Monthly Archives: May 2016

The importance of self care for GPs: tackling burnout through comedy

doctor in the house photo 2smallAhmed Z Kazmi is a doctor and stand-up comedian. If you would like to see his show ‘Doctor in the House’ he will be performing at Brighton Fringe 20-24th May 2016, Hollywood Fringe 19th-26th June 2016 and Edinburgh Fringe Festival 4-14th August 2016. For lots more information and to purchase tickets please go to www.doctorahmed.net

At my medical school interview I was asked what I did to relax, I remember thinking that was an odd question. My GP training curriculum included lectures entitled ‘How to avoid burn out’ and I remember sighing and rolling my eyes. It was not until I was in the role of qualified GP for some time that I started to feel a drain on my wellbeing. Then in 2015 my father died from cancer and I really struggled to remain the empathetic and attentive doctor I had prided myself on being. The presence of grief and mourning added an additional ball to the juggling act of clinical duties, professional development tasks, administrative tasks, family and friend obligations and the banal tasks of daily living, and I found myself struggling. I suddenly saw the relevance of the question asked of me at my medical school interview and the rationale for the lecture on burn.

I think it is fair to say general practice is a high intensity occupation. The high volume of patient contacts per day plus the short consultation duration coupled with often unrealistic patient expectations create a sense of panic and unrest during the working day. The relatively frequent rearrangement of service structure and health policy combined with a constant media flurry around the NHS and general practice can produce for many GPs a gloomy atmosphere within which to work. This environment was sadly a contributing factor in my decision to move from the UK in 2014 and practice in Australia.

As mentioned earlier, it was not until last year that the importance of non-academic outlets and self care became evident to me. I used to consider exams or diplomas or courses a leisurely parallel to my role as a GP. I loved to learn, enjoyed keeping up to date and saw an update course as a luxury activity. With social media being inundated constantly with healthcare politics I found myself almost totally unable to switch off from the job, even in my personal time,  and for the first time decided to temporarily reduce my working hours and take up a hobby unrelated to my vocation. But alas the apple never falls far from the tree. I decided to try my hand at stand up comedy (not after an unsuccessful attempts at becoming a pole dancer and instagrammer respectively) and quickly had to embrace that my work as a GP was in fact my largest source humour. I decided to make a stand up show about the funny side of being a doctor. I wished to create something that would be playful and entertaining whilst remaining respectful to patients and the profession. I took a few months to write and rehearse the cabaret comedy show ‘Doctor in the House; What your doctor really thinks’ and made my comedy debut at the Perth Fringe Festival in February 2016. All my shows sold out and I received positive reviews from critics, colleagues and spectators. I managed to raise over $5000 AUS for a local cancer charity from ticket sales and donations. In addition to this I used the show as a vehicle for some more serious subtexts including patient responsibility, cancer awareness and bereavement. Above all the experience did renew my empathy and interest in my vocation.

The experience taught me that even in this current climate we can create opportunities for fun and laughter around our work. It is all too easy to become stationary in a vehicle stuck in mud where the wheels are turning but the car is not moving forward. Several of my friends had hobbies during medical school: music, art, fitness but sadly these were made redundant as general practice and family pressures grew. I would encourage the reader to gently reflect on the following questions:

  1. Do you feel content at work?
  2. Do you feel you are nearing burn out?
  3. If you are content, well done, how can you ensure that continues? If not how might you address it?
  4. Think of one or two hobbies/interests/activities (big or small!) you would like to do more of or have never tried and would like to sample.
  5. Lastly think about how you might actually start to undertake the activity and create room for it in your life.

I am not suggesting everyone take a four month sabbatical and go on a world fringe festival tour of their solo stand-up comedy show… But I think now more than ever it is imperative for GPs to become good at self-care. Yoga? Swimming? Mindfulness meditations? Reduction in sessions? Cookery class? Or, yes, even stand-up comedy. What would you say to your patient in a similar position, need I say more!

Altmetrics at the BJGP: a beginner’s guide


Unsure about altmetrics? Check out this video, less than three minutes long, that will give you an introduction.

We’ve been using altmetrics at the BJGP for a while now. You can see them for each individual article by clicking on the ‘Info’ tab (as shown below).

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At the bottom of the Info tab is the altmetric information where the wider impact, beyond that of simple citations, of the article is represented in graphical form. For instance, here is the ‘donut’ for the article shown and you can click on it to visit its own Altmetric page.

