Monthly Archives: July 2016

Brave New Medical World 2084

Des Spence

Des Spence

Des Spence is a GP in Maryhill, Glasgow.
Des Spence

sigarettaDeath has been banned and we will all live forever. Hurrah!

The medical profession has decreed that as long as we take all the necessary measures to avoid risk that we can live forever. Doctors through scientific research have established the major risk factors in life and the government is now seeking to tackle these under new legislation.

The most basic risk avoidance involves wearing a crash helmet at all times to avoid head injury. Suits developed by Michelin the French tyre makers will need to be worn to avoid possible damage from falls. Masks and sunblock will be worn outdoors and citizens will be banned from going outside during daylight hours to prevent UV sun damage.

Sport will be limited to tiddlywinks but visors must be worn to prevent eye damage. All trees will be cut down, bicycles, skate boards and hula hoops banned. Exercise is very important and from now on will be done passively using electrode stimulation to the various muscles groups at night-time.

Cars, planes, boats and trains are all overtly dangerous and should no longer be used. The activities of walking and running are currently the subject of ongoing research but should be limited to essential activities only. Mobile phones do cause cancer in bacteria research and can longer be used. The internet with all the inherent risk from spam, trolls and cyberbullying will be closed down. TV reduces activity in children and will longer be available.

Alcohol which has been associated with many risk-taking behaviours should not be consumed. Pubs and clubs will be shut to address the risk of passive smoking and the temptation to drink. Smoking (the greatest single evil known to humanity after sausages) will become a criminal offence. Sexual intercourse is now recognised to be inherently dangerous, associated with emotional changes and infections, and should be ceased. Although not currently deemed criminal behaviour it seems likely that laws will be passed in near future against the perpetrators of sexual activity. Those found taking cannabis, ecstasy, cocaine and heroin will be regarded as insane and detained under the Mental Health Act.

Dogs and cats will be removed from human areas for risk of allergic reactions. Prawns, eggs and peanuts control will be taken over by the Health and Safety Executive because of the extreme risk to health that they present. All mothers must exclusively breast feed until 15 years of age to prevent allergy.

Food will no longer become available because the dangers presented by salt, saturated fats, cheese, meat (BSE, E coli), sugary cereal, bananas, crisps and chocolate. Those citizens weak-minded enough to become fat will be sectioned under new powers in the Mental Health Act  because of the extreme risk to health. A new soup containing a balance of vitamins and calories will now become the new staple. This has been scientifically developed to contain no flavour.

All citizens from birth must take the multi-pill (statin, beta blocker, ACE inhibitor, sulphonylurea). Failure to comply will become a criminal offence. Finally, all work and school will be banned for fear of work related stress and bullying. The two medically approved activities are to be visiting the doctors to have your medical neurosis topped up and reading self-help books. Risk and all its dangers is banished. Thank goodness for the work of doctors.

Why have an operation if you can avoid one?

GAPhotoGeorge Ampat is a consultant orthopaedic surgeon hoping to help patients find non-surgical solutions.

Why have an operation if you can avoid one? It’s a simple question with an obvious answer but increasingly surgery is being used where it may not be necessary. There is a general consensus amongst the general public that surgery is a “fix all” solution; but, by and large, this is not the case. Unfortunately the onus of explaining the risks of surgical interventions and the potential lack of benefit following surgical intervention solely rests on the surgeon.

The Medical Director of NHS England, Sir Bruce Keogh, warned that as many as one in seven surgical procedures performed are unnecessary. Sir Bruce estimates that around 10 to 15% of NHS expenditure is on overuse of treatment, with a cost totaling upwards of £1.8 billion a year.1 With the NHS under increasing financial constraints, we cannot afford to continue overburdening it with unnecessary operative procedures.

The NHS has seen a number of successful campaigns with information dissipation, for example, promoting the need to stop prescribing of antibiotics for a cold.2 Why is there not a similar campaign to warn patients about the complications and adverse outcomes of surgical interventions? The onus of explaining potential complications of surgery and the potential lack of benefit is left entirely in the hands of the surgeon. This is not fair. A recent book by Professor Ian Harris, a Sydney orthopaedic surgeon and lecturer at the University of New South Wales, suggests that surgery is offered because it is generally accepted by the public as the best solution and therefore avoids patient complaints. Professor Harris goes as far as to suggest that surgery often serves as a “placebo effect”.3 It is possible, that to avoid similar complaints, surgeons in the UK, are forced by the public, to provide the option of surgical intervention, when it may not be necessary.

