Category Archives: Clinical

Self discovery with an ankle fracture

Kate Dawson is a full-time remote and rural ​GP on the Isle of Benbecula in the Outer Hebrides.

At our staff night out, I slipped on a wet dance-floor, and in a moment, fell and became a patient. I couldn’t put any weight on my foot, and my ankle swelled dramatically. As a consequence, I have learned a lot about myself, our systems, my colleagues, and about being a patient.

Our practice manager showed the most clinical acumen, and provided paracetamol and an icepack. The party continued as I watched from the side-lines,

I was on duty in A&E in our community hospital two days later and arranged for my ankle to be x-rayed. I knew there was something up when the radiologist asked me how much my ankle hurt; I had walked into the department, having done a full surgery. She confirmed that I had a comminuted fracture of my right ankle, in the run-up to Christmas, a time of year when medical locums are hard to find. I had an air-cast boot and crutches provided by the A&E nurse, and continued to the ward-round.

Three weeks later, the swelling was down but the orthopaedic surgeon was not happy, and I was admitted for open reduction and fixation in the Western Isles Hospital, adding another few weeks onto my recovery.

Firstly, I had no idea how much hard work it was using crutches. I had no problems with the co-ordination, but the strength required to walk more than ten yards is significant. My hands hurt, my shoulders were cramping up and my gluteal muscles had to learn how to balance me on my good leg. It took me quite a while to get to grips with this.

Secondly, my sisters both broke their wrists, and we have been able to compare notes about progress, the advice we were given and the progress we have made. It led me to examine the information and support we give to patients with common wrist and ankle fractures. The information that we have is quite brief, and focuses only on plaster care. Between the three of us, we have written four patient information leaflets, which are now being reviewed by a patient panel, plaster technicians, orthopaedic surgeons and physiotherapists. The aim is to adopt this board-wide.

The physios are very keen to be able to provide support with walking aids, exercises and treatment plans much earlier. We are meeting to discuss how we improve the pathway for patients with musculoskeletal injuries.

I am prone to doing everything myself, and I had to learn to ask for help.

Thirdly, the kindness that I experienced first-hand from colleagues and patients alike was wonderful. I am prone to doing everything myself, and I had to learn to ask for help. There is an art to this, making sure that your wishes are clearly expressed and the need for action described. Our wonderful practice manager rearranged the rota to cover my two weeks ‘resting’ with my leg up post-op, colleagues and locums all stepped up to fill the gaps.

Fourthly, I have learned that slowing down doesn’t mean that I do less. Instead of rushing around, sorting out everything in a whirl, I must plan my route through the day to take into account lifts, locations and tasks to be done. I have successfully ‘reabled’ myself by buying aids online, unbelievably cheaply, and remained independent where possible.

Lastly, this experience of being a patient has also illustrated very clearly how my agenda as a patient can be reframed by a few wise and confident words from a fellow professional. The orthopaedic surgeons and physiotherapists knew exactly how to motivate me into doing the right things, with good direct communication.

In exchange for a broken ankle, I have found my practice team to be kind and resilient, and I have developed the arts of patience, planning and delegation. I have started the improvement of the care that we offer patients with MKS limb injuries, anticipating better outcomes in the future.  My focus on good consulting skills is going through another cycle of improvement, and the cat is pleased too; I am sitting down more, and my lap is available more often.

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!

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.

Medicine in an Age of Empires

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 by clarita at Morguefile.com

I recently attended a talk at the hospital post-graduate centre where the speaker introduced herself as the hospital’s new ‘heart failure consultant’ rather than the new cardiologist. This set me thinking, as many things do, about the strange nature of secondary care medicine. Single organ specialisation is now a thing of the past, apparently our hospital based colleagues are best employed dealing with single problems of single organs. Many of the same thoughts occurred to me when I listened to a lipid specialist describe the difficult and technical differentiation of familial hypercholesterolaemia from poly-genic hypercholesterolaemia in patients with a cholesterol of 8. They all ended up on statins by the way, and they did very well.

