Tag Archives: GP Journal Club

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.

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

GP Journal Club: the primary care–secondary care battleground

Sampson R, Barbour R and Wilson P. The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study. BMC Fam Pract 2016. 17:(1): 1-12

The next GP Journal Club is on the 8th May at 8pm. You can download the paper here.

image1Rammya Mathew is an academic GP at UCL and is chairing the next GP Journal Club.

Sampson et al have done a fantastic job of characterising the somewhat strained relationships that exist across the primary care-secondary care interface. On reading the paper, I couldn’t help but feel that so much of the narrative rings true of my own experiences on the frontline. I am well aware of the difficulties we face in primary care and how it can sometimes feel as though we are on the battlefield with our hospital colleagues. However, we often fail to realise that they have their own frustrations regarding our working practices, and whilst we are both seeing the situation from our own perspectives, it is indeed the patient who becomes the victim of unintended combat.

I find it incomprehensible that we are supposedly working together for our patients, but at the same time, we struggle to pick up the phone and talk to each other. There have been times when I have patiently listened to an automated switchboard message for a whole three and a half minutes in the middle of a busy morning surgery, only to then be greeted by the glaring beep of an ominous dead tone. But what if our hospital colleagues want to speak to us – between jam-packed surgeries that are sandwiched with home visits, when do we make ourselves available to them? With an ever increasing workload, it sometimes seems unimaginable that we might be able to create the time and/or space required to enable meaningful dialogue between primary and secondary care.

In my experience, working together breeds a great sense of satisfaction but there are certain do’s and don’t, which have to be respected. I’m sure that on both sides of the fence, we are cautious of not allowing our egos to get in the way of good patient care. But when does integrated working and shared care overstep the mark and quite frankly become ‘dumping’? Recently, there has been a growing sense of frustration in primary care at the ‘GP to chase’ rhetoric, which plagues hospital discharge summaries and outpatient clinic letters. This prompted the following response on Twitter:

‘Hospital docs please, respectfully etc, note difference between GP and labrador’.

It feels like one-way traffic in general practice, but the truth is that our hospital colleagues feel equally dumped on by us. I can certainly hold my hands up and say that there have been times when I have been unable to handle the uncertainty and I have fired off a half-hearted referral, just to ease the pressure and share the load. I wouldn’t for a second blame the doctor at the receiving end for bemoaning my actions. The sad reality is that despite all the gatekeeping we do in general practice, we sometimes get it wrong and make ‘inappropriate’ referrals; when hospital wards and clinics are bursting at the seams, its unsurprising that this is greeted with great dissatisfaction. It seems as though, whilst we are sinking, we get unhelpfully defensive and look to point the finger at each another. It sometimes feels as though we purposely close our eyes to each others’ plight, just as a means of survival.

So how do we join forces on the battleground? It may sound simplistic but perhaps we need to spend more time in each others kingdoms. At the very least it would engrain reasonable expectations of what the other can do. As GPs we gain invaluable experience of hospital medicine during our training years. On the other hand, there are specialists who have never set foot in general practice, beyond undergraduate level training. This leads to misunderstandings about workload and archaic views of what GPs do. As professionals, we stand to gain a lot by coming together. Namely, respect and understanding. But if we truly succeed in breaking down institutional divides, it will be our patients who reap the benefits of holistic interdisciplinary care.

Collaborative working is of growing importance in the face of an ageing population and rising multi-morbidity, but the way in which we practice now just doesn’t allow for it. In recent years our focus in primary care has been on improving access, but some speculate as to whether this has just perpetuated spiralling demand. Every day, minor ailments walk through my door that would have resolved without any input from a GP. I sometimes feel as though we are seeing more and more patients at the expense of providing holistic and coordinated care for those who most need it. It is clear that we need to to invest in the primary care-secondary care interface for the sake of these patients, but what can we safely stop doing in order to make this happen?

Join us for the @GPJournalclub discussion at 8pm on the 8th May to discuss this paper and to explore the primary care–secondary care interface in more depth.

Feel free to leave suggestions for questions on the night – tweet me @RammyaMathew, or leave a reply in the comments box.

GP Journal Club – April 2016

The April GP Journal Club is now on Storify.

The paper discussed was: Lorgeril M, Rabaeus M. Beyond confusion and controversy, can we evaluate the real efficacy and safety of cholesterol-lowering with statins? JCBMR 2016;1(1):67

The next GP Journal Club will be in May – you can follow @GPjournalclub and #gpjc on Twitter. Click here for the GP Journal club blogposts.

