Author Archives: BJGP Blog

About BJGP Blog

The British Journal of General Practice is an international journal publishing research, debate and analysis, and clinical guidance for family practitioners and primary care researchers worldwide. The BJGP Blog brings opinion to research and clinical practice.

Arclight: a new ophthalmoscope and otoscope

John PorterJohn Porter recently completed his GP training and is enjoying living in Bath and working as a salaried GP in Bristol.

There are items of equipment without which a GP in clinic cannot function. Top of this list comes a stethoscope. Closely followed by an ophthalmoscope or otoscope.

As I neared the end of GP specialist training the time was nearing to hand back the practice supplied equipment and to put a hand in my pocket and buy an ophthalmoscope/otoscope of my own. A few hundred pounds, this tends to be the most expensive item needed to get started after training.

With my credit card about to take the hit I got talking to a friend who had returned from working as a doctor in Uganda and was continuing to use a novel ophthalmoscope/otoscope designed for use in developing world environments in his work as a NHS hospital doctor.

After giving it a once over my initial impression was that the Arclight device worked well. (www.arclightscope.com). I could see the benefits the novel lightweight device would have when used in areas of the world where its inexpensive price and the lack of need for batteries is an advantage, and wondered if it also had a place in the bags of GPs in the UK.

Out of personal interest in low cost and innovative technology I acquired and distributed 36 devices to both qualified GPs and final year trainees to find out more (mean clinical experience was 11 years).

I started with questionnaires to gain insight into what GPs thought of their current kit. What I found was that the vast majority of GPs who took part used their ophthalmoscope between 5 to 10 times per week. Their confidence in ophthalmoscopy using their regular devices was 6.4/10 (mean), with a range of 4/10 to 9/10 (1 being no confidence and 10 being very confident). In otoscopy confidence was 7.8/10 (mean) and ranged from 6/10 to 10/10. Problems with batteries and bulbs, being cumbersome to take on visits and expense were widely shared complaints.

Arclight devices were trialled in clinics for 6 weeks. End questionnaires found confidence in ophthalmoscopy using Arclight scopes was 6.9/10 (mean), a range from 3/10 to 9/10. Confidence in using the Arclight scope for otoscopy was 8.1/10 (mean) and ranged from 6/10 to 10/10.

Users found that the Arclight scope’s light weight and small size was beneficial to them in general practice, as were the bright LED lights which were found to stay consistency bright. Suggestions for improvements in the device included making USB charging less fiddly and improving the stability of the otoscope ear pieces when fitted. 75% of users said they would continue using this device after this trial and 92% would recommend the device to a friend.

Outcome

It would appear that the Arclight ophthalmoscope and otoscope device would be very welcome in GP bags (and I would anticipate around the necks of hospital doctors and medical students).

Interestingly I found user confidence with the Arclight scope better than that reported from the traditionally used more expensive and cumbersome devices without their frequently encountered battery and bulb problems.

Dr John W Porter, GP, Kingswood Health Centre, Bristol & Dr Keir EJ Philip, Core Medical Trainee, Barts Health NHS Trust.

Of note neither I nor my friend Keir Philip have interest invested financially or otherwise in Arclight ophthalmoscope/otoscope devices, we’re just intrigued by this sort of thing!

Top 10 most read BJGP research articles published in 2016

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from bjgp.org in 2016.

1. Overdiagnosis of asthma in children in primary care: a retrospective analysis. 
http://bjgp.org/content/66/644/e152

Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.

2. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. 
http://bjgp.org/content/66/644/e214

Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

3. Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study.
http://bjgp.org/content/66/644/e207

Prognostic uncertainty remains an important driver of health care professionals’ antibiotic prescribing. Experience and training in recognising severe respiratory tract infections (RTIs), together with more evidence to help professionals identify the children at risk of future illness deterioration, may support identification of the children most and least likely to benefit from antibiotics.

4. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study.
http://bjgp.org/content/66/649/e531

This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.

5. Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey.
http://bjgp.org/content/66/650/e674

Most of the childcare providers’ sickness policies contain requirements that are inconsistent with Public Health England guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit.

6. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study.
http://bjgp.org/content/66/643/e71

Among people aged 16–40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the Mood Disorder Questionnaire to be a useful supplement to non-standardised questioning.

7. Identifying depression among adolescents using three key questions: a validation study in primary care.
http://bjgp.org/content/66/643/e65

Depression in teenagers can have serious consequences and the incidence seems to be increasing. Three short questions, suitable for use in general practice, are useful for identifying depression in adolescents in primary health care.

8. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.
http://bjgp.org/content/66/643/e114

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.

9. Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England.
http://bjgp.org/content/66/642/e1

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, less than 10% of those who drink excessively report having received advice on their alcohol consumption.

10. Molluscum contagiosum and associations with atopic eczema in children: a retrospective longitudinal study in primary care.
http://bjgp.org/content/66/642/e53

Consultations for molluscum contagiosum in primary care are common, especially in 1–9-year-olds, but they declined significantly during the decade under study. A primary care diagnosis of atopic eczema is associated with an increased risk of a subsequent primary care diagnosis of molluscum contagiosum.

 

Child & Adolescent Mental Health Problems – Twitter Journal Club

img_4397Carrie Ladd is a part time NHS GP, a spare time RCGP Clinical Fellow in Perinatal Mental Health and a full time mum… doing overtime! You can find her on Twitter @LaddCar and she has a website.

On Sunday 28th November, Dr Lucy Pocock and I co-hosted a session of the Twitter based journal club #gpjc to discuss one of the emerging priority areas of General Practice – Child and Young People’s Mental Health. The BJGP paper we discussed was a systematic review of primary care practitioner’s perceptions to barriers in managing these problems. All contributors seemed to agree that GPs are seeing more and more cases of mental health problems in adolescents but there was some debate as to whether this piece taught us anything new about the challenges we face in supporting these young people.screen-shot-2016-12-05-at-14-36-21

The themes identified in this review as ‘barriers’ were familiar to those joining the discussion and they are in common with most other mental health sub-specialities. Fear of judgement or stigma may limit disclosure, concerns over confidentiality may limit discussion and lack of referral options locally may restrict what help is available. This review also highlighted a lack of confidence in GPs themselves recognising childhood mental health problems and this may prove a springboard piece of work to address this unmet need in the near future.

This was a large systematic review covering 4151 articles in initial stages with 43 being looked at in detail – 30 quantitative and 13 qualitative. The articles were from a range of countries and one of the points in our discussion questioned whether this undermined or strengthened the validity of the results. Although Australia and Ireland could be seen to have similar health systems/ socioeconomic factors to the UK, perhaps South Africa and Puerto Rico less so? Also many of these studies were not specifically GPs but paediatrics as well which is important to be aware of.

In the final section of the discussion, we looked at how we can mitigate these barriers and collaboration seemed a key theme. Several people suggested better lines of communication with our mental health colleagues. Quarterly MDTs between psychiatry/CMHT & the GP practice, Psychiatry colleagues spending a day a week in General Practice is being done in one innovative GP surgery. In another great example of collaborative working, a specialist eating disorder therapist is based in a predominantly University Population Bristol based GP practice.

Finally, close of discussion included signposting to the RCGP Mental Health Toolkit which is available free, open access to all and mention of Young Minds and MindEd resources which are well worth a look up if new to you. The conversation continued after the scheduled hour and the 10 minute consultation model was cast aside as not fit for purpose when a patient comes to talk about mental health problems with longer appointments welcomed by the #gpjc group.

It is clear that from the GPs who joined the discussions on Sunday, this is an area of general practice we could do better, and we need to galvanise interest and support for a society wide movement to raise awareness and prompt further investment in Child and Young People’s Mental Health services.

If you haven’t popped over on a Sunday evening, check out @GPjournalclub for their monthly discussion group – see you there.

Obituary for St James Church Surgery: the death of a practice

St James Church Surgery 1987-2016:
the demise of small General Practices

A personal celebration and lament

David Zigmond

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Small general practices used to be very common and mostly popular. Yet due to healthcare policies they are now increasingly rare and almost extinct. What are we losing? This is a portrait, in words and photos, of a recently closed practice.

St James Church in Bermondsey, London served as an NHS General Practice for nearly thirty years. Its closure, in August 2016, was forced by rapidly tightening regulations about working premises and practices.

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Until its demise, this small practice retained an uncompromising ethos centred around the kind of personal continuity of care that can come only from personal contacts, relationships and understandings. Early on in my stewardship – as the Principal GP – I thought that this kind of human matrix was best assured by a small, traditionally modelled family-doctor practice with a low turnover of clinical and reception staff: such a compact, stable nucleus can be far more personally manoeuvrable and responsive, than can be managed in larger practices. Yet, paradoxically, this ethos has become countercultural and, eventually, untenable.

