending for same-day or urgent appointments, PAs attended a younger patient group who present with less medically acute problems and fewer long-term conditions, compared to those attended by GPs. After adjusting for case-mix, there was no difference between PA and GP consultations in the rate of investigations, referral to secondary care, prescriptions issued, or the rate of patient re-consultation for the same or a closely related problem within 14 days. Patients report high levels of satisfaction with PA and GP consultations. The average PA consultation was longer than with a GP, although costs per consultation with a PA were lower.

7. Reduction in self-monitoring of blood glucose in type 2 diabetes: an observational controlled study in east London.

In many people who have type 2 diabetes but are not treated with insulin, self-monitoring of blood glucose (SMBG) is an often unnecessary task that confers no benefit, while being at very high, and increasing, cost. This is the first study to describe a systematic and major reduction in unnecessary use of SMBG. In people on metformin or no treatment, SMBG use was reduced from 29.6% to 6.0%; in all non-insulin users the rate fell from 42.8% to 16.5%. If replicated nationally, this would avoid unnecessary testing in 340 000 people and save £21.8 million that is currently spent on diabetes prescribing.

8. Patients’ online access to their electronic health records and linked online services: a systematic review in primary care.

Online services have been successfully piloted by large American organisations (such as Kaiser Permanente) but this success has not been replicated in the UK. This study found that patient satisfaction improved through enabling better self-care. Clinicians had concerns about the additional burden and workload from online access but evidence found their fears were only partly realised. There is a lack of good quality research in these areas in the UK; especially research that measures impact (such as health outcomes).

9. Patient information materials in general practices and promotion of health literacy: an observational study of their effectiveness.

Patient information leaflets (PILs) provide information to patients to encourage participation in their health care. Research evidence has variously concluded that PILs do affect patient health outcomes, but that many are poorly written. This study shows that less than 25% of PILs in general practice meet recommended reading-level guidance, and that most would be too complex for 43% of the English population. Less than 10% of the PILs covered managing illness or health promotion.

10. Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study.

Demand for GP care is rapidly increasing, but the supply of GPs is problematic. Currently, the number of GPs going into training is also problematic. Plans to expand GP training to 50% of medical graduates have been proposed. Teaching medical students in general practice increases the probability that they will opt for a career in general practice and so appropriate undergraduate experience will be important for workforce planning. Since the late 1960s GP teaching of medical students has increased to occupy 13% of the clinical teaching in UK medical schools. This study suggests that this growth has stopped, and may be in decline. Effective financial mechanisms may help to alleviate this, but central intervention may be required to deliver it.

GP Journal Club – Sunday 28th February 2016 at 20:00 GMT

The next GP Journal Club will be discussing the PLOS Medicine article: Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care by Douglas et al. You can download it here.

Yonder: Health checks, insomnia, nursing homes and spirituality

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

Health checks
The NHS Health Check programme has divided opinion ever since it was first launched in 2008. The idea of proactively checking and managing an individual’s vascular risk may seem sensible but the evidence about the effectiveness of this approach has been lacking and has led to much debate in the medical community in recent years. As part of a contract with general practices to deliver this programme in the North West of England, a team of researchers recently surveyed GPs and practice managers across 55 practices.1

Time and software were key barriers to implementation, and payments were considered insufficient to cover the considerable increase in nursing workload that was required. With fewer than half of respondents deeming the programme beneficial to their practice, the paper concludes that practices will need much more support from commissioners if the programme continues to run.

Insomnia is extremely common and the cause of enormous frustration for patients, families, and GPs alike. A recent UK-based study sought to understand more about the causes of this frustration by interviewing both patients and health professionals in primary care settings in Nottinghamshire and Lincolnshire.2 Clinicians focused more on treatments rather than insomnia itself and felt advice about sleep hygiene was often disregarded. GPs often colluded with patients to prescribe hypnotics to avoid confrontation, and cognitive behavioural therapy (CBT) was rarely considered, despite being a recognised management option. Patients, meanwhile, often used hypnotics in ways that were not intended and felt GPs focused too much on the underlying causes of the insomnia rather than the impact of it.

Improving undergraduate and postgraduate medical training, establishing a recognised primary care pathway including pharmacists and local mental health services, and increasing public awareness of non-pharmaceutical treatment options were all suggested as possible strategies by the study authors.

