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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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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CPD Catch Up

If you’re like me, there’s been too much going on over the Festive period to focus on CPD and e-portfolio. Hopefully this blog will give you some pointers to get back on track!

If you are preparing for the CSA or planning to start soon, don’t miss the short CSA series which started in the December issue. The first article discusses the format of the exam and is followed by Ten Top Tips for the CSA. The second article in the January issue covers the application process and how best to prepare. Good Luck!!

Another useful topic for both VTS and those of you preparing for appraisals, is the article on ‘How to Make Quality Improvement simple’. With regards to appraisals there is no requirement to have an audit anymore, but we have to evidence our quality improvement contributions. This article is a fantastic walk through how best to tackle this.

On a clinical note, Pelvic prolapse is an extremely common problem which can have a profound impact on quality of life. There is a great deal we should be offering in primary care for diagnosis and management. The article in the December issue is a really useful summary alongside what can also be offered in secondary care.

If you have anything related to diabetes listed in your PDP, the November issue is the one for you. There are three great articles. The first on Diabetes in Pregnancy, then an interesting discussion of Foot Sepsis and finally regarding the Cardiovascular Complications of Diabetes.

Finally, I was given a book for Christmas from a good friend about Finding Joy, the main premise being that we have to note the happy things which happen and not just look at the negatives. It struck a chord with me as I fear I might be prone to discussing those things which irritate way before the good things in my day. It seems these authors are not alone with this theory. In the November ‘From the AiT Committee‘ article by the fab @DuncanShrew, he talks about how ending his day explaining what he had enjoyed to the student with him, turned him from feeling slightly stressed to feeling pleased and positive. I think this is something to try to hold on to as much as we can. Especially with the increased criticism and pressure being placed on GPs over the last couple of days, it is as crucial as ever to make a point of noticing the positives for us as an individual. It won’t fix everything, but it might help with the day-to-day.

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Acoustic Neuromas – what you need to know

Acoustic neuromas – or more correctly vestibular schwannomas – are slow growing, benign tumours but if not detected early can have devastating consequences. They arise from the nerve sheath and can go on to compress cranial nerves and the brain itself. By earlier recognition there are more management options which can reduce morbidity and mortality.

To read more about how to diagnose one, as well as how they are investigated and managed, have a read of this article which has been published OnlineFirst on the InnovAiT website.

#ENT #unilateralhearingloss #tinnitus #Neuro

 

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All Work and No Play

I thought I sort of understood fibromyalgia. Well, as much as was realistic to for a condition which has no diagnostic test, no definite clinical progression and that many people are not even convinced has a pathophysiological cause. But then I met a young patient who did not have a diagnosis of any sort and looked on the surface as being very well. However, she was increasingly disabled with pain, her mood becoming lower as well as having persistent abdominal symptoms. When it was my place to broach the subject of Fibromyalgia it suddenly all felt a lot less clear in my mind. Dr Rachel Imrie’s article which is now available OnlineFirst, gives a brilliant summary of the condition and what our current understanding is and discusses the vital ways in which a GP can offer support.

If you haven’t already read it in the OnlineFirst, June’s issue is filled with all of the brilliant resilience and burnout articles I talked about in last week’s blog, as well as a truly moving article written by Dr Chris Manning. He talks very openly about his own experiences and questions the history of medicine alongside current understanding as to how we now find ourselves so vulnerable.

One of my favourite quotes this month is ‘Sustained stress makes us more dull-witted and unfriendly’ – which I read as an evidence based, high brow version of ‘All work and no play makes the GP dull and grumpy’. I have heard or read many discussions amongst GPs as to how best ‘switch off’ from work and we always have a prepared answer for interviews as to how we recognise and manage stress in ourselves but how often do we actually put it into practice? I think I managed it a little better when I first finished medical school, but now with all the other life factors (for me, mainly children) it is genuinely hard to find the time. I have taken some nuggets from these fantastic articles to implement, especially to ‘Take Back Control‘, I hope you can find some which work for you too. Let me know @rcgp_innovait
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Women’s Health, but don’t forget the men

We had a brilliant special issue on Women’s Health in March which covered many pertinent topics such as PCOS, heavy menstrual bleeding and infections in pregnancy which would certainly help achieve a PDP or add some CPD points so have a look here if you haven’t already.
There is also a not to be missed article from back in February, on psychosexual medicine which is an area in primary care which can so often be avoided or ignored, often without even realising, but here you can read about some very typical cases with suggestions and advice on how to manage them.
As it is often hard to find the time to sit down and read, there is also a Women’s Health podcast now available for free online. As well as a catch up of the essential need to know changes in guidelines and recommendations in the News and Views section, there is a really helpful discussion on Genital Herpes which until dealt with a few times, can definitely cause as much anxiety in the GP as in the patient – when to test? when to use a blood test? how best to treat? what about in pregnancy? when to refer? These are all questions addressed in this short interview with a GU Consultant. Other topics discussed are pre-eclampsia and perinatal mental health which is increasingly being brought to the forefront. There was a lively discussion on this subject on Twitter recently with @rcgp and other experts – the storify version can be read here.
To even things up a bit, the latest (May) issue gives some well deserved attention to Men’s Health. Not just Scrotal Emergencies and Prostate Cancer but vascular problems also, such as AAA and Acute limb Ischaemia. You can already read this online if the Great Green Magazine hasn’t yet reached you.
We can’t let this week pass without mentioning the strike. However you have been involved, I hope that as trainees you have felt supported and valued for the brilliant job that you are all doing.
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REFRAME: Resilience training for GPs

REFRAME is a half-day resilience workshop, originally developed for Foundation doctors, and refocused for General Practitioners. This mixed methods pilot study evaluated whether resilience training is acceptable to NHS GPs and relevant to the problems that concern them. Fifteen participants attended and most were looking for information to help them manage their working life and avoid burnout. The qualitative data provided powerful positive feedback suggesting that participants found the practical information, and the act of setting aside time to share problems with peers, of value. Understanding the neurobiology of stress provided important personal insights and illuminated vital areas for potential self-management with the majority motivated to make simple but potentially effective changes to their lifestyle and working environment thus enabling them to become more resilient. Participants indicated that they would value access to online resources.  REFRAME, as a brief resilience training module, has been accredited by the RCGP.  Further development through focus groups of both content and course evaluation is under way.

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Leadership: making it happen

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Leadership is critical to the delivery of all aspects of high quality patient care and general practice is no exception to this. As general practitioners we need to accept that effective leadership and management is part of our professional responsibility, whether it is managing an individual patient or running a Clinical Commissioning Group.  Leadership is about having a desire to make a difference and to move things forward.  This can be achieved by undertaking three simple steps:  understanding what the problems are and having an idea (or vision) of how to improve them, engaging with others to work out how best to achieve this, then finally delivering the change. Hopefully this article will inspire you to continue your leadership journey and implement leadership skills in your professional role, thereby contributing to an enhanced quality of life for yourself, your colleagues and the patients that we serve.

Visit InnovAiT Online to find out more and register for Online First access.