A small but significant example: the staff decided not to have the now prevalent automated telephone greeting and ushering devices. Instead, the telephone was always answered by a friendly receptionist: voices became known, recognised and matched to the face of the patient later arriving, and be personally greeted, at Reception. Fragments of data and stories could then make larger, human wholes; personal understandings grew organically; quiet bonds of affection offered comfort, containment and support. Therapeutic influence often started with the receptionist.

Such subtle human interactions are impossible with automated devices and algorithms – yet now, almost everywhere – the cybernetic is inexorably driving out the humans.

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In these last twenty years the culture of the NHS has – despite ubiquitous and reassuring soundbites – moved away from such responsive humanity and into rigid systems managed by corporatism and industrialisation. Despite this difficult and increasing organisational estrangement, the surgery at St James consistently managed to harbour exceptionally good patient and staff experience, loyalty and safety. So this small practice survived as a bright, but doomed, island-beacon of traditional humanistic healthcare perched perilously above a rising ocean-tide of institutional depersonalisation. Eventually the tide rose faster than we could erect defences: in particular we could not cope with, or afford, the vast and ratcheting demands of compliance legislation.

Despite popular support and the very evident real-life excellence of this surgery it was deemed, by non-negotiable procedures of the Care Quality Commission (CQC), to be too anomalous for their vouch-safety. The decision to summarily close the practice in 2016 was dramatic in its emphasis and decisiveness: you can read about this in Death by Documentation1 and The Doctor is Out2.Meanwhile, do peruse these pictures of our much-loved practice: the container for so much, and so many kinds of, humanity and its vicissitudes; a conduit for so many life-events, poignant encounters and their guided supports.

As you take an imaginary wander around this once very alive, now deceased, workspace you can see easily how little the physical ambience of this clinical service resembled its more contemporary purpose-built peers. This was both fortuitous and deliberate: august spaces were filled with bright, warm colours, soft comfortable furnishings, hangings of expressionist and impressionist art, humanly crafted objects from natural materials. More typical ‘clinical’ objects, surfaces, instruments, notices and accoutrements were mostly relegated to the background, though always with convenient accessibility.

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All humanly constructed environments also convey meta-messages about values, roles or expectations. The ambience at St James said: Healthcare is a humanity guided by science; that humanity is an art and an ethos. The now prevalent, and certainly more approved, practices of modernity seem to say: Healthcare is a science administered by our regulated experts. Wait quietly.

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What effect did this have? Well, our staff and I drew much pleasure, comfort and enlivenment from our libidinal surroundings, just as the sensually aware homeowner does. Very significantly, patients would often express this too: “It’s so lovely coming in this room, it always cheers me”, or “I feel better and calmer already, just sitting here, doc…” were typical of hundreds of appreciations I heard over the years. Such exchanges fuelled our wish to come into work each morning.

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NHS management bodies took a very different view. Eventually the CQC would – with Olympian judgement and resolve – pre-empt any further contention over personal preference v institutional prescription: the Practice was closed by legal (Magistrates) Order. In their evidence the CQC cited previous official assessments – over several years – recurrently showing miscellaneous failures of compliance to the increasing regulations across a wide range: disabled access and facilities, documented checks of fire exits and my own (non) criminal record…

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But what of the real-life evidence? Of enormous patient and staff popularity and loyalty, excellent care and the remarkable lack of complaints, litigation, untoward events or deaths, staff sickness or accidents. These counted not at all. Nor did the power of patient choice: there were many, evidently compliant, neighbourhood practices eager to recruit but emphatically declined. Nor was heed paid to the fact that many of the regulations were far more suited to large airport-like practices with their much greater staff and patient turnover and anonymity: these made little sense for our small practice. This plea was deemed inadmissible.

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A longer view shows that the portents for such inevitable ‘constructive decommissioning’ had been gathering for many years. A decade ago we were forewarned by a lesser-powered inspectorate: you can read about it in Planning, Reform and the Need for Live Human Sacrifices3. In more recent years NHS financial plans, too, were designed for the unlikely survival of small practices.

So, St James Church Surgery – with its rich local history of human engagements, affections and memories – was finally closed by legal mandate. The fact of its long and exceptional popularity was deemed an irrelevant inconvenience. But the questions raised by this elimination are with us always: What do other people want and need? How do we (think we) know? Who decides, and how?

And more ordinarily: when you go to see a doctor what kind of space, greeting and dialogue do you wish for?

