Author Archives: Jonny Coates

Jonny Coates

About Jonny Coates

Jonny Coates is one of the First5 GPs that’s not in Australia. He works in Newcastle upon Tyne.

Shared medical appointments: better by the dozen

Jonny Coates

Jonny Coates

Jonny Coates is one of the First5 GPs that’s not in Australia.He works in Newcastle upon Tyne.
Jonny Coates

file0001900347815A great deal of medicine is education.  The title ‘doctor’ is derived from the Latin word for teacher.

Before getting that title, I spent three years working as a TEFL (Teaching English as a Foreign Language) teacher: first in Spain, and then with VSO in Eritrea. I’m no expert educationalist; but I learnt enough to see that a 1:1 interaction is often not the best way to impart complex information.

In general practice, I see patients exclusively on a 1:1 basis, in short 10 minute bursts. I have to explain and discuss difficult concepts, and am often left frustrated that I can’t do this justice in a rushed 10 minute consultation. Many of my patients share this frustration.

It’s all the more frustrating, because I often have almost-identical conversations (let’s say lifestyle change in diabetes) numerous times each week, with different patients. I’ve often wished I could have all those patients sat together, and instead of delivering six sub-optimal 10 minute explanations, I could spend an hour doing it really properly, and have more in-depth discussion.

But the increased time we’d have wouldn’t be the only advantage. What I learnt from teaching – whether it was classes of 8 businessmen in Barcelona, or 80 school students in Eritrea – is that learning in groups provides the opportunity to learn from each other; for ‘horizontal’ as well as ‘vertical’ (top-down) learning. It is active learning: the concepts are brought alive through being discussed.

So when I read about ‘shared medical appointments’ on the RCGP Bright Ideas website it rang a whole heap of bells. Here was a way of consulting that sits between the 1:1 appointment and a group education session (where a teacher addresses the group, but only as a group, not individually).

And so, I wrote to Rob Lawson, the article’s author, who set up a group of like-minded clinicians.  Now, a few months down the line, we’ve tried them in our practice.

We invited patients to have their COPD reviews in a group.  Patients were seen in the waiting room, on a Saturday morning. They were given refreshments on arrival, and signed a confidentiality agreement. The practice nurse and pharmacist collected key data: FEV1, their MRC dyspnoea score, smoking status and sats, and put all this information on a white board.  Then I came in, and proceeded to consult with each patient in turn.

The nurse facilitated these conversations, directing me and other patients as appropriate. When an issue came up that had relevance for numerous patients (as it invariably did – smoking, spacers, nebulisers, inhaler technique, pulmonary rehab, rescue packs) I spent longer discussing it, often using the whiteboard for explanations. Other patients with relevant experience chipped in.

Patients really liked it, evidenced by their evaluations (see below), but more importantly, by the practice grapevine – conversations with receptionsts, overheard things in the waiting room. A common refrain was how much they’d learnt, and how good it was to know that other people were in the same boat. The appointments themselves felt warm and supportive, and there were lots of laughs; a breath of fresh air for us clinicians.

 

evaluation-image

Some great things happened, during and after the appointments:

We had an unprecedented uptake in pulmonary rehab classes. Like many practices in deprived areas, we’ve previously had very low uptake in these classes (and the same is true for DESMOND for diabetes). There was some great peer-peer learning and motivation: a patient saying how good they feel for stopping smoking/doing exercise/using a spacer is much more powerful than me as a doctor saying it. Connections formed between patients – e.g. two patients who previously didn’t know each other, but walked home from the appointment together, and agreed to give pulmonary rehab a try together.

Patients got answers to questions they didn’t want to ask themselves. For example, a patient raised panic attacks in the context of COPD: we know these are a big issue for patients with respiratory disease but it’s often not raised by either patients or doctors. We were able to go into this in detail, and it was clear that this resonated with many other people in the group. This was extremely powerful in normalising what they were going through, and how to seek help. There were challenges of course, mainly logistical: space (we can’t use the waiting room during the week), staff time, recall systems. These are surmountable, but need thought if we are to extend the use of these consultations. In terms of resource, we expect that these should be at least cost neutral (compared to current ways of working) once we get teething problems out of the way.

