Refusal of treatment

In case you haven’t seen already we are really keen to receive your thoughts and suggestions on InnovAiT. What do you like now and how can we make it better for you? All AiTs please do take a couple of minutes to complete the survey available here http://rcgp-news.com/t/49LX-4X71-8FV8UYH28/cr.aspx
Last month you shared some very interesting comments and thoughts on the clinical scenario regarding dental pain. There was general consensus that the patient needs to see a dentist but that assessment should be considered as to how unwell the patient is (?septic ?admit), if there is a sinister underlying cause (refer to maxfax/consider immunosuppression). There is clear BMA guidance as to how we should manage this situation which can be found in the feedback for last month’s scenario here http://elearning.rcgp.org.uk/course/view.php?id=219.
Below is this month’s Clinical Scenario regarding refusal of treatment. Let us know how you would manage this situation.
Mr Halliday has severe asthma. He lives alone but has a home carer daily. His daughter is his next of kin and lives nearby. He has recently been admitted to hospital with a severe exacerbation of his asthma. The discharge summary states that Mr Halliday has poor understanding of his asthma which was putting him at significant risk of further severe exacerbations. The following week you receive a request from Mr Halliday’s carer for an urgent home visit as ‘his breathing is bad again’. 
When you arrive he is clearly struggling with his breathing but refuses to see you, speak to you or be examined. He has thrown his inhalers in the dustbin and says that he’d ‘be better off dead’. You try to tell him that without treatment he could die from his asthma but this makes no difference. On returning to the surgery you call the mental health crisis team to ask their advice about how to manage this situation. They agree to go to see him to assess his capacity to refuse admission but, when they arrive at the house, his daughter answers the door and says that mental health assessment is not required. She sends the crisis team away without seeing Mr Halliday.

Suggested points for discussion
Could you have admitted Mr Halliday to hospital in his ‘best interest’ when you saw him, even though he is refusing admission?
How might you manage this situation?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (November 2017) forum discussion within the OLE:
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Benzodiazepine dependence

elderly

Benzodiazepine dependence is an increasingly recognised and often iatrogenic problem. Where does the balance lie between ‘safe’ use and dependence? How do you manage your elderly patients who have been on their nightly diazepam for years and insist they can’t possibly manage without them? For newly qualified GPs or registrars this can be even harder when you are often following in the footsteps of well established GPs who may have had a different prescribing pattern. Do you have a practice policy or is there variation between the GPs in your surgery? Does the reason for request alter your thoughts? Fear of flying or the dentist which may only require a short prescription, or insomnia which may be an ongoing problem. If you are already running late, is the lengthy discussion to encourage the patient not to use them going to take too long?

Lots of doctors have different opinions – some can be hardline and almost never prescribe, others may comfortably issue and repeat them. Do you know where your prescribing trend sits? If you are preparing for the CSA, are you happy with how you would manage a request?

In this month’s InnovAiT, there is a great article by Dr Ayla Cosh and Dr Helen Carslaw going into detail about these issues and how to support withdrawal as well as some great links to other resources.

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Dental Infections – Clinical Scenario

This month’s Clinical Scenario from the RCGP forum is regarding dental infections. There is a huge amount of discussion from Indemnity organisations and social media groups about how these should (or shouldn’t) be handled. Are you clear what you would do?

Dental Abscess
A 25-year-old patient presents to the GP with a history of toothache. The pain has developed over several days. He says he does not have a dentist and has not needed to see a dentist for several years. He is managing to eat and drink normally and the pain is relieved with simple painkillers. There is no history of fever or systemic illness. He is insistent on having antibiotics from the doctor. He is sure this is appropriate as he had a similar bout that responded well to antibiotics from another doctor seen out of hours. After careful assessment, the GP feels antibiotics are not warranted and forwards him to the emergency dental services.
The GP subsequently receives a complaint from the patient who went on to develop a large dental abscess requiring surgical drainage. He complains that the GP failed to manage his dental infection correctly and should have given him antibiotics.
Suggested points for discussion:
  • What is the differential diagnosis?
  • What are the indications for prescribing antibiotics for dental pain?
  • What safety-netting advice is important to document?
  • What is your local referral pathway for emergency dental issues?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (October 2017) forum discussion within the OLE:
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Enfranchising our patients

Blog kindly submitted by Dr Jonathan Mills and Dr Unniparambath Prabhakaran.