The photos of the home of this affectionately-held centre are only of the space itself: to avoid any issues of confidentiality I have not pictured the people that vitalised the place. As in the best medical consultations, we often have to imagine those crucial, though absent, others.

I hope this small gallery, in memoriam, will not only preserve cherished memories: for the future it can help generate larger questions about the complexity of what we wish for, how we jeopardise these things, and how, instead, we may secure them.

Understanding the erasure of this old, traditional bastion of family-doctoring can help fuel what should be an endless debate. How do we discern between change and progress?

—–0—–

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References

  1. Death by Documentation. The penalty for corporate non-compliance. David Zigmond (2016)
  2. ‘The Doctor is Out’, The Observer, 18.9.16
  3. Planning, Reform and the Need for Live, Human Sacrifices. Homogeny and hegemony as symbols of progress. David Zigmond (2006)

1 and 3 are available via David’s Home Page: http://marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm

Note
If you want to read more about how these kinds of questions were answered for many years at St James (and many of the better small practices), the anthology If You Want Good Personal Healthcare See a Vet: Industrialised humanity. Why and how should we care for one another? David Zigmond (2015), New Gnosis (available from Amazon), explores these themes.

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com.

The Do-It-Yourself ‘Package of Care’

liam-piggottLiam Piggott qualified from St. George’s Hospital, and completed his GP training in Brighton. He works as an out of hours and urgent care GP, and is pursuing surgical training.

As an out of hours GP, nothing can be more soothing to hear than the words “package of care”.

Think of the setting, the very familiar crisis of a long-widowed frail patient, living up until now independently, who tips over edge following a UTI, fall or similar event. Often in their late 80s, with no family nearby, who by product of their generation would not readily ask for, or accept, help. Typically, the patient doesn’t require a hospital admission, and is quick to tell you they do not want to be admitted if possible. If you are lucky, a call to a community assessment team, be it a nurse-led crisis team or rapid response service, leads to “thank you Dr Piggott, we will call around and assess the patient today and arrange a package of care”. I can say from repeated experiences locally to where I work, these services are excellent. They typically include an urgent home assessment and provision of carers and/or night sitters, and following on from this input from social workers, occupational therapists, physiotherapists and district nurses if required. Seeing the patient as I do, usually as a one-off encounter, it’s difficult to follow the journey the patient takes after this is, in regaining independence and wellbeing as far as possible.

This lead me to reflect on the very personal experiences over the last two to three years of older relatives that nearby to me, and yes, I did ask their permission prior to writing this article. The relative in question, after a good old bout of urosepsis, found in himself very much in the above situation. Incidentally, he had a nephrectomy in 1947 – I wonder if he was one of the first patients on the NHS to have had this operation? Moving on, the above mechanism for his home care worked smoothly and quickly, and a flurry of activity lead to our new favourite term; a “package of care”.

But what interested me were not just the clinical aspects of what my relatives immediately required, but what helped them, over a very long period of time, to reach a quality of life and level of independence they had previously enjoyed. They had effectively arranged a “do it yourself” package of care. There are so many things in our day to day lives that we take for vantage. Things so simple and second nature, we don’t even think about them, or perhaps until we are unable to do them. The immediate ones are obvious; cooking, cleaning, using the toilet. But how about clearing a garden, going to the dentist, or withdrawing money from a bank?

Slowly but surely, and with a little help along the way, they began to construct and arrange ways of returning to their independence. A neighbour recommended a trusted gardener, who even took my them to a hospital appointment (not bad, for £10 an hour). The Parish magazine directed them towards a chiropodist who would visit them at home. A friend suggested a local lady who did hairdressing in customer’s homes. In time, they had these, and a window cleaner, a coffee morning group, an odd job man and a visiting community optician for good measure. Once the acute illness had resolved, these almost invisible community services and networks restored their confidence and enjoyment of life. They certainly now have a more active social life than me.

Oh, and what of the author, this heroic young doctor ? Well; he takes the bins out every Thursday night.

Brexit and statins: a tale of scepticism

christien-fortune-headshotChristien Fortune is a final year medical student at The University of Manchester and has interests in cardiology and medical education.