Our biggest concern as clinicians before doing these, was confidentiality. However, in common with the experience of other countries, patients didn’t raise any concerns about this. We only discussed things that patients themselves volunteered, so the patients were in control of what was disclosed. In fact patients were surprisingly candid.

Where next? We plan to continue piloting these, and diversify into other disease areas. Diabetes and childhood asthma/eczema are the next areas we’re trying, and I’d like to try them in chronic pain in the future. Elsewhere, they have been used for a huge variety of conditions (acute and chronic), with great success.

If you are a clinician interested in finding out more, or trying these for yourself, the UK SMAC group now has 40 members from primary and secondary care. We are holding a meeting in Sheffield in October, and new members are welcome. If you are interested, please get in touch by leaving a comment, or by emailing Rob Lawson, the secretary of the UKSMAC group: roblawson@core-health.com.

This milk tastes sour: cows’ milk allergy and industry-sponsored disease creep

jcJonny Coates is one of the First5 GPs that’s not in Australia.  He works in Newcastle upon Tyne.

Hospitals are awash with Pharma freebies. CCU is littered with the logo of the latest statin, the psychiatrist’s pen bears the name of the latest modified-release SNRI, and the chest clinic post-it notes are adorned with inhaler brands.

The paediatric ward is slightly different though. Just as the rest of the hospital is branded by Big Pharma, the paeds ward is branded by ‘Big Formula’. The logos on the pens and lanyards of the paediatricians, and the adverts filling their journals, are all for formula milk brands.

And the formula companies are now hungrily eyeing up primary care.  At a recent CCG educational event, our local paediatric immunologist gave a talk on cows’ milk allergy (CMA) in children.   We were handed glossy, branded copies of the MAP (Milk Allergy in Primary Care) Guideline.  We were offered “free” courses to study for a diploma, courtesy of the ever-beneficent formula companies.

According to the guideline, a diagnosis of CMA should be considered if a child has “one, or often more than one” of the following symptoms:

  1. Colic.
  2. Vomiting, ‘reflux’, GORD.
  3. Food refusal or aversion.
  4. Loose or frequent stools.
  5. Perianal redness.
  6. Constipation.
  7. Abdominal discomfort.
  8. Blood/mucus in stools of an otherwise well infant.
  9. Pruritis/erythema. Significant atopic eczema.
  10. ‘Catarrhal’ upper airways symptoms.

Remember: “One, or often more than one” of these.

I had my third child 10 months ago. She has had many of these symptoms fairly frequently. As did both of my other children. In fact, I would find it extremely hard to find any child who doesn’t have “one, or more than one” among the many children I see each day in surgery. They are all extremely common symptoms in infancy.

Most of these children with mild symptoms don’t ever come onto our radar as clinicians, as parents correctly realise that they are part of normal childhood. However, since the companies are now marketing their products directly to patients through websites (www.isitcowsmilkallergy.co.uk), TV adverts (here) and newspaper articles (more GP-bashing from the Daily Mail), I suspect we will be seeing much more of it. We are at great risk of medicalising normal infancy.

Financial links to a variety of milk manufacturers, including Mead Johnson Nutrition and Danone, have been disclosed by authors, as outlined in a 2013 BMJ article. Mead Johnson Nutrition are the very people behind my glossy handout, and the website and TV ads outlined above. This has echoes of the recent scandal around dementia screening, when campaigns to increase diagnosis turned out to have been funded by a drug company with a new product to sell (discussed here by Margaret McCartney).

I do not doubt for a moment that CMA exists, and I do not doubt that it makes some infants very ill. I do not doubt that specialised formula milk is an excellent treatment for these children.  I have seen and treated cases myself (both during my paediatric jobs and as a GP): of babies becoming very unwell due to CMA, and making a remarkable improvement with the correct milk.

I do however, have significant concerns about GPs being asked to diagnose and treat CMA on the basis of this low-threshold diagnostic guideline, which is promoted by milk manufacturers, and whose authors are paid by those very same companies.

Worst of all, these companies are marketing directly to patients to drum up business.

This is industry-sponsored disease creep, and we should be questioning it much further before accepting it.

 

This article is crossposted from Jonny’s own blog: https://jonnycoates.wordpress.com/2016/02/17/this-milk-tastes-sour/

Update 30th March. In response to feedback this blog was edited to remove a reference to the MAP guideline being funded by milk manufacturers. This was an error: the guideline itself was not funded by industry.