With the recently held (and somewhat unexpected) general election in June, this provided an opportunity for us to reflect that as GPs, how we encourage our patients to exercise their democratic rights, and are we aware just who can vote?

Whilst voting can be straightforward for many people who have registered, as GPs we should be mindful of those who are disenfranchised by the very nature of difficulty getting to the polling booth or posting a vote. This is particularly the case for those in care homes, hospital and psychiatric units, where physical health problems restrict participation, or the locked nature of some of the wards serves as a barrier to exercising the right to vote. In the 2010 General Election, psychiatric inpatients were half as likely to register to vote. If registered, they were again half as likely to vote compared to the general population (McIntyre et al., 2012). The majority of those unregistered were not aware of their eligibility to vote or the registration process.

Historically, inpatients in psychiatric settings were disenfranchised in UK general elections as ‘lunatics’ and ‘idiots’ under the Representation of the People Act 1949, before the electoral Administration Act (2006) granted psychiatric inpatients a right to vote whether they were informally admitted or detained under the civil sections of the Mental Health Act 1983 (MHA). Thus psychiatric patients have a right to vote personally, or by proxy, and should be encouraged to register to vote and exercise that right should they choose. For clarity, patients who are sectioned under civil sections of the MHA (this also includes prisoners remanded to hospital under the MHA on Sections 35, 36 or 48) are entitled to vote (Royal College of Psychiatrists, 2015). However, prisoners detained after conviction of a criminal offence who are ordered to hospital be the courts and those who have impaired capacity (which includes dementia) do not in themselves demonstrate legal incapacity to vote, and these individuals should be supported if they intend to register and vote (Royal College of Psychiatrists, 2015).

A GP may have patients in the community under care of psychiatric teams, subject to mental health legislation (such as Community Treatment Orders) who are also entitled to vote, despite restrictions to their liberty such orders may pose.

Similarly, patients who are homeless can make a ‘declaration of local connection’ should they spend a significant period of time at a particular address or location. Those in residential and nursing homes may lack the physical ability to go to a polling station, or even to physically mark a ballot paper, but again this should not be a bar to choosing their representatives. Care homes should be encouraged to help residents register and vote. Where someone is unable to vote but wishes to do so, remind them they can nominate a proxy to enable them. As GPs, we work under the premise that adults have capacity until proven otherwise, we should also work under the assumption that patients have capacity to register and vote.

McIntyre J, Yelamanchili V, Naz S, Khwaja M, Clarke M. Uptake and knowledge of voting rights by adult in-patients during the 2010 UK general election. The Psychiatrist 2012; 36: 126-130

Royal College of Psychiatrists, Voting rights for mental health patients, (2015), available via http://www.rcpsych.ac.uk/mediacentre/pressreleases2015/votingrights.aspx Last accessed 18/7/2017

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Working abroad

Here is this month’s Clinical Scenario from RCGP Learning in conjunction with Doctors.net. Several of my peers from VTS training have either worked or moved permanently abroad since qualifying and this seems to be the case nationally. The pull of family needs here and the appeal of working abroad is a very real one – let us know your thoughts on the comments page which you can access from this link http://elearning.rcgp.org.uk/mod/pageplus/view.php?id=7485.

Dr Anderson has just completed his GP training in the UK and has been doing some locum work. He has seen an advertisement for a GP post in rural New Zealand and thinks that he might apply. However, his mother has a long-term illness and he is worried that, if he does go to work abroad, he might not be able to return to work in the UK as a GP should his mother deteriorate and need his help.

Suggested points for discussion

  • What are the rules about UK-trained doctors returning to work in the UK after some time abroad?
  • How might Dr Anderson maintain his right to practise in the UK whilst working abroad?
  • Would these rules be different if Dr Anderson was trained in New Zealand and wanted to come to work in the UK?
  • What other factors might influence Dr Anderson’s decision?