Poster1SSuccess of the campaign against prescribing antibiotics for common colds was only possible by educating both the public and the health professional.2 By following the same model posters promoting the need to avoid unnecessary surgery should be displayed in GP surgeries and hospital clinic waiting areas. This should mirror with an educational campaign among general practitioners to decrease referrals for surgical intervention. This joint campaign would relieve the NHS of a huge financial burden whilst ensuring patients do not have to undergo unnecessary surgical intervention.

Posters such as these (http://bit.ly/1U6hxnO) should be displayed publicly. This campaign is also likely to decrease the stress on a consultation where the surgeon is attempting to talk the patient out of surgery and the patient is wrongly assuming that this is a lesser choice in order to save costs etc.

References

1.     One in seven treatments not necessary. http://www.telegraph.co.uk/news/health/news/11733871/One-in-seven-treatments-not-necessary-warns-NHS-chief.html

2.     McNulty CA1, Cookson BD, Lewis MA. Education of healthcare professionals and the public. J Antimicrob Chemother. 2012 Jul;67 Suppl 1:i11-8

3.     The easiest way to satisfy people is to operate. Leading surgeon reveals doctors perform unnecessary surgery to stop patients complaining. http://www.dailymail.co.uk/news/article-3478578/The-easiest-way-satisfy-people-operate-leading-surgeon-reveals-doctors-perform-UNNECESSARY-surgery-stop-patients-complaining.html

The merits of time off from practice

Thuvaraka Ware

Thuvaraka Ware

Thuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.
Thuvaraka Ware

photo-1460398495418-62c9b5d79fbfAlthough we would otherwise think and hope it, there remains a culture within medicine that disincentivises time off for anything, from parental leave to sabbaticals. The reasons for this are myriad, from concerns about de-skilling to the fear of the unknown and coming off the conveyor belt of speciality training.

There is, of course, security and contentment in knowing where you are heading and following a chosen and well-trodden path, weathered by many before us. But what are we denying ourselves by racing to the end without exploring the diverse options available to us? Despite being a motivated, intelligent and compassionate workforce, with many transferable skills, it sometimes feels like our choices are limited.

During my maternity leave, I did not have the time to do much more than nurture my children, both of whom are intent on removing themselves from the gene pool in interesting ways. But the time away from clinical practice let me breathe, reflect on my career so far and derive meaning in my role as a doctor. I was able to explore ideas I would not have normally, like writing; I also got back to doing art, using skills developed during the warm haze of my grammar school years, but left languishing in some part of my mind not regularly used for analysing blood results and honing consultation skills. I optimised this period of reflection further by making use of a fantastic mentor, who helped me realise my strengths and the aspects of my work that gave me real satisfaction. On my return to the practice, I felt better able to direct my training with purpose and creativity.

I do not think that I would have achieved this without the time off, as the emotional and mental strain of work leaves little room for fanciful ideas at the end of each day. It is no surprise that the mental health of medics is one of the poorest of any professional in the country, as we so rarely give ourselves a break. Taking time off may be very useful to check in with our inner id, to ensure we are happy on the path we find ourselves – or give us a stimulus to find another one.

This experience has also spilled over into other aspects of my life. By feeling like I am doing something meaningful at work, I am able to take this personal sense of value and make the limited time I have with my family richer and more colourful. And the newfound purpose adds to the feeling that hopefully I will leave behind something grander and more significant, than the day to day tasks of reassurance, negotiation and docman reviews.

So be brave and take a break from work! Take pause and stock of your place in it all. You only get one chance at this and after all, as they say, its all about the journey.

Tasked based medicine and the generalist

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

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photo-1463171379579-3fdfb86d6285Perhaps I have had a run of bad experiences but I sometimes feel that our secondary care colleagues are beginning to act as technicians and not physicians, directing themselves to a particular task to rule in or rule out a particular diagnosis, and ignoring the fact that the patient is suffering from symptoms, not from a diagnosis. For instance, you may refer a patient complaining of acute onset shortness of breath to the medical team, querying a PE, to have them sent back to you with ‘no exertional desaturation, d-dimer negative, no evidence of PE’. So now you find yourself with a breathless patient who mere hours before was tantalisingly close to investigative possibilities that would have given you an explanation for their breathlessness, but who is now back in the community, still breathless, and as distant from those investigations as they were when they first came to you.

I don’t hold this against those working in secondary care, they are usually as swamped as we are, and they get given a task, get on with it, and then move on to deal with the mountain of other tasks awaiting them. But this task based approach to medicine makes for some very clunky and uncoordinated care for patients with complex or difficult to diagnose conditions. These patients can end up batting back and forth to the hospital being seen by different specialists in different specialties to get the investigations that they need.

