News & Views
General Practitioner and Associate Clinical Professor, Warwick Medical School and Honorary Editor, RCGP Publications
E-mail: Rodger.charlton{at}warwick.ac.uk
 |
Managing the acutely ill child |
|---|
 TOP Managing the acutely ill... Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
When I was training and even now as an experienced GP, one of the most difficult consultations can be managing the young child who would appear to be acutely ill in relation to diagnostic uncertainty and appropriate management. Even for those who have worked in hospital paediatrics, the spectrum of illness seen in children in the community is very different. The April issue of the British Journal of General Practice (BJGP) is therefore particularly helpful to those in training and for trainers like myself with an editorial and three papers on this subject. The editorial states, ‘Children are different’ and we all know that this is true. It is reported that on average that only 1 in 50 children is referred to a paediatrician each year and that this rate has not changed for a decade. This referral rate seems low but makes the point that the majority of the care of children takes place in primary care. Interestingly asthma was the top reason for referral in 1988 and now does not feature in the top 5 with GPs largely taking on the management of this condition. Concern is raised regarding the current NICE guidelines which are based on the symptoms and signs used in secondary care as these may have a different predictive value when used in primary care. It is argued that softer holistic signs may be more valuable, for example, parental concern as predictor of serious illness rather than relying on pulse and respiratory rates, temperature and capillary refill. The editorial concludes; ‘A good doctor individualizes the generalized evidence available’.
Cave, J.A.H. Editorial. Managing the acutely ill child. British Journal of General Practice. (2008); 58(4): p. 228–9.
|
Using vital signs to assess children with acute infections |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
This paper reports the survey of 210 GPs working within a 10-mile radius of Oxford and concludes that vital signs are uncommonly measured in children under the age of 5 years who have acute infections in general practice and are considered less useful than observation in assessing the severity of illness. If the measurement of vital signs is to become part of standard practice, the issues of inaccurate measurement and diagnostic value need to be addressed urgently. At present, GPs use an overall or global assessment to help them identify children with serious infections, but the extent to which they also use vital signs is not known.
Thompson, M., et al. British Journal of General Practice. (2008); 58(4): p. 236–41.
|
Triage of febrile children |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
This paper is based on a GP cooperative reports from The Netherlands that parental concern in febrile children without ‘alarm symptoms’ aged between 3 months and 6 years is a good reason for a consultation. Similarly, children with alarm symptoms were also very likely to be seen.
Monteny, M., et al. British Journal of General Practice. (2008); 58(4): p. 242–7.
|
The medical history |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
We were frequently taught at medical school that in 90% of patients, the history would enable us to make the diagnosis. The author of a paper on the subject, Nick Summerton, a GP academic in Hull describes how the medical history is a powerful diagnostic technology and that an appropriate balance should be sought between the medical history and other diagnostic modalities and that more explicit consideration must be given to the performance characteristics of the history in the context of a diagnostic processing pathway. He recalls something that we often overlook in general practice that not everyone who is ill has a disease. He writes: ‘An overarching focus on investigations also highlights a failure to appreciate that not every "abnormality" is synonymous with an organic disease: no specific physical disorder can be established as the cause in between 30% and 75% of patients with symptoms.’ The article concludes: ‘The medical history is more than a nostalgic relic of little relevance to modern practice. However, there is now an urgent requirement for careful consideration to be given to how, where, and by whom this diagnostic technology is being used.’
Summerton, N. The medical history as a diagnostic technology. British Journal of General Practice. (2008); 58(4): p. 273–6.
|
View on polyclinics |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
In the April issue of the BJGP, GP, James Willis, writes: ‘When I read David Aaronovitch in the Times echoing Lord Darzi and arguing that "It is unrealistic to have a cradle-to-grave GP ... Ignore the doctors. Polyclinics are the future." I say no, you are wrong, polyclinics are the past, they were tried in Livingstone New Town, they were tried in Soviet Russia. And when the caption under the accompanying picture of Dr Finlay says "That was then, this is now." I say, well done, now you are right, your "then" is a picture of warm, human interaction, which I well recognise and which I want for the future; your "now" is nothing, a void perhaps because there wasn’t room, or editorial courage, to depict a cold string of digits. And when Aaronovitch says he doesn’t want a generalist doctor, thank you, I resist the temptation to quip that I don’t want a generalist newspaper columnist. Because actually I do, as, unlike him, I have thought through the power and legitimacy of generalism.