This degree of sub-specialisation has, of course, big knock on implications for the way we deliver care in general practice. If, as a hospital consultant, you establish yourself as the lead for a niche service then you really have to tout yourself as the best person to be dealing with that particular problem, perhaps even the only person who should be dealing with that problem. If you want to spend your time looking after malfunctioning left little toes then you need to tell everybody else to leave the left little toes to you because they simply won’t do a decent job of it. Here, guidelines are key. Guidelines are both the supply route and the fortification of all the little medical empires that spring up all around us.

For me this is the best explanation for all the guidelines that at some early and arbitrary point advise that the GP ‘consider referral’. At this point many of us will obediently refer to the specialist only to find that the specialist almost immediately loses interest in the patient and passes them on to his team of specialist nurses who then efficiently steamroller the patient along a single issue algorithm. The single organ’s single problem is often dealt with wonderfully well but how often is the patient left at the end of it feeling slightly bewildered and taking a handful of tablets every day that they don’t really understand?

Perhaps this is all well and good. While the new service functions it allows us to unload all our left little toe problems to the hospital but, about thirty seconds after its launch, the new left little toe service will almost certainly be swamped by GPs following the guidelines. Suddenly our patients are waiting an age to receive treatment that we really could deliver ourselves. But there is a new problem now because, if something goes wrong, we’re left defending a decision not to refer to our specialist when the guidelines told us that we should have done.

At this point the guidelines are no longer an aid to us but they serve only as a length of medico-legal rope with which GPs can be hanged. Disempowered by the guidelines that tell us to refer, we are left either not providing standard treatments for our patients or facing the risk that, if something goes wrong, we could end up in hot water.

In circumstances like this it is good to ask Cui Bono? And not just because saying stuff in Latin makes you seem frightfully bright. This fragmentation of care often seems to be to the detriment of the patient and it can certainly make it harder for us to take management decisions. Sometimes the greatest benefit is to the consultants in maintaining their role as guardians of their own niches.

If we are to achieve the shift of patient care back into the community then guidelines should be written with a view to helping the generalist and not the specialist, and written by people who understand what it is to be a generalist. I could go further and suggest that we should stop funding consultant led services whose practice can be boiled down to a single A4 sized flow chart and spend more of our precious money on generalists both in and out of the hospital.

You’re the Doctor

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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When a patient says ‘you’re the doctor’ it can mean several things. Sometimes it means ‘I trust you and the advice you’ve given me’, sometimes it means ‘I don’t like what you’re saying but I don’t feel like I’m in a position to argue’, and sometimes it means ‘just get on with it and do what you’ve got to do’.

Whatever it means when a patient says this, it always feels like a kick in the teeth to me. Since my first day at medical school, the day on which I underwent my Balint lobotomy, I’ve been told to be patient centred. I’ve been taught that there really are no doctors and patients just symbiotic, therapeutic alliances from which mutually agreed treatment plans will emerge.

So when a patient tells me that I’m the doctor I feel like they’re not playing the game. When a patient says this, my inner consulter screams, ‘No! I’ve handed over to you now, just like Roger Neighbour told me to, we need to share this decision like Pendleton suggested, and then we’re going to modify your health seeking behaviours like Stott and Davies wanted’. But an astonishing number of my patients haven’t read any of Neighbour’s work. Even fewer seem to be familiar with the Cambridge-Calgary model, which may explain why some of them don’t seem to get in when I’m ‘closing the session’ and seem instead to want to talk about more problems.

A recent BMJ article, written by a patient, talked about this experience from the other side. The author spoke of feeling bemused and uncomfortable when her GP asked her questions like ‘what do you think is wrong?’ or ‘what do you think we should do about this?. Interestingly, the author found the relentless pursuit of her ‘ideas, concerns, and expectations’ was actually damaging to the therapeutic relationship as it resulted in her losing faith in her doctor.

