News & Views
General Practitioner and Associate Clinical Professor, Warwick Medical School and Honorary Editor, RCGP Publications
E-mail: rodger.charlton{at}warwick.ac.uk
 |
The third person in the consultation |
|---|
 TOP The third person in... Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
We are reminded by a research paper in the journal Family Practice of the computer on which we depend and use frequently during the consultation but has introduced another ‘partner’ into the doctor–patient relationship. This has changed the dynamics and interactions in the consultation and the impact of the computer can shape how the consultation flows. There has been a considerable move to being patient centred. As the authors of this paper conclude; ‘the concept that humans have a relationship with the computer may seem alien, but that relationship exists’. We perhaps should be aware of how computer centred we are also becoming in our consultations.
Pearce, C. Family Practice (2008); 25(3): p. 202–8.
|
Fishing and history taking |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
An article in the Canadian Family Physician reminds us of the challenge of learning the skills of a focused assessment and the four main strategies for diagnostic work in clinical practice: pattern recognition, algorithm, complete inductive history and the hypothetico-deductive method. An analogy is made with learning to fishing with terminology such as the ‘thrill of the catch, assess the waters, choose the lures (specific questions), net spreading and reeling it in’. The article concludes; ‘Fishing with nets is a starting point. Fishing with lines and lures can be more successful’. Trainers have the important task of helping their trainees ‘gain enough experience to go from net to the line’.
Lacasse, M., Maker, D. Canadian Family Physician (2008); 54(6): p. 891–2.
|
Dementia |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
Nearly the whole of the 19 July issue of The Lancet is devoted to dementia. An editorial provides the stark reminder; ‘dementia is perhaps the cruellest manifestation of ageing, inexorably melting away all that which makes us individual and human’. Of importance to GPs is that with increased life expectancy the incidence of dementia is increasing. Currently 1% of the total population has dementia and this is forecast to double in the next 30 years. Many are undiagnosed and there are lack of effective drugs. The editorial reminds us of how; ‘people with dementia and their families struggle with a hotchpotch of formal and informal care in an atmosphere of financial uncertainty. In rest homes around the country, elderly people exist on unnecessary antipsychotic drugs’. This is an important area of practice with a huge challenge.
Editorial. The Lancet (2008); 372: p. 177.
|
The future of primary care |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
An editorial in the 19 July issue of the British Medical Journal describes what future government policy may be regarding the NHS. In relation to prevention, there is to be a vascular risk assessment programme for people aged 40–74 by GPs and other services. The Department of Health will work the RCGP to develop an accreditation scheme for general practices. Change is to be locally driven and there is a commitment to ‘redefine and reinvigorate practice based commissioning’. Community health services and primary care trusts will likely undergo further substantial organizational change and there is a further ‘intention to focus on ways of improving productivity and quality in these services’. This will include ‘developing measures of performance that can be used by commissioners and providers to secure better value for money’.
Ham, C. British Medical Journal (2008); 337: p. 125–6.
|
Writing poetry—‘A road to humanity’ |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
As I opened the contents of the July issue of the Australian Family Physician, this article caught my eye. Hilton Koppe, a GP and senior medical educator recalls his management of a person with depression and was surprised to learn that his management was not as good as he had believed when he read her reflections in her poetry. Following his initial shock and emotion, he has started to write prose and poetry to reflect on this and other experiences as a doctor. He now runs a series of creative writing workshops and has been overwhelmed by the response. Those who attend describe how they ‘feel less isolated, to be better understood and to regain a sense of purpose in their work as a doctor’. He describes how it remains to be seen if an exploration of the humanities will help doctors’ well-being in the long run but that he is certainly encouraged by these promising beginnings.
Koppe, H. Australian Family Physician (2008); 37(7): p. 563–5.
|
Palliative care as a specialty |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
There is great debate in the Canadian Family Physician as to whether palliative care should be a specialty or not in the June and July issues. Vinay writes that ‘Our first social objective is to enable all of our citizens approaching the end of their lives to benefit from the palliative approach as quickly as possible, regardless of where they live’. His concern is that we could quickly start to rely exclusively on those specialists accredited to deliver this care and whether we should instead enhance the training and involvement of all family physicians. Vinay goes on to say that ‘Family physicians work across a vast area, and there will never be enough subspecialists to meet the needs of patients’. In medical training in Canada, there is a conviction that all physicians should be comfortable with the palliative approach, regardless of their field of practice. Vinay concludes that ‘what we need to do here is trust the excellent practitioners we are training and help them to take up this challenge’ and this is perhaps the same for GPs in the UK.