I don’t claim that these opinions should be accepted without question. Of course I don’t. I expect them to be subjected to the same filters of intellectual scrutiny as any other ideas. But I do expect to be given credit for my experience, and not for it to be used as a cheap excuse for shrugging off my contribution.‘
Willis, J. Dr Grumpy will see you now. British Journal of General Practice. (2008); 58(4): p. 296.
|
Medical ethics |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
For GP training, the new MRCGP uses three assessments: Workplace-Based Assessment, the Applied Knowledge Test and Clinical Skills Assessment (CSA). These assessments are not just tools to judge competence clinically and the ability to undertake procedural skills. They are also looking at organizational and ethical skills. In relation to medical ethics, this is frequently now referred to as values in medicine. An excellent ‘Real life Ethics’ case is detailed which makes the subject entirely practical and that almost impossible situation of 100% ensuring patient autonomy when a patient is dying. This challenging article not only debates the fair allocation of a GP's time to his or her patients but also engages us to think what we would do if a medical emergency, in this case, status epilepticus, arises in a patient with late-stage malignant melanoma and cerebral metastases who has previously expressed and legally documented that it is her absolute wish not to go to the local hospital. What is in the patient's best interest balanced against your duty of care as a doctor balanced against respecting and fulfilling their wishes. Then there is the dilemma about what to do in relation to protocol-driven health care and the 999 ambulance service protocol dictates that the patient should be taken to the nearest hospital. This is an ideal article to discuss at the local vocational training scheme.
Brown, E., Pink, J. Real life ethics—autonomy versus duty of care. British Journal of General Practice. (2008); 58(4): p. 288–9.
|
Dust mite control |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
How many patients who have asthma do you ask about a possible allergic basis and perhaps even suggest that the common house-dust mite may play a role? When I was a GP in New Zealand in 1992, the concept of a Hoover to remove the house-dust mite was postulated to reduce what was described as IgE sensitization to the allergen, house-dust mite, in those individuals with atopic asthma. The 26 April issue of The Lancet states: ‘There is no evidence that interventions, such as using mattress protectors and removing soft toys from beds, are beneficial in the management of asthma in people who are sensitive to house dust-mites.’ The evidence base comes from a Cochrane Collaboration where a review pooled data from 54 trials of 3002 patients with asthma. It is recommended that current guidelines and advice are now updated.
Anonymous. Editorial. Dust-mite control measures of no use. The Lancet. (2008); 371: p. 1390.
|
|
View on the CSA |
|---|
|
TOPManaging the acutely ill...Using vital signs to...Triage of febrile childrenThe medical historyView on polyclinicsMedical ethicsDust mite controlView on the CSA |
|---|
Dr Sabena Jameel, Course Organizer in North Birmingham, was invited by her Deanery to observe this exam on floors 18–20 of multi-storey building used by the College across a road from East Croydon train station. She wrote: ‘My main reasons for attending were to view for myself the CSA process enabling me to reassure and offer practical logistic advice to trainees and secondly intrigue about the conception, structure, calibration and quality assurance considerations involved in the development of this assessment.
After attending the candidates debrief I shadowed a few assessors as they rotated around consulting rooms. I was given the choice of which cases I observed. I found it beneficial focussing in 5 of the 13 cases but watched 2-3 candidates consult given the same scenario. I was able to see a range of candidates and note their subsequent assessors mark. It was an interesting exercise identifying the word pictures which indicated positive and negative descriptors of the candidates’ abilities. Some of the descriptors had been reviewed during the standardisation exercises in the morning.
The cases themselves were stimulating, varied and well-thought out. It was reiterated that cases were extensively researched and pinned to the GP curriculum. The actors deserve praise as they were extremely convincing. 1 of the 13 cases is a pilot case. Ten minutes is allocated for each case with a buzzer sounding to signify start and end points. Ten minutes passed quickly but I was impressed by some candidates’ ability to get to some very sensitive topics with convincing empathy in the allocated time. The whole process of room allocations, person movement and paperwork dissemination was seemingly slick and efficient. No-one is allowed to discuss the cases, including myself as they are copyrighted.
On my observer feedback form, I honestly could not think of any significant improvements. I am glad I made the effort to attend today.‘ (April 2008)
(Dr Jameel gave permission to reproduce and edit her observations.)
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||