This is unsettling but not surprising news. The fact that a number of patients simply want to be treated as a patient is obvious to us all from everyday practice. Many people simply want to be told what’s wrong with them and what to do to make it better.

There is an assumption in medical education that this dynamic, the one in which the doctor is in control, comes naturally to all doctors and so doesn’t need to be taught. But even if this type of consultation does come naturally to many doctors, we spend years of training disempowering doctors from taking on an authoritative role in a consultation by punishing them every time they do so in an exam situation.

The current paradigm for the medical consultation is heavily weighted towards eliciting ideas, concerns and expectations, and the MRCGP clinical skills assessment mark scheme reflects this. This encourages rigid adherence to consultation models so that the appropriate boxes can be ticked on the mark scheme. And this can be really detrimental to the natural communication skills that many doctors already possess, turning them from instinctive consulters to consulting play actors.

Articles such as that in the BMJ are evidence that we need to ensure that our doctors can consult flexibly, are able to recognise different consultation dynamics, and are able to be the doctor when that is what the patient wants them to be.

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

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

Latest posts by Adam Staten (see all)

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

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

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.

Casting down the pseudo-religion of clinical examination

Des Spence

Des Spence

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

file3371281797656The glass bounced off my back and smashed into the drinks gantry shattering a whisky bottle. All I remember is the glass, the blood and that terrible screaming. Glass fights are dangerous, especially as barman, and for $1.80 an hour I often wondered if it was worth it. But it had its compensations for it was the best practical module on communication skills I ever had and I have used my experiences everyday of my medical career. Teaching undergraduates for the last 10 years I have enjoyed regaling them with my ‘pub communication’ stories.

I am convinced of the value of teaching communication skills but what of the scared cow, clinical examination? I was taught by rote – rigid application of clinical skills – inspection, palpation, auscultation and percussion. I was humiliated for not hearing split heart sounds, ridiculed for missing bronchial breathing, scolded for not saying “ninety-ninety” instead of “one-one-one” and I was laughed at for missing a breech presentation.

My objection is not that many of my tutors had a charisma bypass nor their dissocial personality disorders, my issue is that most of what they taught me to be unquestionable ‘fact’ was in reality complete nonsense. I will go further, not only were most of the clinical signs utterly worthless but many are downright dangerous.

How many times have I heard creps at the lung bases and in good faith organized a chest x-ray only for this to be reported 16 weeks later as being normal? I wonder about the times clinical examination has falsely reassured me leading to a delay in diagnosis – to my shame I can think of a few. The real unquestionable fact is that clinical examination is neither sensitive nor specific and devoid of any quantifiable predictive value of disease. Let’s be honest, most of clinical examination is merely the pseudo-religious ceremony of medicine passed down from our distant pagan healer ancestors.

I am, however, forced to pass these dark arts onto the next generation of unsuspecting doctors (secretly I subvert the students but please don’t tell my university). Even the iconic stethoscope is in reality little more than a simple stage prop used by insecure junior doctors who lack the gravitas to convince patients that they are doctors.

It is time for the unbearable and unthinkable but we must cast down the false deity that is clinical examination. In the new dawn light we should take the few worthwhile glittering gems from clinical examination but ditch the rest. Instead, let us teach students about health seeking behaviour, dealing with uncertainty and how to rationally investigate and manage common presenting symptoms. This might end the modern tsunami approach to investigations whose huge yield of minor incidental findings then burst and flood out the NHS outpatients. This might actually help prevent the rampant health neurosis that we as a profession are thoughtlessly inflicting on our poor patients.

Please, put your tumblers down for one last moment as I have a final point of heresy. Ultrasound is cheap, quick and easy, so why don’t we teach students to use an ultrasound probe? This could be used in many different clinical situations but I guess it might be heavy to wear round the neck! All I remember is the glass, the blood and that terrible screaming.