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Difficult decisions

Did you see the brilliant August Special Edition on Difficult Decisions? In case you missed it, there is a wealth of discussion around many different difficult decisions which regularly affect us.

I was really interested in the article ‘The ethics of GP commissioning’ by @gentlemedic, a Clinical Lecturer from Oxford University and Dr Cox, GP with special interest in Ethics and medico-legal work. I work for our local CCG and have to advise with a much wider population view so was particularly interested in this discussion, but also the ethics around the decisions we make to manage the care of our individual patients or practice population.

The great @DuncanShrew writes about the impact on us, of all the decisions that we have to make which was certainly a message which rang true with me. I have heard it said that as GPs we make a decision every 10-20 seconds  – whether to pursue that mention by a patient of chest pain in amongst the other plethora of symptoms, or in amongst a list of 80 medicines management is it ok to re-issue this medication, or whether to read the urgent screen message whilst the patient is in with us or wait until they have left. I remember on more than one occasion of getting home from a long day, my husband has asked if I would like a cup of tea and I have genuinely struggled to answer. Decision fatigue is very real for me.

The article ‘The psychology of uncertainty in difficult decisions‘ is a fascinating closer look at our reactions to the horribly uncomfortable moments of just not knowing what to do easily referred to as ‘WDYDWYDKWTD moments’ (What do you do when you don’t know what to do). The fear that if only a better doctor was seeing this patient or looking at these results because they would obviously know what to do. I recognise that I had these a lot as a trainee, and in no way do I now know all the answers, but having strategies for how to manage the situation is so very helpful. I couldn’t really understand this when my supervisor told me to learn how to manage the situation, it felt like a cop out, that actually we should just work harder to know all the answers. The realisation that we can’t and that our role is also to risk assess is both helpful and daunting. This article is a good opportunity to consider why we feel the way we do in those WDYDWYDKWTD moments. The following article then considers sharing this uncertainty with our patients.

There are also lots of shorter scenarios posing difficult decisions which are produced in partnership with RCGP and Doctors.net with the opportunity to post your thoughts in the discussion afterwards. These are available at http://journals.sagepub.com/Ino/tenminutescenarios?pbEditor=true 

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Latest RCGP Forum Clinical Scenario

A really meaty scenario this month, which has left me feeling very grateful for all the partners in our practice happy take concerns on board.
Don’t forget that you can catch up on all the previous scenarios and discussion too, great for CPD or discussion points with your supervisors.
Medicines reconciliation
 
A GP colleague asks for your advice. Six months previously, he had joined a new practice as a partner. One of the other partners left the practice two months ago after an argument with the senior partner. He is concerned that reception staff are asked to add medications from discharge summaries to patient electronic records. He had noticed a few mistakes that could have been serious. He felt strongly that the whole medication reconciliation system for patients discharged from hospital needs an overhaul. He mentioned this to a couple of the other GPs in the practice who agreed with him, so he brought it up at a practice meeting. The senior partner instantly dismissed his concerns without discussion saying that there had been no major issues with the existing system and there was no reason to change a system that was working ‘perfectly well’.
 
Suggested points for discussion

 

  • What proportion of medication errors relate to errors in medicines reconciliation?
  • How would you advise your colleague to approach this issue in his practice?
  • How could your colleague explore this issue further to find evidence that change is needed?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (August 2017) forum discussion within the OLE:
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Equal Pay

With the BBC releasing today details of salaries of their top earners and having pre-warned us that only one third of these will be female, this month’s Clinical Scenario is especially relevant. It is worth considering this situation from the point of view of the salaried GPs, the partners and as trainees about to apply for jobs.

