InnovAiT 2008 1(1):2-3; doi:10.1093/innovait/inm021
© The Author 2008. Published by Oxford University Press on behalf of the RCGP. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.
News & Views
Dr Rodger C Charlton
General Practitioner & Associate Clinical Professor, Warwick Medical School & Honorary Editor, RCGP Publications
E-mail: rodger.charlton{at}warwick.ac.uk
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Future global healthcare crisis
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Professor Barbara Starfield of the John Hopkins University,
Baltimore has written a thought-provoking commentary in the
latest edition of the
Journal of the American Board of Family Medicine 20:511–2, entitled Global Health, Equity, and
Primary Care. She describes the global challenge to primary
care and general practice of ageing populations and so more
of what she refers to as ‘multimorbidity’. There
is an increasing likelihood of survival from acute manifestations
of disease and that the costs of care will grow with increasing
availability of technological interventions. She says that "World
organisations of primary care physicians need to take up the
challenge before it becomes a crisis". She describes the approach
to organising services using the disease-by-disease orientations
as becoming increasingly dysfunctional. She writes: "Multimorbidity
is demanding not "chronic disease" management but, rather, a
chronic care model in which person-focused primary care is the
key element." This is particularly poignant given the jointly
written editorial in the College journal from July; "Continuity
of personal relationships is one of the most important distinguishing
characteristics of general practice. It is at the expense of
general practice that the new GMS contract fragments primary
care into reimbursable commodities, thereby providing incentives
for disease orientation rather then person-focused relational
continuity. The price may well be an increase in costs, hospitalisations,
and adverse events. It is to be hoped that those in the NHS
responsible for the GMS contract are aware of the issue and
make allowances for it in the future."
Starfield, B. and Horder, J. (2007) Interpersonal continuity old and new perspectives British Journal of General Practice 57: 527–8 (July 2007)
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NICE guidance & Chronic Fatigue Syndrome
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Baker and Shaw have summarized the most recent guidance from
the National Institute for Health and Clinical Excellence (NICE)
on diagnosing and managing chronic fatigue syndrome (CFS). The
authors suggest that a diagnosis of CFS/ME should be considered
in an adult after symptoms have "persisted for four months and
after exclusion of other likely causes of the symptoms. In a
child, the condition should be diagnosed (or the diagnosis confirmed)
by a paediatrician after symptoms have persisted for three months
and after exclusion of other likely causes." In relation to
specialist care, NICE suggests that cognitive behaviour therapy
and/or graded exercise therapy is offered "to people with mild
or moderate CFS/ME and provide these therapies to those who
choose them, as these interventions show clearest evidence of
benefit." There is considerable correspondence regarding this
article in the rapid e-responses which should be read in a topic
that continues to be researched. Baker, R., Shaw, E.J. Diagnosis
and management of chronic fatigue syndrome or myalgic encephalomyelitis
(or encephalopathy): summary of NICE guidance
British Medical Journal (2007);
335: 446–8. (1 September).
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Benefits and risk of homoeopathy
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In the November 17
th edition of the Lancet the practice of homoeopathy
is again debated. The author reports five large meta-analyses
of homoeopathy trials that have been done and the conclusion
that homoeopathy produced no statistically significant benefit
over placebo. And yet that it can still be clinically useful.
An issue of concern was raised in this article that one study
found that "half of all homoeopaths who were approached advised
patients against the measles, mumps, and rubella vaccine for
their children". The author makes the strong statement that
"a routine feature of homoeopaths’ marketing practices
is to denigrate mainstream medicine". He concludes; "To ban
homoeopathy would be an over-reaction, as placebos could have
a clinical role. However, whether the placebo effect is best
harnessed by homoeopaths will remain questionable." This reminds
one of Balint's textbook in 1957;
The doctor, his patient and the illness, and the ‘doctors as drug’ - "...no
pharmacology of this important drug exists yet. To put this
discovery in terms familiar to doctors, no guidance whatever
is contained in any textbook as to the dosage in which the doctor
should prescribe himself, in what form, how frequently, what
his curative and maintenance doses should be, and so on. Still
more disquieting is the lack of any literature on the possible
hazards of this kind of medication, on the various allergic
conditions met in individual patients which ought to be watched
carefully, or on the undesirable side-effects of the drug."