In the fabled land of post-June 23rd Britain and Northern Ireland, politics in the UK has been understandably dominated by the UK’s decision to exit the European Union. Vote Leave’s successful campaign, in part, utilised the public’s deep seated suspicion of the juggernaut that is the multinational political union of the European Union; one that in the eyes of the “Brexiteers” yielded little benefit despite its large cost to the UK. What was remarkable was the resonation of Leave’s message with the older population; according to YouGov poll over 64% of over-65s voted to leave the EU.1 The merits of EU membership can be debated until the end of time, but something which is unequivocally clear is that the older generation, in general, did not want to be part of the EU.1

As a casual observer of the UK political scene and avid viewer of the BBC programme, Question Time, I couldn’t help seeing striking parallels between the public attitude towards the EU and another juggernaut, this time of the pharmacological variety. To understand the aspersions surrounding statins is bewildering; at the time of writing, a Cochrane review of 19 studies assessing the value of statins in the primary prevention of cardiovascular disease revealed a marked reduction in all-cause mortality, major vascular events and revascularisation.2 Objectively, it seems unmistakably clear that statins have a major role to play in preventing our cardiovascular disease-baiting, overweight country. Unfortunately, the very nature of opinion does not lie in objectivity. In my admittedly limited experience, I have found a sizeable number of older patients sceptical about the benefits of statins. In broad agreement with my anecdotes, a study looking at adherence in secondary disease prevention for coronary artery disease in a US population revealed that consistent use of lipid-lowering therapy was 44%.3 The US does have other financial factors which will play a role in adherence, however, I’m sure that for certain healthcare professionals, this message will sound familiar. It is interesting that in the case of both the European Union and statins, scepticism seems to be the default setting of the UK’s older generation. Why is it that for a demographic, we (either Remain or medical professionals, take your pick) fail to convince them of a benefit which may be inconspicuous?

Although the older generation’s relationship with statins doesn’t pose quite as bigger problem to the future of our economy as the Referendum result will, it does still have important ramifications to an individual’s cardiovascular-related mortality. A failure to address the unhealthy relationship in those who are wary about the effects of statins has the potential to detrimentally affect the very lives we seek to care for. In a Scottish population, those who were compliant with statin use were more likely to have had the consequences of hyperlipidaemia emphasised.4 Tolmie et al also highlighted the need to a regular addressing of any concerns patients may have in order to prevent patients discontinuing medication without letting their doctor know.4 At the same time, there has to be some serious PR to promote the undoubted benefits of statins in the appropriate cohorts.

Interestingly enough, as was the case in the referendum, a major stumbling block in convincing the public about the benefits of their respective causes is the work of the tabloids. In a 15-day period, the Daily Mail published articles on their website with the following titles, “Statins ‘may be waste of time’…”,5 “Millions of people may be needlessly taking statins every day…”6 and “Don’t give up your statins…”.7 This startling contradiction indicates the type of mixed messages that the public is being told; it is unreasonable to expect the general public to be able critically analyse the underlying research and human nature means that the take home message will be the title in bold above the text. Naturally, this type of journalism creates the perfect conditions to promote widespread reservations about statin use. Therefore, it is up to healthcare professionals to combat the seeds of doubt surrounding statin use and provide a clear and coherent message about the advantage of using statins.

Now, the ship may have sailed across the Channel with respect to the UK’s membership but its sister ship containing some positivity about statins is still in the docks, albeit with increasingly frayed moorings. As doctors, we need to make sure that we shore up the public’s trust in statins; it is, of course, in their interest and that is something that it is easy to overlook.

References

1. Moore P. How Britain Voted. YouGov 2016 [Available from: https://yougov.co.uk/news/2016/06/27/how-britain-voted/.
2. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013(1):CD004816.
3. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113(2):203-12.
4. Tolmie EP, Lindsay GM, Kerr SM, Brown MR, Ford I, Gaw A. Patients’ Perspectives on Statin Therapy for Treatment of Hypercholesterolaemia: A Qualitative Study. European Journal of Cardiovascular Nursing. 2003;2(2):141-9.
5. Spencer B. Statins ‘may be a waste of time’: Controversial report claims there’s NO link between ‘bad cholesterol’ and heart disease. Daily Mail. 13 June 2016.
6. Spencer B. Millions of people may be needlessly taking statins every day: Study claims lowering cholesterol may NOT slash heart attack risk. Daily Mail. 20 June 2016.
7. Spencer B. Don’t give up your statins: Experts say warnings that made patients stop taking vital drug have put lives at risk. Daily Mail. 28 June 2016.

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

Volunteering in the Calais ‘jungle’

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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”.