Vinay, P. Canadian Family Physician (2008); 54: p. 974.
|
Management of pernicious anaemia—one to discuss with your trainer |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
A letter entitled, ‘Swallow your pride’ appears in the Canadian Family Physician, which questions the frequently discussed issue as to whether the only treatment for pernicious anaemia is lifelong vitamin B12 injections. There is evidence that sufficient amounts of vitamin B12 can be absorbed orally when large enough doses are given. In symptomatic individuals, it is proposed that one parenteral dose is given with the initiation of oral treatment rather than lifelong injection treatment. In individuals lacking intrinsic factor (or for any other form of malabsorption), the amount of B12 passively absorbed from 500 mcg taken orally per day is equivalent to a 1000-mcg injection per month. Jones writes; ‘Authors of a recent Cochrane review stated that "Vitamin B12 is rarely prescribed in the oral form in most countries, other than Canada and Sweden, where such replacement recently accounted for 73% of the total vitamin B12 prescribed. Possible reasons for doctors not prescribing oral formulations include unawareness of this option or concerns regarding effectiveness due to unpredictable absorption’.
Jones, R. Canadian Family Physician (2008); 54: p. 978–9.
Vidal-Alaball, J., et al. Cochrane Database Systematic Reviews (2005); 20(3): CD004655.
|
Foot care in diabetes |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
The August edition of the College journal is almost entirely devoted to diabetes. David Jewell, GP and editor of the journal reminds us why. The prevalence of diabetes in one part of the UK is 4.7% and has doubled between 1994 and 2003. Let us start from the bottom upwards and perhaps one of those areas that can be overlooked, the feet. The section in the ‘Back Pages’, ‘Top Tips in 2 minutes’ reminds us that many foot problems present without pain as a result of peripheral neuropathy and that the absence of pain should NOT be taken as reassurance that there is not a serious problem. The author states; ‘Always, always look at the other foot’ as the same risk factors of neuropathy, peripheral vascular disease, callus, poor nail care, poor footwear are invariably present. And if a problem is found address five key areas which may be present: infection, vascular, mechanical, metabolic and social'. To prevent hospitalization and amputation, good preventative self-care and early treatment is essential.
Simmons, D., et al. British Journal of General Practice (2008); 58(8): p. 591.
|
Performance and the workplace-based assessment |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
Workplace-based assessment (WPBA) is an evolution of the structured trainers report from summative assessment prior to the nMRCGP. The aim is to assess how a doctor performs in the workplace. The nMRCGP is based on the educational pyramid of competence described by USA professor of education, George Miller. The Applied knowledge Test (AKT) assesses that a General Practice Specialty Training Registrar (GPStR) ‘knows how’, the WPBA assesses competence and what they ‘can do’ and the Clinical Skills Assessment (CSA) assesses performance and what a GPStR ‘does do’. There is overlap between the CSA and WPBA in assessing competence and performance. Miller has suggested that no single assessment method can provide all the data required for judgement of anything so complex as the delivery of professional services by a successful doctor. In an article on the subject, Rughani describes how the three components of the nMRCGP allow all levels of the pyramid of assessment to be represented. There is no doubt that the WPBA can test ‘real performance’ in ‘real life’ situations. It may be in the future that WPBA is used to address all levels of Miller's Pyramid and as with all assessments its reliability, validity and feasibility are being evaluated. The AKT and CSA record an ‘end of training snapshot of performance’, whereas the WPBA provides a continual assessment and makes provision for assessing the ‘ generalism’ of general practice which is particularly broad which the AKT and CSA cannot assess alone.
Rughani, A. British Journal of General Practice (2008); 58(8): p. 582–4.
|
Guidelines and potential adverse effects of certain anti-hypertensives in pregnancy |
|---|
|
TOPThe third person in...Fishing and history takingDementiaThe future of primary...Writing poetry--'A road to...Palliative care as a...Management of pernicious anaemia...Foot care in diabetesPerformance and the workplace...Guidelines and potential adverse... |
|---|
In the August edition of the College journal, Martin reports a study in Birmingham and the prescription of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in women of childbearing age. It is reported that British Hypertension Society (BHS) and NICE guidelines do not mention the potential dangers of ACE inhibitors or ARBs in pregnancy. This article suggests that the BHS and NICE guidelines may put younger women at risk if doctors are unaware of potential fetotoxic and teratogenic consequences of prescribing ACE inhibitors and ARBs. Issues such as adequate contraception should be discussed if using these agents or using alternative agents which are safer. Also healthy lifestyle factors should be highlighted, for example, gentle exercise. Also, checking the threshold for diagnosis and so excluding, for example, white coat hypertension and perhaps the need for drug treatment.
Martin, U. British Journal of General Practice (2008); 58(8): p. 582–5.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||