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Desperately seeking Plato

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

file0001075296394We were in Athens with a couple of hours to kill. Acropolised out, too early for Ouzo. We had seen Socrates’ jail cell (almost certainly apocryphal).  We had seen the remains of Aristotle’s Lyceum, lovingly excavated. We had felt the weight of Pericles and the genius of Phidias. So we had a chance to check out an old rumour that the site of Plato’s academy was now marked only by a Texaco garage. (We had just found a Lidl on the site of the battle of Marathon, so who knows?) There it was on the map, “Plato’s Academy Archeological Park”, just a few miles out from the centre of Athens.

According to Alfred North Whitehead all philosophy is a series of footnotes to Plato. When my out of hours driver had been mind blown by the illusory world of “The Matrix”. I explained that this came from a two thousand year old thought experiment that we call Plato’s Cave. Suddenly my driver was interested in philosophy. Plato tackled the problems of perception and how we can (or cannot) know reality long before Descartes or Kant. He and a few mates created western thinking.

So we asked a taxi driver, gnarled as an ancient olive tree, to take us to Plato’s Academy. He looked confused. “But there’s nothing there.” We say that’s OK, we would just like to see the site and take some pictures. “Well, I haven’t been there for years” he said. We offer him our map, which he declines. We leave the tourist trail, driving through run down streets, the never ending layers of graffiti resembling Jackson Pollock’s stream of consciousness. A corner shop displays its stock of “Essex” washing powder, the finest goods on offer.

Unfortunately we have chosen a taxi driver straight from My Big Fat Greek Wedding. He explained all of Greek history with a running commentary on language and civilization, demonstrating exactly What The Greeks Did For Us, which by a remarkable coincidence turned out to be absolutely everything. Triangulating with what I already knew I reckoned about a third was approximately true, albeit exaggerated. We decided not to mention Lord Elgin.

We reached the area on the map. There was a post apocalyptic park of sorts. A couple of adjacent areas of worn and scrappy grass with a few dejected trees were surrounded by railings within what looked like a condemned South London Council Estate. We drove around randomly looking for something the driver recognized. There were no signs, no indication of an archeological site (surely the only square mile in Athens so deprived). The driver stopped to exchange enquiries with puzzled locals, none of who had ever heard of Plato and all of whom clearly wondered if we needed strong psychotropics.

We settled for jumping out of the taxi and taking random photos of the grass, concentrating on the occasional stone wall, which may or may not have been more than fifty years old. The driver became excited by some stone columns in a lock up yard, but on close inspection they were recent architectural salvage. However we found some overgrown stone ruins behind yet another fence, inaccessible and unlabeled. We declared these to be the ruins of Plato’s Academy, and duly photographed the hell out of them.

Driving off through the dystopian labyrinth we found a structure resembling a grey shipping container with the sign “Plato’s Academy Digital Museum”. It was locked. We walked round and found two elderly Greeks. “Come back tomorrow” they advised. A good suggestion except that by then we would be in France.

We drove back. So many shabby streets. We had not even found the Texaco garage. We heard more dodgy political theory than the whole of Plato’s Republic. How was it that this city, so full of ruins (and so full of itself) could not remember its greatest philosopher? We could find no trace of Plato. Not even a cave.

We sped back towards our hotel. Time for Ouzo and another view of the Acropolis.

Visit bjgp.org to find and read David’s series ‘An A-Z of medical philosophy’. 

The Joy of Diagnosis: how to attract candidates to general practice

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

file8841261948414Diagnosis is one of the most rewarding aspects of medicine and is one of the most attractive features of general practice.  There are few areas of medicine, arguably just general practice and the Emergency Department, where you get the opportunity to encounter a patient ‘fresh’, no prior history, no prior investigations, just you, the patient, and your clinical acumen. In general practice we often get the opportunity to make a diagnosis several times in the same ten minute period and, for me, the less investigating and referring I have to do to make a diagnosis the more satisfying it is.

I think this is an undervalued part of our job. An attempt to sell a career in general practice to medical students and junior doctors usually involves talk of holistic and continuous care, variety of work and variety of opportunity but rarely do you hear an emphasis on the pleasure of seeing droves of patients teeming with fresh pathology. True, much of the pathology is mundane, but then much of it really isn’t, and the enormous challenge in our job is recognising pathology in all fields of medicine, surgery, psychiatry, paediatrics and on, and on.

By far the bulk of medical diagnoses in this country must be made in general practice and yet it seems to me that we allow our thunder to be somewhat stolen by the physicians who set themselves up as the master diagnosticians and the keepers of arcane knowledge. Take the differences in the membership exams for the colleges of GPs and physicians as an example.