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Death of the first Glasgow University professor of general practice
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The November issue of the
British Journal of General Practice (2007;
57: 928–9) and the
British Medical Journal 2007;
335: 727 (6 October), recall the death of Hamish Barber, who
died on August 26
th 2007 who wrote on the first Textbooks of
General Practice Medicine. As well as being a pioneer in academic
general practice he was an expert model boat builder, mountaineer,
yachtsman and cook. In general practice he rapidly established
a platform on which others could build.
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Prasugrel versus clopidogrel in acute coronary syndrome
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An interesting article appears in the New England Journal of
Medicine in relation to anti-platelet treatment and if you think
you had difficulty in pronouncing Clopidogrel then there is
a new treatment called, Prasugrel. This paper looks at
Prasugrel versus Clopidogrel in a study of 13,608 patients with Acute Coronary Syndromes and concludes; "In patients with acute coronary
syndromes with scheduled percutaneous coronary intervention,
prasugrel therapy was associated with significantly reduced
rates of ischemic events, including stent thrombosis, but with
an increased risk of major bleeding, including fatal bleeding.
Overall mortality did not differ significantly between treatment
groups."
New England Journal of Medicine 2007;
357: 2001–15.
(November 15
th).
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Contentment in general practice
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There are many interesting articles in this month's edition
of the College Journal. Those in training will be interested
to read Professor Tom O’Dowd's editorial on ‘Contentment
in General Practice’. Professor O’Dowd is the professor
of Trinity College Dublin and knows well what it is like as
a GP in the UK having previously worked as a GP in Nottingham.
He describes how the pre 2004 GP contract with the ideal of
"cradle-to-grave 24 hour care" was too much to bear and was
"probably crushed under the weight of patient and government
expectations that GPs should be available on demand". He writes
how prior to the new GP contract that GPs’ job satisfaction
in England had fallen to its lowest point in over a decade.
He reports on how British general practice is now an attractive
well-paid career and says; "Long may it continue".
Contentment in general practice — for now. British Journal of General Practice 2008; 58(1): 5–6.
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Ear wax
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No GP would dispute that ear wax is the cause of many consultations
and it is a topic where the ideal management is the basis for
tutorials by the GP trainer. Richard Coppin and colleagues present
the findings of a randomised controlled trial of 237 patients
to compare the effectiveness of self-treatment bulb syringes
with routine care. The authors describe how ears blocked by
wax can be uncomfortable and irritating and that those who experience
the symptoms of a suddenly blocked ear or loss of hearing often
seek rapid relief. The conclusions of this paper are that bulb
syringing before irrigation is effective and acceptable and
may reduce request for traditional ear syringing. It may be
that a patient comes to you to enquire about the safety and
efficacy of self-treatment bulb syringes and this paper will
prepare readers for that consultation.
Coppin, R., Wicke, D., Little, P. Managing earwax in primary care. British Journal of General Practice 2008; 58(1): 44–9.
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Chaperones
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Another topic for a tutorial with the GP trainer is the role
of chaperones and when to use them. Debbie Wai and colleagues
look at this subject. In this essay they ask the question as
to whether chaperones protect patients. Current GMC guidelines
are provided regarding the use of chaperones and that they should
only be used during intimate examinations. The concluding sentence
in this article is vital to all doctors; "In order to prevent
actions being misinterpreted, it is imperative that the practitioner
communicates exactly what he/she proposes to do and the reason
for it. Two commentaries are provided on this article and further
challenge the reader's reflections on this important topic including
resource implications and the fear all doctors have of being
wrongly accused of misconduct.
Chaperones: are we protecting patients? British Journal of General Practice 2008; 58(1): 54–7.
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