News & Views
General Practitioner and Associate Clinical Professor, Warwick Medical School and Honorary Editor, RCGP Publications
E-mail: rodger.charlton{at}warwick.ac.uk
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Where should I practice as a GP? |
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 TOP Where should I practice... Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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Some people say I am not a proper GP as I practice in the leafy suburbs of a village. But it does not matter where you practice as a GP as you will engage in consultations with people who are ill. Different skills are required in different environments, but you can rarely predict what a patient will present with. I have previously worked in an urban practice in Derby and also as a GP in New Zealand and each practice has brought different challenges and rewards. The ‘back pages’ of the May issue of College journal remind us of two important areas of practice. First, with the homeless who are described by a doctor in Amsterdam as a ‘growing population that is vulnerable to preventable disease, progressive morbidity and premature death’ who have ‘multiple and interacting social and medical problems’. RCGP Publications have published an important book on the subject, ‘Homelessness—a primary care response’, where the author, Dr Nat Wright, founder of the No Fixed Abode homeless team in Leeds, provides an invaluable guide to setting up a practice welcoming the homeless population. Second, Dr Ashley Liston, who left his partnership ‘in a pleasant practice to work in a struggling practice in a needy part of Sunderland as a salaried GP’. I would recommend reading this essay on the subject which could well appear in an nMRCGP assessment where he describes his motivation as ‘The Inverse Care Law’, a phrase coined by Julian Tudor Hart, a GP, who worked in a deprived mining community in Wales. He cites factors that encapsulate good general practice, ‘Patients want kindness, honesty, good communication, respect and trustworthiness’.
Van Laere, I. British Journal of General Practice (2008) 58: p. 367
Liston, A. British Journal of General Practice (2008) 58: p. 368–9
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Age-related macular degeneration |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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Many of us receive little training in Ophthalmology, but this is no excuse for ignorance and it is important to read an excellent editorial on age-related macular degeneration (ARMD) and advances on diagnosis and treatment in the May issue of College journal. The opening paragraph reminds us that ARMD is a devastating reality for 8% of adults over 65 and that new therapies have the potential to halt and improve visual loss. The majority of sufferers have atrophic or ‘dry’ macular degeneration which is a slow process for which there is no effective treatment. The remaining patients have ‘wet’ or neovascular disease which can cause sudden central visual loss and it is estimated that there are 21 000 new cases a year in the UK. It is recommended that these patients undergo retinal angiography and assessment for possible treatment in 2 weeks. The worrying alternative is being registered as visually impaired. The considerable challenge to GPs is which patients with gradual visual loss to refer urgently remembering that all patients with sudden central visual loss must be seen as soon as possible.
Solebo, A., et al. British Journal of General Practice (2008) 58: p. 310–1.
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What's new in contraception? |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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Recently our ST1 doctor asked if we could include a seminar on contraception on the Vocational Training Scheme as this was an area that training had not prepared them for. Shortly after this conversation, we discussed what to do about a woman who wished to convert from oral contraception to a transdermal patch of ethinylestradiol and norelgestromin. I had no experience of this method and was reminded of some important points when I read a review of ‘non-oral contraception’. It would appear that it produces higher plasma levels than the combined oral contraceptive pill without the peaks and troughs of the oral regimen. It is reported that its main mode of action is the suppression of ovulation with secondary effects on cervical mucus and the endometrium. It is suggested that compliance is good as a patch lasts for 7 days. Patches are worn for 3 consecutive weeks with 7 days for each patch followed by 7 patch-free days for a withdrawal bleed. The same contra-indications and cautions apply as for the combined pill. Where a patch is displaced for more than 24 hours, a new patch should be applied and condoms advised for 7 days. Hopefully, with this information you will feel better prepared if a patient asks your advice. (The first patch is initiated on days 1–5 of the cycle.)
Everett, M. Prescriber (2008) 19 (suppl 9): p. 29–42.
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Bedside manner and professionalism |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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This is a phrase that has perhaps been superceded by the word professionalism. However, it is a phrase still quoted by the public and the media and has subtle differences. It derives from the times when patient consultations frequently took place at the hospital or home bedside and doctors wore white coats. Bedside manner is defined in the Oxford English Dictionary as ‘the deportment of a medical man towards his patient’. However, like professionalism, a good bedside manner is less easily defined. Aspects of a good bedside manner include both a doctor's positive behaviour and attitudes towards a patient and how well they communicate both verbally and non-verbally with them. In all, it is being sincere and polite wrapped in with the ability to get across to the patient that they have the utmost concern for their welfare.