It may just be the local guidelines and protocols where I work but I often feel that I make referrals simply to get a particular investigation done. Colonoscopy for example. There are certain patients who clearly need a colonoscopy, such as those with suspected inflammatory bowel disease. I can take the history, take the bloods, check the faecal calprotectin but then, at the final diagnostic hurdle, I have to refer, and so my patient will wait weeks to see either an SHO or a registrar in clinic who will take the history again, probably repeat the bloods, and then agree that they need a colonoscopy.

Part of the problem has been the inverted investment strategy of the last decade that has seen the number of hospital consultants increase at double the rate of GPs. This burgeoning cohort of consultants are sustained in purpose by the artificial rationing of investigations and the production of guidelines where every step is caveated with the advice to consider referring to a specialist.

Clearly resources are finite and we will always need appropriate stewardship of diagnostics but is this not best done at arms-length by specialists, rather than with face-to-face consultations?

In this month’s BJGP Sampson, Barbour and Wilson explore the use of email communication between primary and secondary care and their findings suggest that its use is patchy and limited.1 But should this not be the default means of accessing secondary care investigations for the majority of our patients? A brief email exchange between GP and specialist to guide and rationalise investigations is surely a far more effective use of everyone’s time and money than sending patients to have an outpatient appointment to have investigations arranged that could have been arranged weeks before?

This would enable GPs to do what they are supposed to do: provide holistic and co-ordinated care for their patients. It would also allow consultants to do what they are supposed to do: be consulted. There is some evidence that working in this way can cut the need for outpatient appointments by up to 50% in some specialties which would certainly ease the pressure on the whole system.2

As outlined in the same paper, there are some potential problems with email communication, particularly around the issue of confidentiality, but there are already systems in use around the country that have overcome these issues. Surely the use of these should be much more widespread.

NHS England’s Five Year Forward View has lofty ambitions of moving care back into the community. Allowing GPs much freer access to the full range of diagnostics will hugely facilitate this aim.

References

1. Sampson, Barbour, and Wilson. Email communication at the medical primary–secondary care interface: a qualitative exploration. Br J Gen Pract 2016 Jul; 66 (648)

2. Roland M, Everington J. Choose and Consult over Choose and Book. Health Serv J 21 Jan 2016

The blue pyjama brigade: primary care in Lesotho

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

IMG_2833Here at RCSI Bahrain our students wear blue scrubs to hospital attachments, but it’s a long time since I have been in scrubs. With some trepidation I had agreed to take four final year RCSI students to work for a fortnight in a small hospital in Lesotho.

Lesotho is a small mountainous nation, landlocked within South Africa. 40% of the population live on less than 1 US$ per day and almost a quarter of the adult population is HIV positive. You are 10 times more likely to die in an RTA than in the UK, and 50 times more likely to be murdered.

I had never been to Africa before. We landed at Johannesburg airport to meet up with a larger contingent from Action Ireland Trust (AIT), an Irish charity involved with development work in Africa. I drove our students across South Africa as part of the bigger party in in a convoy of mini vans. This is the one task I do feel prepared for – after the Middle East even driving in Africa feels OK. The hotel is interesting; nothing seems to work except my air conditioning, which sounds like a small lawnmower.

Together with an AIT doctor I am to supervise our students doing appropriate clinical work. RCSI goes out every year. The Lesotho Medical Council already has our details and copies of our documentation. The actual registration process normally happens on the first morning, when we attend in person with our passports and some cash. But this time the computer says no. Since the last visit the registration process has been “improved” with help from a grant from the EU. It took interventions from an Archbishop, an Ambassador and a government Minister to get us registered. My registration certificate from the Medical Council of Lesotho is now a treasured possession.

And so I became part of the blue pyjama brigade. Myself, my AIT medical colleague and our four students, resplendent in blue scrubs, descended on a small hospital some 30km from Lesotho’s capital, Maseru. The hospital serves a rural population of 200,000. Five GPs with nurse support provide 99% of the medical care for this population via the hospital and a handful of remote clinics. They run the hospital together with a fabulous Hospital Manager and a Nursing Officer.

In Bahrain 30% of the adult population has diabetes and these generate the chronic medical workload. In Lesotho it is HIV and its progeny, TB and PCP. We see new cases every day in packed open access clinics. We see Pott’s disease, TB lymphadenopathy, miliary TB, the list goes on. Having worked in South London I’ve seen many stabbings but now I see my first ever spear wounds (and more ordinary stabbings for good measure). Almost everyone is anaemic. We admit sick kids and serious adult pathology. We deal with broken bones and lacerations. The GPs look after the inpatients also – there is no one else. Only major surgical cases can be transported to Maseru. A close member of a hospital staff member’s family is murdered but she still turns up for work.

