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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Diverticulosis

Diverticular disease feels so common place that it’s easy to be slightly nonchalant about it. However, the impact it has on the population is significant and even more so for those patients who develop complicated diverticulosis such as abscesses, fistulae or perforation. Interestingly you are more likely to have these if you smoke or take NSAIDs.

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At a time when the importance of antimicrobial stewardship is increasingly recognised, the decision to prescribe a broad-spectrum antibiotic cannot be taken lightly. Having a solid understanding of the clinical features of acute diverticulitis can help with the decision of when to issue.

The article in this month’s InnovAiT by Dr Whatling gives a fantastic overview for what we all need to know in primary care.

To follow the digestive theme in this edition, there are articles on acute gallbladder disease and benign ano-rectal disorders. Amongst other helpful tips, the latter has a good reminder of haemorrhoid staging and when to refer.

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Health Anxiety

In a googletastic time, anxiety about one’s health can be increasingly difficult to support as a GP. The journey as a doctor to understand that the patient is presenting due to their health anxiety, can be a drawn out and difficult one. It can probably only happen well with continuity of care, confidence and a good relationship with the patient. There are many pitfalls along the way.

Here is this month’s clinical instalment available for your thoughts, comments and reflection. See what you would do….

Samantha is 34 years old and a single mother. She has a past medical history of a meningioma that was completely excised 15 years ago. She has been discharged by her neurosurgery team. Two years ago, she presented with recurring headaches. She was seen by a specialist neurologist, had brain imaging, and was reassured that her headaches were tension type headaches and not a recurrence of her tumour. She subsequently asked for a second opinion and was seen by another neurologist who repeated all her tests and came to the same conclusion.

She has always attended the GP surgery frequently, but over recent months has been making appointments every week about her headaches and calling the surgery asking to speak to a GP in between. She is convinced that she has a recurrence of her ‘cancer’.  She is also making frequent appointments for her son, who is well and has no persistent symptoms or abnormal examination findings, and demanding that he is referred for specialist investigation to make sure that he ‘doesn’t have anything nasty’.

father comforting son in tears

Suggested points for discussion

  • How might you manage this lady’s headaches?
  • How might you manage her health-related anxiety?
  • Is her anxiety about her son a safeguarding issue?  If so, how might you manage that?

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Clinical Scenario Forums

You may remember a previous blog letting you know about the new Clinical Scenario forums available on the RCGP  Learning site in conjunction with Doctors.net.

These are now up and running with lots of scenarios to consider how you would handle them. If you have a Doctors.net login you can comment too. It is useful to consider different options of how to manage a situation and these are discussed in the comments below each scenario which can all be used as CPD for your eportfolio.

This month’s, shown below, is around overuse of medication. My thoughts on reading it, was relief that I (hypothetically) recalled the patient and having issued the medication – it didn’t just get buried in amongst the many others. Depending on how well I knew the patient I would either give her a quick call or reject the request asking for more information as to why she needed it, but also copy it into the journal notes that this had happened so that if anyone else received a request they would know. But what do you think? Am I being too keen? Should it be a simple reject and the onus is on the patient to get back in touch? Or perhaps, as it is the first real extra request just send it on? Do comment on the site, or tweet us.

Overuse of medication

While reviewing a batch of prescription queries in the Electronic Prescribing System, you come across a request for a month’s supply of 40 mg citalopram tablets. It is for a woman who you saw last week and it strikes you as odd as you recall issuing her with some medication then. The prescription is not on repeat and so is not flagging as being overused but the date of the last prescription issued is just a week ago.

You check back in her notes and find that she had her usual prescription a month ago, another from you a week ago as she said she needed them early as she was going on holiday. Therefore this is the third request in a month for antidepressant medication.

Suggested points for discussion

  • What would you do in this situation?
  • What safeguards can be put in place to prevent patients at risk of suicide from making extra prescription requests to stockpile medication?

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Could you be an Learning Disabilities Clinical Lead?

One of the changes in the recently released GP contract was an increased recognition of Learning disabilities (LD). The directly enhanced service requires an annual health check for all on the LD register and there is now a higher payment for available for this (of £140).

In our next issue, and already available OnlineFirst there is a comprehensive article about health promotion and screening for people with LD or the interchangeable term ‘Intellectual disability’. The latter is used to differentiate more clearly from learning difficulties such as dyspraxia or dyslexia.

Equity to healthcare and screening is a huge issue and we can start to improve this in our surgeries. The article by Drs Awan and Chauhan, describes the very practical Top Tips for Effective Consultations, a simple explanation on assessing capacity and how to manage when there is a lack of capacity for a decision.

Has your practice already got an LD lead? If not, this may be a great place to gain experience – and tick those leadership PIP boxes – this article will get you started.

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What is CBT and How to Use it & Understanding Childhood Depression.

Cognitive behavioural therapy is a well used term but are you comfortable with what it actually entails? Can you describe it to patients (compared with other counselling methods) or even use some of the strategies in your consultations? If you are able to, it can be particularly helpful, especially when waiting times are long allowing you to further support a patient in the meantime. A GP and clinical Psychologist have teamed up to write this article which offers good techniques to use within a 10 minute consultation. Below is the Core Principal of CBT which is really helpful to explain how CBT works to patients.
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A situation where knowledge of CBT techniques can be helpful is in childhood depression. This is an easily missed and highly anxiety provoking presentation for many trainees and GPs. It is the most common psychiatric disorder in children and adolescents. Ensuring you take a good risk assessment, establishing a support plan as well as having a good range of third sector or online support are crucial. Fluoxetine is the SSRI of choice if the young people have not responded to psychological therapies. The article by Dr Mills and Dr Baker describes the primary care assessment, diagnosis and management of this condition.
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