It is timely therefore that the RCGP 2007 William Pickles Lecture should be entitled ‘Education and the changing face of medical professionalism’. It is reported how in recent years that ‘professionalism has been one of the most prominent topics in medical education literature, its definition, its attainment, its assessment, all fraught with difficulties’. Sean Hilton in his lecture provides a helpful concept in that medical professionalism ‘encompasses all that we do, and makes the difference between a doctor and a good doctor’. His lecture is published in the May issue of the College journal and I would recommend that all doctors read it. He concludes by reminding us of the immense and ongoing change in the NHS but that our professionalism must have permanence and that our education must foster it. He reminds us that the college motto, ‘Cum Scientia Caritas’, just about encapsulates all he has tried to say in the lecture. For anyone who wishes to learn more about the college motto where general practice can be viewed as both an art and a science, the 1969 edition of the College journal provides an article on the subject where the motto may be defined as ‘scientific skill with loving kindness’.
McCulloch, G.L. The James Dundas Simpson Address: Cum Scientia Caritas. The Journal of the Royal College of General Practitioners. (1969) 18: p. 315–20.
William Pickles Lecture. British Journal of General Practice (2008) 58(suppl 5): p. 353–61.
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Increasing incidence of diabetes |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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The May 24 issue of The Lancet is almost entirely devoted to diabetes. Any associate in training looking for areas to revise for one of their assessments must know about diabetes, its diagnosis and management. The International Diabetes Federation estimates that 246 million adults worldwide have diabetes and that the incidence is escalating to epidemic proportions and that by 2025 the figure is expected to reach 380 million. Diabetes accounts for about 6% of total global mortality, half of which may be due to cardiovascular disease. The rise appears to parallel that of the increasing incidence of diabetes. Two other issues should also be considered. The risk of diabetes in the offspring of women with gestational diabetes has increased and the incidence of gestational diabetes is increasing now affecting up to 5% of pregnancies. Finland has the highest incidence of type I diabetes in the world. A cohort study suggests that the number of new cases diagnosed at or before 14 years of age will double in the next 15 years and the age of onset will be younger. This has implications for other European countries. Diabetes is forming an increasing proportion of the GP's workload and it is a condition we need to be alert to and up to date in its management and complications.
Anonymous. Editorial. The Lancet (2008) 371: p. 1723.
Harjutsalo, V., et al. The Lancet. (2008) 371: p. 1777–82.
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Revised UK guidelines—emergency treatment of anaphylaxis |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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An editorial in the May 24 issue of the British Medical Journal summarizes the revised guidelines. It is important to call for assistance early and maintain the ABCDE approach [airway, breathing, circulation, disability (level of consciousness) and exposure (of the skin)]. Prompt intramuscular injection of adrenaline (epinephrine) is the initial treatment of choice. (age 12 years or more, inject 0.5 mg but 0.3–0.5 mg in those under 12) (Error and delay in adrenaline dosing have been attributed to the common practice of using ratios, such as 1 : 1000, so concentrations such as milligrams per millilitre are preferred.) Other measures which may indicated include putting the patient in a comfortable position, managing their airway, providing oxygen and administering intravenous fluid. Following recovery referral should be made to an allergy specialist to ascertain future risk and its appropriate management. This is no agreement on the role of other commonly used drugs such as glucocorticoids and antihistamines.
Simons, F.E.R. British Medical Journal (2008) 336: p. 1141–2.
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Reform of death certification |
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TOPWhere should I practice...Age-related macular degenerationWhat's new in contraception?Bedside manner and...Increasing incidence of diabetesRevised UK guidelines--emergency...Reform of death certification |
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Revisiting recommendations of the Shipman Inquiry and reforming the process of death certification are topics for the May issue of the College journal and the CMO Spring Update. The proposed reformed process will introduce a single system of effective medical scrutiny for deaths not reportable to the coroner. There will be a Medical Certificate of Cause of Death (MCCD) for burials and cremations alike. Each MCCD will be scrutinized by an independent medical examiner appointed by a Primary Care Organisation (PCO) with links to the clinical governance team who will collate clinical information. The medical examiner who has access to the medical records, the doctor signing the MCCD and the relatives will provide authorization for burial or cremation and hopefully this will not delay the funeral. It is anticipated that the new process will be implemented by 2011 following pilots.
Baker, R. British Journal of General Practice (2008) 58: p. 307–8.
CMO Update Spring 2008. Issue 47: p. 3.
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