News & Views
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Australia, new acronyms and learning |
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 TOP Australia, new acronyms and... Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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Visiting the College library is always a treat and an opportunity to look at the many worldwide family medicine journals. The Australian Family Physician introduced me to some new acronyms and I am sure the Australian College is getting to grips with our many nMRCGP acronyms. For Associates in Training, there is an Education section of the journal entitled: ‘AFP in Practice’ where AFP stands for the Australian Family Physician. This section is designed to promote small group learning. The activity relates to a paper that has appeared in the journal and, for example, ‘Discuss which children have challenged you professionally and ways of managing them for both the health professional and the patient’. (Further details appear online: www.racgp.org.au/afpinpractice.) Another paper of interest is: ‘Lessons from the TAPS study’. TAPS is the ‘Threats to Australian Patient Safety’ and a collection of 648 anonymous reports of events that GPs felt should not have happened and the clinical lessons that resulted. An example is cited of the delay in a GP reading a note detailed by a receptionist in their message book of a child with pain in the scrotum and what education was provided to receptionists.
Makeham, M., et al. Australian Family Physician (2008) 37 (suppl 6): p. 438–9
O’Shea, C.O. Australian Family Physician (2008) 37 (suppl 6): p. 447
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Home visits |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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House visits once formed a major proportion of a GP's working day. Triage and practice telephone advice services, together with media campaigns by the British Medical Association and others have reduced unnecessary visits. There are times when house visits provide great insights into a patient's home circumstances, for example, full ashtrays and sinks with dirty plates and so the potential impact on illness. There is a duty of care for a small proportion of patients that can only be treated at home, for example, the terminally ill. Although no longer a traditional role, few other professions are so gratefully received into a stranger's house than a GP. A Polish paper on the subject describes a decrease in the frequency of home visits in the years 1998, 2002 and 2006. Reasons for this were thought to be greater accessibility of primary care services, improved continuity of care which enabled a better assessment of an individual patient's need and so whether a home visit was required and the role of community nurses. It was observed that the proportion of chronically ill and elderly patients who made home visit requests had increased. Home visits will always have a place and provide valuable information on a patient's living conditions, family relationships and lifestyle.
Marcinowicz, L., et al. European Journal of General Practice (2007) 13 (suppl 4): p. 237–8
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General Practice is becoming more difficult |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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The president of the Icelandic College of Family Physicians is celebrating the 30th anniversary of their College this year. In an editorial, this doctor describes the European challenge for all GPs: ‘The growing population of older people with chronic and complex problems’ and that ‘increasing co-morbidity is very challenging and fits well with the ideology of family medicine where the focus is on the patient and the continuity of care but not on a single disease’. The importance of teamwork, self-care, continuity of care and avoiding fragmentation of care are all emphasized.
Baroardottir, E. Scandinavian Journal of Primary Health Care (2008) 26: p. 3–4
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Behaviour change and motivational interviewing |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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I was listening to a talk from an expert patient to medical undergraduates and he described the use of ‘motivational interviewing’. Stephen Rollnick from the Primary Care Department at Cardiff University describes this in detail in the journal: South African Family Practice and its application to health care. He writes: ‘Does it work? The answer appears to be "yes", not always, and not without a good dose of humility: no "talking cure" can ever directly address the social and economic conditions that make change so difficult for people’. He describes the process as the reverse of direct persuasion, such as telling or advising. One should rather elicit from patients their own good reasons to change. He describes that the process of guiding a patient to consider change is driven by the use of ‘empathetic listening statements that capture the patient's dilemma and explore how change might be compatible with their core values’.
Rollnick, S. South African Family Practice (2008) 50 (suppl 2): p. 52
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Research and General Practice |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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How does a GP combine the two? Norwegian GP Holtedahl describes how general practice is both varied, rapid and challenging and so for a doctor filled with curiosity the environment is ripe for an enquiring and reflective mind. New ideas and questions continuously arise. For a long time, the evidence base for primary care has come from secondary care where most disease was treated. With the move to care in the community, primary clinical care should be supported and developed by general practice research.
Holtedahl, K. Family Practice (2008) 25: 132–36
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POEMs |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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Yet another acronym. Patient Orientated Evidence that Matters (POEMs)—this a recent acronym used in many journals of medicine including the USA journal, The Journal of Family Practice. POEMs ask all those questions you wanted to but dare not let anyone know, such as, whether you can safely stop warfarin for an elective procedure. An interruption of warfarin therapy for 5 days or less is documented as showing little increased risk of thromboembolic events. Similarly, at time of increasing antibiotic resistance, there is no real evidence to support the use of antibiotics following the successful incision and drainage of a superficial skin abscess.