‘An eye for an eye makes the whole world blind’ – reflections on working with Syrian refugees

image Nikesh Parekh

Dr Nikesh Parekh

Nikesh Parekh is a GP trainee, a research fellow in ageing and part-time public health medical associate in London. Colin Tourle is a semi-retired GP in Hailsham.

There are 1.5 million Syrian refugees in Lebanon, of which the vast majority are hidden away in camps near the Syrian border. These are some of the most impoverished victims of the war in Syria, who lack the financial resource to travel further afield for safety.

With the support of Iasis medical charity (www.iasis.org.uk), we were privileged to travel to three refugee camps within a mile of the Syrian border in Lebanon’s Bekaa Valley to provide medical clinics.

The camps encompass vast swathes of land with back to back tents. Word would spread that doctors have come to offer free help and before long a mass of people, usually 75% women and children, would be gathered outside eager to be seen. Crowd control was nothing short of the chaos at a sporting event! It was hard seeing children queuing outside a dust filled tent waiting for us to see them when one could only feel they should be playing in a garden somewhere with a football or trampoline.

We had never quite anticipated how varied the presentations might be, from the expected urine and skin infections, to eczema, to renal stones, to muscle pains, to hypoglycaemic episode, to a likely bone malignancy. Recognising the likely bone cancer in a 7-year old boy was particularly moving. This child needed a haematologist and costly intervention. How on earth will this really happen – where is there a specialist hospital unit? Will the Lebanese doctor discriminate against the Syrian? Who will transport the child back and forth? Who will cover the costs? Who will look after the immunocompromised child if chemotherapy is the treatment of choicer? Is it too late anyway? These were all the kinds of questions one reflects on, and the unknowns are heart breaking.

Making a diagnosis is always a game of probability, but never really more so than in this resource limited setting, where health literacy of patients was minimal and gathering a good history was challenging even with translators. Attention was often diverted onto their painful stories of loss and despair in this prolonged war with no end in sight. The refugees just want to go back to Syria, the land where they grew up, where they had a living, where they had good memories with their families and friends, and where they were individuals as opposed to ‘refugees’. They certainly do not want to make a trip to Europe as far as possible.

Various pressures were on us and it is emotionally, physically and logistically intense – seeing as many people as wanted to be seen, being in a completely unfamiliar clinical setting where the concept of privacy in a medical consultation is non-existent, knowing that unless someone is life-threateningly ill you wanted to avoid hospital because patients knew that it was chargeable and would be reluctant to go. No one has money, and dignity is dying out fast.

There were some just excited by the opportunity to see some new faces in their camp. We knew they were not sick and they knew they were not sick but we accepted this and made a non-verbal deal; We would examine them and show off the stethoscope and they wouldn’t spend too long pretending to have a problem with every organ system. These sorts of cases made us both reflect on a question one inevitably has at the back of their mind but we didn’t dare ask for fear of the answer – how much of a medical difference am I truly making? – but we realised that we don’t need to answer this question because there was no doubt that the presence of a doctor to show care and provide reassurance without asking for anything in return was worth gold. It gave back some dignity, reminded these innocent victims that they are humans and that the world cares for them. They are not forgotten despite their isolation behind white plastic tent sheets labeled with the blue, bold letters ‘UNHCR’.

Next GP Journal Club is Sunday 3rd July at 8pm: migraine and CV disease in women

image1The next GP Journal Club will be discussing the BMJ paper:

Migraine and risk of cardiovascular disease in women: prospective cohort study by Kurth et al. 

You can download it here.

Migraine occurs in 15% of the UK adult population and is three times more common in women. This large cohort study from the US suggests that female migraine sufferers are at increased risk of experiencing cardiovascular events. What will this mean for those of us in primary care who have responsibility for managing cardiovascular risk? Should we be advising all female migraine sufferers to take a statin, for instance?

Please read the article and consider your response to the following questions, which will form the basis of our discussion:

  1. Was their PPI strategy appropriate? Would the study have benefited from more patient involvement?
  2. Elevated cholesterol and hypertension were treated as binary variables, is this acceptable
  3. 15.2% of the women reported a diagnosis of migraine at baseline. Is this what you would expect if the cohort was representative?
  4. Does it surprise you that the effects of migraine weren’t modified by other factors such as hypertension and smoking?
  5. Based on this study, should we be paying more attention to assessment of migraine sufferers’ CV risk?

Hope to see you all on Twitter next Sunday at 8pm.

Lucy Pocock