IMG_2485We drive to an outlying clinic. I thought the potholes on the main roads were bad, but now we are driving over unmade roads in the hills, eroded and rough. Driving across a ploughed field would be easier. Yet driving each day across the hills and plains of Lesotho is heart wrenchingly beautiful. Changing the inevitable flat tyre was not so beautiful. We were quickly surrounded by smiling faces and helping hands but the smiles disappeared when an unreasonable payment was demanded. I remembered the stabbings we had seen. We gave out some Rand and left quickly.

To say this was a humbling experience is a cliché, yet so true. General practice in the UK is well developed, stressful and increasingly dysfunctional. In Bahrain it is developing rapidly, it is stressful but functioning unencumbered by politicians and micromanagement. In Lesotho it is an immediate battle of life and death. Our five Lesotho colleagues are facing an unthinkable tide of pathology and trauma. Despite Alma Ata and the Millennium Development goals the inverse care law lives on.

Volunteering in the Calais ‘jungle’

calais and france 003

Niamh and Emily en route to Calais

Niamh Scally graduated from Norwich Medical School in 2013 and completed foundation training in Manchester. She is currently enjoying an F3 year before starting her paediatric training in London later this year. She has an interest in health inequalities and care of hard to reach groups.

Emily Player is a GP trainee on the Norwich VTS scheme. She graduated from Norwich Medical school in 2013 and has completed an academic foundation programme in Norwich. She has an interest in medical education and nutrition as well as migrant health and healthcare for vulnerable groups.

We are both junior doctors, feeling helpless and frustrated by the current refugee crisis we decided to travel to Calais to help in whatever way possible with this crisis on our doorstep. We used our annual leave and boarded the Eurostar for the one hour journey across the channel.

We arranged volunteering through the ‘Refugee First Aid and Support’ group on Facebook. We booked our accommodation in the local youth hostel where we met fellow volunteers, arranged lifts to camp and recruited more volunteers including student mental health nurses and dieticians to our medical team.

As undergraduates we had both volunteered in an orphanage in Kenya and later, on elective placements worked in developing countries providing healthcare at a basic level. Now we volunteer in France, there were no ‘grown ups’, and a distinct lack of authoritative presence, with the exception of the police vans which guard and intermittently blast tear gas across the camp.

The days go rapidly, like in the NHS there is not much time to drink or wee and for this we are grateful as we have seen the toilets. We mostly saw URTIs, wounds, scabies and were often confronted with the symptom ‘all over body pain’. We are still unsure if this is due to the cold and damp conditions people sleep in, the malnutrition, the fatigue from ‘trying’ all night or if it is somatisation of the mental pain they suffer everyday when contemplating their situation – this bottleneck they have arrived at here in Calais, twenty miles across the channel from their goal of a better life in the UK. ‘Trying’ itself is an incredibly dangerous activity; one refugee died ‘trying’ in the 5 days we were in Calais.

14259_0_supp_3_795wqtWe were seeing around 200 patients a day when all three caravans were up and running, which solely depends on volunteers. We referred a handful of patients a day to the Le Passe clinic; a service ran by the government hospital in Calais. MSF had been running a similar service until the beginning of March, when their contract expired and their main efforts were relocated to Dunkirk. Examples of cases we referred to Le Passe included febrile children, a non-weight bearing unaccompanied 16 year old child who incurred a police brutality injury, a head injury inflicted by a local fascist group that requiring suturing and a 65 year old Syrian man alone on the camp complaining of palpitations, clinically in AF with oxygen saturations of 88%.

As healthcare professionals along with the refugee’s working as translators we treat numerous tear gas injuries, the dietician was able to give advice on refeeding syndrome to refugees on a hunger strike and together we refer on average 10 unaccompanied children to the youth team a day. The youth team, also volunteers, ensures the children have food, shelter and phone credit, they offer emotional support and a safe place to be during the daytime. They also provide information on staying in France and seeking asylum or expediting their application to the UK as vulnerable minors.

We couldn’t comprehend that there are children alone in the camp; other volunteers reassure us that there are often elders and friends looking out for them, but this doesn’t reassure us, this situation is not normal for anyone let alone a child. It is not normal to run away from tear gas. They are incredibly vulnerable to exploitation. More must be done by the EU governments to ensure these children are being protected. As one of the translators eloquently put, “we are living in the jungle but we are not animals”.