POEMs. The Journal of Family Practice. (2008) 57 (suppl 5): p. 303–5
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Beta-blockers—are drugs in a class the same? |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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How do you decide which NSAID, Cox-2 inhibitor, diuretic or statin is best for a patient? There is not always an easy answer and yet in an evidence-based science such as medicine, there should be. However, one group of drugs where the area is well researched and clearly defined is that of beta-blockers. There are important differences between individual beta-blockers, for example, bisoprolol or carvedilol are more effective than other beta-blockers in congestive cardiac failure. An editorial in the June issue of the College journal recommends that we should not assume that members of a class of drugs have exactly the same effects as each other and beta-blockers are an excellent example. A very useful table is provided of differences in lipid solubility, cardioselectivity, partial agonist activity, membrane stabilizing effect and peripheral vasodilatation. Why do you need to know this? Cardioselective beta-blockers such as atenolol may be less problematic in patients with asthma whereas thinking of another class of drugs, Cox-2 inhibitors, such as rofecoxib, increase the risk of heart attack or stroke.
Aronson, J.K. British Journal of General Practice (2008) 58 (suppl 6): p. 387–9
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End-of-life care in COPD patients |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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It is difficult to define when the end of life starts and caution should be taken that the phrase, ‘end-of-life care’ should not be used as a synonym for ‘palliative care’. Perhaps, it merely denotes the care in the final stage of a terminally ill patient. With changing definitions, the application and focus of care has moved from cancer patients at the time of the advent of the modern hospice movement to all patients who are dying, for example, those with chronic diseases such as COPD who have reached an end stage. An editorial in the June issue of the College journal describes how it is both important and difficult to define the point for many patients when ‘community-based care with a predominantly palliative element is more appropriate’. However, ‘judging this transition point requires experience, sensitivity and open communication among the hospital team, GP and the patient. Once this transition point is reached, it is crucial that the patient is not lost to follow-up and that planning of long-term support occurs’. One of the dilemmas as whether to use opiates is discussed and the editorial cites evidence as to their value in treating dyspnoea in COPD and also that oxygen may provide symptomatic relief.
Halpin, D., et al. British Journal of General Practice (2008) 58 (suppl 6): p. 390–2
Nauck, F., Jaspers, B. Is palliative care synonymous with end-of-life care? European Journal of Palliative Care (2003) 10 (suppl 6): p. 223
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Emergencies in palliative care |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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When a patient has been diagnosed as having a cancer that cannot be cured, the emphasis on treatment is palliative and so on maintaining quality of life. It may be that this can involuntarily influence clinical judgement when it comes to certain acute events as a patient's cancer progresses and they inevitably deteriorate. However, GPs need to be particularly aware of treatable emergency conditions, which may occur unexpectedly in terminally ill cancer patients as a result of cancer and be able to manage these conditions quickly and appropriately, such as breathlessness, convulsions and haemorrhage. Prompt action can alleviate much suffering and may even prevent an unnecessarily distressing and premature death. It can also impact on quality of life which may not be great, but prevent it from becoming awful within a few hours. ‘Top tips in 2 minutes’ provides some very practical advice on this subject, in ‘The Back Pages’ of the June issue of the College journal.
Bastable, R., et al. British Journal of General Practice (2008) 58 (suppl 6): p. 448–9
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Back pain and sciatica |
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TOPAustralia, new acronyms and...Home visitsGeneral Practice is becoming...Behaviour change and...Research and General PracticePOEMsBeta-blockers--are drugs in a...End-of-life care in COPD...Emergencies in palliative careBack pain and sciatica |
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‘Common things are common’ and so is back pain and sciatica. Imagine AKT questions in the nMRCGP and some of the things you perhaps did not know. An editorial and papers in a recent British Medical Journal detail how disc prolapse has a genetic basis and so environmental factors such as heavy lifting, manual labour and trauma are not necessarily the primary cause. Furthermore, commonly used non-surgical measures such as manipulations, epidurals, physiotherapy and analgesics have little effect on the course of sciatica. Surgery is effective and alleviates at least 90% of radicular pain. However, it is less successful for back pain and 70% of people will continue to have back pain after surgery and up to 10% of people will continue to have long-term back pain after surgery. There are major gaps in our knowledge of the underlying mechanisms of disc degeneration and prolapse. Nevertheless, there is evidence to support surgery 8 weeks after the onset of sciatica if symptoms persist. Research papers in the same issue of the journal suggest that early surgery achieves more rapid relief of sciatica than conservative care. Also that the faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. However, outcomes were similar for early surgery and conservative care by 1 year and these did not change during the second year.
Fairbank, J. British Medical Journal (2008) 336: p. 1317–18
Peul, W. British Medical Journal (2008) 336: p. 1355–58
van den Hout, B. British Medical Journal (2008) 336: p. 1351–54
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