Abstract
Transition to adult care
Over the years I have seen a variety of problems when children with long-term conditions transition to adult care. Lucy Watts gives a patient’s view of this and makes suggestions for how the process could be improved.
Watts L (2018) Stepping up to adult services. BMJ 362(8169) 412–413. DOI: 10.1136/bmj.k3886.
Physical examination
In our surgeries, as well as for the clinical skills assessment (CSA), we need slick and focused examinations that will identify pathology. I liked this one on shoulder examination. You could collect up your favourites and share around your training scheme.
Tovertafel
Our local library has a Tovertafel – a light activated table that can be used by any groups, for example people with dementia and their carers, to encourage interactive play and physical activity. As a registrar or as a locum it can be difficult to find out what assets are locally available. Social prescribing is becoming more popular, but is only as good as the local information available. Do you know how your practice or your area shares information about useful resources?
Thought-provoking
I find the writing of Atul Gawande very thought-provoking. He writes articles for the New Yorker, all of which are stimulating. I enjoyed reading the article on incremental care that discusses the quiet benefits we can give in primary care as opposed to the drama of solving life or death crises.
Gawande A (2017) The heroism of incremental care. Available from: www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care (accessed 18 June 2019).
Learning disabilities mortality review
People with learning difficulties die younger than their peers, even when other associated illnesses are taken into account. Because of this all deaths of people with learning difficulties are reported. Those where there are concerns about their care, or where further learning may be gained, receive a full multi-agency review. The most recent review (deaths in 2017) highlighted poor communication between agencies, gaps in care and lack of understanding of learning disability and of the Mental Health Act.
www.hqip.org.uk/wp-content/uploads/2018/05/LeDeR-annual-report-2016-2017-Final-6.pdf
Contraception and domestic violence
A UK-based case-control study showed that women exposed to domestic violence and abuse were more likely to have a consultation for emergency contraception. There are some lines of questioning that we often find difficult when we first start seeing patients. It might be worth thinking about how you do broach or might broach this topic
Jackson J, Lewis N, Feder G, et al. (2019) Exposure to domestic violence and abuse and consultations for emergency contraception: Nested case-control study in a UK primary care dataset. British Journal of General Practice 69(680): e199–e207. DOI: 10.3399/bjgp18X700277.
Network approach
The Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies mental disorders according to the symptoms that are the manifestation of the disorder (just as physical symptoms are a manifestation of physical disease).
The network approach to mental health problems views the illness as a system of causally related symptoms, so it is not the ‘mental disorder’ that provokes the symptoms, but that symptoms themselves provoke or reinforce other symptoms. This approach is summarised, with a helpful diagram, in a recent British Journal of General Practice article. Being able to focus on specific symptoms and triggers can help personalise the conversation with the patient, and perhaps help decide on some non-medical, as well as medical, treatments.
Bekhuis E, Hartman T, Boschloo L, et al. (2019) A new approach to psychopathology: The example of depression. British Journal of General Practice 69(680): 146–147. DOI: 10.3399/bjgp19X701717.
Updated pill guidance
The recent Faculty of Sexual and Reproductive Health updated guidance on combined hormonal contraception reminds us of the risks and benefits, including highlighting the increased effectiveness of long acting contraception.
The guidance now gives specific advice about shortening, or avoiding, gaps between pill packets. It explicitly recommends first prescriptions of a year (as opposed to 3 months) in duration. It acknowledges online consultations. You can download the document from the website. There is a brief summary and a section on ‘what should be done in a first consultation’.
www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/
Social media
The RCGP has launched a Social Media Highway Code. The authors have summarised the pros and cons of using social media and used the underlying principles of published guidance, including the GP curriculum and the General Medical Council guidance, as well as consultation with a wide range of people to produce a code. For each point of the code they have then given examples of where and how it might be used.
Low mood and cancer
I struggle with assessing mood in people who have cancer. I find it quite hard to decide whether someone is reasonably anxious about their diagnosis or has added depression. Two BMJ articles give suggestions for areas of questioning in the history, and a diagram showing the cognitive behavioural model of anxiety in the context of cancer.
Pitman A, Suleman S, Hyde N, et al. (2018) Exploring low mood in a person with cancer. BMJ 121–122. DOI: 10.1136/bmj.k1488.
Pitman A, Suleman S, Hyde N, et al. (2018) Depression and anxiety in patients with cancer. BMJ 361(8150): 116–120. DOI: 10.1136/bmj.k1415.
Health literacy
Health Education England has produced a toolkit to give ideas about communicating with people (face-to-face and in writing). It gives ideas about ‘teach back’ and ‘chunking’ information, which may help in consultations and be useful techniques to practice for the CSA. There is also advice about reading and testing information leaflets. You could work with your patient group on checking that your leaflets and website are accessible.
IMPART
The International Menopause Society has produced an online learning module on menopausal symptoms, long-term consequences of the menopause and advice about mid-life prevention (International Menopause Society Professional Activity for Refresher Training – IMPART). There is no charge to register and complete the course (you would need to be an associate member to print a certificate of completion, but guidance for appraisal makes it very clear that it is our learning that matters, not collection of certificates).
thebms.org.uk/education/impart-online-learning-for-health-care-professionals/
Non-attendance
Reading about mistakes and problems at other practices often prompts us to look at our own processes. A GP honestly shared the scrutiny his practice came under when a patient of theirs choked to death while detained under the Mental Health Act. A year previously the patient did not attend (DNA) a speech and therapy appointment. In this case, the practice had written to the patient offering a follow up with the GP – an outcome that the inquest regarded as a reasonable response. As a result, the practice audited its workflow processes for DNAs. Patients with severe mental illness were statistically significantly more likely to DNA, so the practice has instigated a policy of additional effort to contact vulnerable patients, including those with severe mental illness, when they DNA hospital appointments.
Martin P (2019) Coroner inquest into ‘hospital non-attendance’ management in primary care. British Journal of General Practice 69(681): 195. DOI: 10.3399/bjgp19X701993.
Brain tumours
I think we all worry about missing serious pathology. I think it is worth reading the full text of a recent British Journal of General Practice article describing the subtle physical and cognitive symptoms described by a group of adults recently diagnosed with brain tumours. The most common were changes in cognition and problems with sleep, often noticed more by family members. The article gives a number of quotes from patients with clear descriptions of unusual ‘soft’ symptoms.
Walter F, Penfold C, Joannides A, et al. (2019) Missed opportunities for diagnosing brain tumours in primary care: A qualitative study of patient experiences. British Journal of General Practice 69(681): e224–e235. DOI: 10.3399/bjgp19X701861.