GP Journal Club 28th February 2016 – Bariatric surgery in the NHS

Paper: Douglas IJ, Bhaskaran K, Batterham RL, Smeeth L. Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care. PLoS Med. 2015 Dec 22;12(12):e1001925.

Link: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001925

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP and is chairing the next #gpjc. @Dr_A_Rashid

Obesity is a public health issue and not a general practice one. Right?

I’ve recently had the good fortune to have talked about obesity with two wise and experienced GPs who held quite differing opinions on this. Although they were both in agreement that it is a serious and growing problem, one felt it was predominantly a social problem with solutions in policy and government whilst the other thought it a more clinical problem with solutions in the consultation room and NHS more broadly.

Although the social causes of obesity are unquestionable and the need for policy change is clear, the already alarming rates of obesity and related diseases mean that we probably need solutions across the spectrum. Weight loss surgery is a concept that often divides opinion amongst clinicians and patients alike. However, it has become an important aspect of obesity management in recent years and is now an established discipline across various specialist centres in the UK. Although the results of bariatric surgery RCTs have been promising, we know that trial findings are not always replicated in routine clinical practice. This month’s paper is a UK observational study that investigated whether there is an association between bariatric surgery and weight, BMI, and obesity-related co-morbidities.

As well as the focus on obesity and related diseases and the relevance to GPs involved in commissioning bariatric surgery services, the paper is also of interest because of the use of the Clinical Practice Research Datalink (CPRD) – an increasingly important research service in UK primary care.

I hope you can join us for the Twitter chat at 8pm on 28th February 2016. Please don’t forget to include the #gpjc hashtag in all tweets. Below are the 5 questions that we’ll be generally basing the chat around but please feel free to raise other points that come to mind when reading the paper.

  1. Was it appropriate to use the CPRD to answer this question? (Are there other data sources that could have been used?)
  2. Were all of the clinical outcomes relevant? (Which are the most important?)
  3. Are you surprised by the speed of weight reduction?
  4. Was it acceptable to use discontinuation of medication as a definition of T2DM and HTN resolution in the absence of HbA1c and BP measurements?
  5. Should NHS thresholds for bariatric surgery be changed?

GP Journal Club – Sunday 28th February 2016 at 20:00 GMT

The next GP Journal Club will be discussing the PLOS Medicine article: Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care by Douglas et al. You can download it here.

GP Journal Club – January 2016

The first GP Journal Club is now on Storify. The paper discussed was Promoting physical activity in older people in general practice: ProAct65+ cluster randomised controlled trial by Illiffe et al and it can be downloaded here at bjgp.org.

The next GP Journal Club will be in February – you can follow @GPjournalclub to find out more. Click here for the GP Journal club blogposts.

New on Twitter: the GP Journal Club

image1Lucy Pocock is an NIHR Academic Clinical Fellow in Primary Care and is on Twitter @drpoco

I have attended my fair share of journal clubs whilst a junior doctor in hospital jobs. However, as a GP trainee there has been little opportunity to read and discuss new and interesting research with peers. Whilst on maternity leave (looking for something to keep me entertained in the dead of night when I was feeding baby!), I discovered Twitter.

Initially I used it just to have a rant about the proposed changes to the junior doctors’ contract, but I began to see other, perhaps more educational, uses for it. I was introduced to the Geriatric Medicine Journal Club (@GeriMedJC) and the GIM Journal Club (@GIMJClub) and wondered if the same approach would work for primary care.

@GPJournalClub was born on 10th December 2015 and had over 100 followers in the first 24 hours; it seemed there was definitely an appetite! Thankfully, the nice folk at the BJGP have offered their support and so a blog about each month’s tweet chat will be hosted here, along with a link to the transcript of the chat afterwards. I hope that we can have a rotating chair each month, who will choose a recent, primary care related paper or guideline to discuss (please get in touch if you’re interested!).

The first tweet chat

Iliffe S, Kendrick D, Morris R, et al. Promoting physical activity in older people in general practice: ProAct65+ cluster randomised controlled trial. Br J Gen Pract 2015;65(640):e731-8.

The first tweet chat will take place on Sunday 10th January at 8pm. I have chosen the first paper (http://bjgp.org/content/65/640/e731) and will be chairing the chat, along with Dr Liam Farrell from #irishmed. I have an interest in care of older people, so my choice reflects this.

I’m hoping that we can have a lively and engaging debate on Sunday, so please join us (search for #gpjc) and encourage all your colleagues to do the same.