Nursing homes
Nursing home residents are typically extremely frail and often have multimorbidity, polypharmacy, and multiple, complex medical and social needs requiring difficult medical decisions to be made. In Sweden, much like in the UK, GPs are usually responsible for the care of individuals in this setting and a recent study sought to understand what Swedish GPs thought about this aspect of their work.3 They described a discordance between the demands from staff and the actual need of care for the individual patients. However, despite the challenges, working in this setting was considered important and meaningful, with GPs feeling confident in their ability to provide a holistic and balanced approach. A positive and continuous relationship with nursing colleagues was considered one of the key aspects of the job and central to ensuring the wellbeing of residents.

In recent years, spirituality has become an increasingly well-recognised aspect of wellbeing that should be addressed as part of a holistic healthcare approach — particularly, for example, at the end of life. Traditionally, hospital chaplains have been recognised as spiritual carers, although religion is just one of many ways individuals can experience spirituality. In order to assimilate current thinking about the role of the doctor in the discussion of spirituality, an Australian research team conducted a systematic literature review identifying 54 studies comprising 12 327 individuals.4 In the majority of studies, over half of participants thought it was appropriate for the doctor to enquire about spiritual needs. However, preferences were not straightforward and there was a mismatch in perception between patients and doctors about what constitutes this discussion and therefore whether it has actually taken place.

Although patients do not expect their doctor to be a spiritual adviser, they do want holistic care and strong doctor–patient relationships, and the authors suggest therefore that efforts should be made to identify those patients who would welcome such discussions.


1. Krska J, du Plessis R, Chellaswamy H (May, 2015) Views of practice managers and general practitioners on implementing NHS Health Checks. Prim Health Care Res Dev 20:1–8.
2. Davy Z, Middlemass J, Siriwardena AN (2015) Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study. Health Expect 18(5):1371–1383.
3. Bolmsjö BB, Strandberg EL, Midlöv P, Brorsson A (2015) ‘It is meaningful; I feel that I can make a difference’ — a qualitative study about GPs’ experiences of work at nursing homes in Sweden. BMC Fam Pract 16:111.
4. Best M, Butow P, Olver I (2015) Do patients want doctors to talk about spirituality? A systematic literature review. Patient Educ Couns 98(11):1320–1328.

GP Journal Club – January 2016

The first GP Journal Club is now on Storify. The paper discussed was Promoting physical activity in older people in general practice: ProAct65+ cluster randomised controlled trial by Illiffe et al and it can be downloaded here at

The next GP Journal Club will be in February – you can follow @GPjournalclub to find out more. Click here for the GP Journal club blogposts.

New on Twitter: the GP Journal Club

image1Lucy Pocock is an NIHR Academic Clinical Fellow in Primary Care and is on Twitter @drpoco

I have attended my fair share of journal clubs whilst a junior doctor in hospital jobs. However, as a GP trainee there has been little opportunity to read and discuss new and interesting research with peers. Whilst on maternity leave (looking for something to keep me entertained in the dead of night when I was feeding baby!), I discovered Twitter.

Initially I used it just to have a rant about the proposed changes to the junior doctors’ contract, but I began to see other, perhaps more educational, uses for it. I was introduced to the Geriatric Medicine Journal Club (@GeriMedJC) and the GIM Journal Club (@GIMJClub) and wondered if the same approach would work for primary care.

@GPJournalClub was born on 10th December 2015 and had over 100 followers in the first 24 hours; it seemed there was definitely an appetite! Thankfully, the nice folk at the BJGP have offered their support and so a blog about each month’s tweet chat will be hosted here, along with a link to the transcript of the chat afterwards. I hope that we can have a rotating chair each month, who will choose a recent, primary care related paper or guideline to discuss (please get in touch if you’re interested!).

The first tweet chat

Iliffe S, Kendrick D, Morris R, et al. Promoting physical activity in older people in general practice: ProAct65+ cluster randomised controlled trial. Br J Gen Pract 2015;65(640):e731-8.

The first tweet chat will take place on Sunday 10th January at 8pm. I have chosen the first paper ( and will be chairing the chat, along with Dr Liam Farrell from #irishmed. I have an interest in care of older people, so my choice reflects this.

I’m hoping that we can have a lively and engaging debate on Sunday, so please join us (search for #gpjc) and encourage all your colleagues to do the same.