Equal Pay
Alison is a female salaried GP who has been working for a practice for 10 years doing 4 sessions per week – 8.30am to 6.30pm on a Monday and the same hours on a Thursday. The job is convenient for her as it is close to home and she can easily fit child care around her hours. She is paid £30,000 per year. The practice appoints a new male salaried GP. He works 3 days a week, 8.30am – 6.30pm on Mondays, Tuesdays and Fridays. One day, in conversation over coffee, he mentions that he actually had two job offers and chose to come to this practice purely because their sessional rate was better. He said he was being paid £9,500 per session. He has no additional duties or qualifications compared to her and is newly qualified as a GP. Both GPs are responsible for paying for their own indemnity.
Suggested points for discussion
  • Is the practice allowed to pay salaried GPs doing the same job different rates of pay?
  • Which pieces of legislation might be applicable to this scenario?
  • How might Alison manage this situation?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (July 2017) forum discussion within the OLE:

Drug Monitoring – Primary and Secondary Care Interface

This month’s Clinical Scenario on the RCGP forum is about drug monitoring. It is a really interesting scenario with lots of discussion points. In a time of trying to improve our resilience, it’s cases like this which rightly or wrongly, make me worry. If a complaint came through – what would you do? Do you have a clinical governance process in your practice to review cases such as this? See what you think….

Drug Monitoring
A patient of yours is seen in the rheumatology clinic and diagnosed with rheumatoid arthritis. The consultant initiates methotrexate treatment and organises baseline monitoring blood tests. When checking patient blood results after morning surgery one day, you discover that this patient’s white cell count is 2.9 x109/L. You review the patient’s notes and see that the rheumatology consultant prescribed the methotrexate, requested the blood test and copied you in to the results for information. Therefore you do not act on the result.
 
Two weeks later you receive an out-of-hours report stating that the patient was admitted overnight with a multi-lobar pneumonia. You telephone the rheumatology clinic to discuss the case and discover that the consultant has been on annual leave for 2 weeks and unfortunately the initial blood results were not acted upon. The patient required hospital admission, which led to financial difficulties for the patient as he was self-employed. When you next see the patient in your surgery, he is very angry with you, asking why you did not contact him about the abnormal blood test. The patient is keen to highlight that the correct advice from you could have prevented his illness.
 
Suggested points for discussion

 

  • How might you address the patient’s concerns?
  • How would you discuss this case with the rheumatology consultant?
  • How might you raise your concerns outside the practice to try and prevent this situation from occurring again?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (June 2017) forum discussion within the OLE:
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Busy Blog

There has been lots happening at InnovAiT since my last blog.

Great news that our Spring Podcast is now available. I enjoyed listening to it whilst in the car today! The recommendations from NICE on multimorbidity are discussed which reminded me how crucial we are for our complex and frail patients. In a week where five CCGs have reportedly proposed raising their thresholds for diagnosis of Autism due to service capacity difficulties – it was very topical to hear the discussion on Autism and Asperger’s. I am also delighted to support the STOMP campaign of stopping the over-medication of people with Learning Disabilities which is discussed in more detail in the podcast.

You may have seen the recent National media coverage around GP workload originating from an article in the BJGP supported by the brilliant Professor Chantal Simon. It has helped raise awareness of just how intense it is to be a GP in the current climate. Having positive stories of how hard we are working to do the best by our patients really helps me to feel proud of what we do. It also serves as a useful prompt for me to look at how we are doing within our surgery for capability and work-life balance so that we can continue to offer great care.

We are inviting your contributions for the ‘Difficult Decisions’ Special Edition to be published in August. If you are a keen writer, have something to share or just fancy having a go, you could submit a blog, case study, your top tips or produce your own podcast. We hope to compile an online collection of your thoughts on areas such as Ethical Dilemmas in genetics or perhaps palliative care, how to advise on the best treatment option for a patient – such as a multimorbid patient as discussed in the podcast, or even how best to achieve a good work-life balance – does something always have to give? Take a look at the website for more information – but be quick – the closing date is 30th June.

Our latest Clinical Scenario is also now available. This month’s discusses when your practice staff ask for your medical opinion. See what you would do and join in the discussion…….

Your practice manager, who is a heavy smoker, asks for your advice about a painless lump that she has noticed in her neck. On balance, you decide to agree to an examination and find that there is a firm non-tender swelling of the right submandibular lymph node. Her right tonsil is also enlarged, although she denies any throat pain. At your recommendation, she goes to see her GP, who refers her to the hospital under the 2 week wait.

Suggested points for discussion

  • How would you respond to a member of staff at your practice asking you to provide a medical opinion?
  • What are the ethical arguments for and against giving an informal medical opinion to a work colleague?

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