The MRCGP is an incredibly pragmatic exam, focusing on common conditions, current guidelines and safe management. It culminates in the clinical skills assessment which is run like a morning surgery but, as it uses actors for patients, features no real pathology. This is the one weakness in an otherwise excellent exam.

In contrast, the MRCP is an unashamed peacock of an exam that bears only the faintest resemblance to reality. I remember learning in great detail about the diagnosis and treatment of Waldenstrom’s macroglobulinemia in preparation for the first part of the written exam as the condition seemed to crop up over and over again in the mock exams. My new found knowledge made me feel all fired up to go out and diagnose my first patient. Then I discovered the incidence was between 2 and 6 per million and I find that, seven years on, I’m still waiting to make that diagnosis and I’m not quite so fired up.

The pinnacle of the MRCP exam is PACES in which there are several stations where you get six minutes to examine a single organ system of a patient in virtual silence. You are then given an opportunity to talk confidently to the examiners about an illness you have probably never seen before, and may well never see again.

In some ways the difference in emphasis is backward. I have never known a secondary care physician make a diagnosis without a battery of investigations to back it up, but it is rare for a GP to make a diagnosis without a heavy reliance on clinical acumen.

Clearly there is a balance to be struck. A detailed knowledge of weird and wonderful conditions can induce the paralysis of the differential when confronted with a strange array of symptoms, but the one advantage of the MRCP is that it forces candidates to trawl the wards looking for clinical signs and so it ensures that they become confident in hearing heart murmurs and tipping spleens in a way that the MRCGP doesn’t.

As guardians of NHS resources, is it not worth us ensuring that our new trainees feel more confident in clinical examination and less reliant on investigation? To this end, should the MRCGP have more emphasis on recognising real physical signs? I think that confidence in examination enhances the pleasure of diagnosis, and I think the pleasure of confidently making diagnoses should be at the fore of marketing our specialty to prospective candidates.

Escape to the Country: challenges of a migrant population for the rural GP

Version 2Bronwen Warner is an FY1 doctor at Oxford University Hospitals NHS Foundation Trust. She spent a month with Heilendi GP Practice in the Orkney Islands as part of her elective at Bristol Medical School.

Patients stumble into the waiting room, propelled by a passing icy squall raging outside. They are almost uniformly Caucasian, wearing warm, waterproof coats and practical shoes. But one speaks with a Cumbrian accent, and another clearly hails from the Home Counties; two more sound Scottish, but my gradually acclimatising ear picks up both a Glaswegian rumble and an Orcadian lilt.

What does a migrant population mean at your practice? Language barriers? Housing issues? Female genital mutilation? In my previous inner city Bristol practice, with its large Somali population, these overt problems were both rife and challenging. But the migrant community there was well-defined and easily identified: flowing burkas muffled under ill-matching quilted coats bought hastily in defence of the cruel and unfamiliar British weather could at least hint at the possibility and nature of any migration-related issues lying underneath.

In the Orkney Islands, the story is different. Patients may look the same and speak easy English, but there is a substantial migrant population with its own health issues. Of the 70 islands making up the Orkney archipelago, about 20 are inhabited.1 On average in 2012-2014, 751 people entered the Orkney Islands, with a net inflow of 86.2

Migrants to the Orkney Islands encounter a myriad of challenges. In addition to the usual logistical issues of registering at a new practice and waiting for transfer of notes, or struggling to agree a management plan for a longstanding condition with a new GP, patients face the further challenge of adjusting to new structures of healthcare provision. Here, the Out of Hours service in several of the Isles (the islands around mainland Orkney) is provided by a Nurse Practitioner, and all emergency transfers to hospital from outside the main island are done via boat or helicopter. The hospital has A&E, maternity and some outpatient services, but most specialties do not have a consultant resident on the islands and many ordinarily routine diagnostic and therapeutic procedures or consultant appointments take place in Aberdeen Royal Infirmary, necessitating a plane or seven hour ferry journey. The nearest ICU is in Glasgow.

The push-pull model of migration is well established: migrants seek a new home both to leave something behind and gain a better situation.3 GPs here agree on the prevalence of mental health issues. A number of patients have moved from ‘South’ to build a new life and escape from problems at home. However, many find the relative anonymity of city life a comfort blanket in contrast to the frank inquisitiveness of an island with a population numbering a few hundred, on which everybody knows everybody’s business. People can also find that the isolation from the friends and family they wished to escape is devastating, and struggle to cope without a supportive social network. The climate can also bring its own challenges: a dazzling sun bouncing off crashing waves through the long days of a summer holiday visit does not predict long dark winters and travel-impeding tumultuous winter storms.

For rural GPs, an understanding of the potential difficulties of a migrant population is vital to managing this patient group effectively. The conversation may be clear-cut, with new patients to a practice needing advice about the logistics of accessing healthcare in an unfamiliar rural setting. However, the scope for psychological issues, which may be longstanding or newly-brewed in an environment of failed adjustment, must not be underestimated. These factors might not always be frankly discussed, but should be at the back of the mind in every consultation.

It could also be worth, in a thriving suburban practice, having the discussion with your patient who is considering an ‘escape to the country’. Is he aware that his low grade non-Hodgkins lymphoma will not be monitored by a consultant a 20 minute drive away? Has she thought about how she will get to the shops in 10 years time when her now stable knees will not allow her to hop on and off the ferry to the mainland? Are they worried that a paediatric emergency in their new baby could necessitate an air transfer? Will his ‘escape’ destroy the inner demons of his depression?

Rural settings such as the beautiful Orkney Islands offer the opportunity for a healthy, active lifestyle in a stunning environment with multiple physical and psychological health benefits. Many migrants will be delighted with their choice of move and achieve the benefits they were hoping for. However, migrant populations in a rural practice bring new challenges to GPs – just as severe but less easily recognised than with an immigrant population from far afield. An awareness of these issues is vital to managing both expectations and problems if they arise. As one of the GPs in my Orkney practice commented, Folk come up here to get away from their problems, but they cannot get away from themselves.”

 

References

1.  The Scottish Islands Federation. Island statistics. 2001. [Accessed 21/4/16]. Available at http://www.scottish-islands-federation.co.uk/island-statistics/

2. National Records of Scotland. Orkney Islands Council Area – Demographic Factsheet. 2015. [Accessed on 20/4/16]. Available at http://www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/orkney-islands-factsheet.pdf

3. King, Russell. Theories and Typologies of Migration: An Overview and a Primer. Willy Brandt Series of Working Papers in International Migration and Ethnic Relations. Malmö Institute for Studies of Migration, Diversity and Welfare (MIM) Malmö University, 2012.

 

Googling symptoms: let’s do it together

Ahmed Rashid

Ahmed Rashid

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

The English Health Secretary, Jeremy Hunt, recently sparked anger when he suggested that parents could look online to determine the severity of their child’s rash. The medical community rightly rebuffed this firmly, highlighting the potential harm that could be caused, notably through the brilliant use of the #rashdecision hashtag on Twitter.

We know, though, that members of the public are increasingly using the internet to seek health information. The NHS Choices website, for example, reports over 15 million visits per month1. Although the pursuit of online medical information seems to be prevalent across all age groups including older people2, it is especially common in younger people, where prior consultation with a health professional before searching is particularly low.3

So, is there some masked truth in what Mr Hunt had to say? Will a time come when the internet can take the place of human clinicians?

A recent clinical encounter prompted me to think about this possibility. One of the joys of clinical practice, and in particular working in general practice, is the stimulation of facing regular diagnostic challenges. The patient, a young man, came to see me with a longstanding skin complaint that affected his feet. Having unsuccessfully searched for a diagnosis online, he was in despair. After examining him myself, I was as stumped as he was and suggested we gave the internet searching another try. His search terms had been “lumpy feet” or variations on that. Having examined his feet, I opted for a more focussed search using keywords “papules medial heel”. I quickly recognised the trusted PCDS (Primary Care Dermatology Society) website, which helped us jointly agree on the diagnosis of piezogenic pedal papules – small fatty herniations through fascial defects of the heels4.

So this means we need new, easier-to-use, online resources with lay terminology and better instructions. Right?

Perhaps we do. And perhaps during my working life, doctors’ roles as diagnosticians will start to diminish. For now though, my experience is that far more patients I meet have accessed inaccurate or alarmist information than those that have benefitted from valuable explanatory material. A recent evaluation of publicly available symptom checkers confirms that there are serious deficits in both diagnosis and triage5. For now then, I’m happy to continue working with my patients to work out how we can best use the technology together.

References

1. Gann B. Giving patients choice and control: health informatics on the patient journey. Yearb Med Inform 2012;7:70-3.
2. Luger TM, Houston TK, Suls J. Older adult experience of online diagnosis: results from a scenario-based think-aloud protocol. J Med Internet Res 2014;16:e16.
3. Powell J, Inglis N, Ronnie J, Large S. The characteristics and motivations of online health information seekers: cross-sectional survey and qualitative interview study. J Med Internet Res. 2011;13:e20.
4. Ma DL, Vano-Galvan S. Piezogenic pedal papules. CMAJ. 2013 Dec 10;185(18):E847.
5. Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. 2015 Jul 8;351:h3480.