Doubling up

The next instalment of the clinical scenarios is now available. It’s certainly a very common occurrence and adds pressure onto any surgery. How do you manage this?

Doubling up

A patient well known to you with multiple health problems has recently got married. Her new husband registers with your practice. He also has multiple real health problems. Every time the wife comes to see you, the husband brings up his own health problems and wants to discuss them with you. He always states that his problems are urgent but never makes his own appointment. You have asked him several times to make an appointment for himself rather than discuss his problems in his wife’s appointment but this behaviour is persisting. They are frequent visitors to the surgery and always make you run late.

Suggested points for discussion:

  • Is it appropriate for the husband to discuss his own health problems in his wife’s appointments?
  • How might you manage this situation?

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:

http://elearning.rcgp.org.uk/course/view.php?id=219

Link to latest (February 2018) forum discussion within the OLE:

http://elearning.rcgp.org.uk/mod/pageplus/view.php?id=7996

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Prescribing and prescription charges.

This month’s clinical scenario is now available for you to consider regarding a situation which I have definitely experienced. Also with regards to mebendazole for treatment of worms in families. Following these, I have fairly clear plans for how I now manage such situations but look forward to seeing if mine are similar to yours.

Prescribing and prescription charges
You are a GP working in an inner city practice in an area of significant socio-economic deprivation. You see a mother and 3-year-old son who has an itchy rash all over his body. The rash is in his finger creases as well as all over his abdomen. You suspect a diagnosis of scabies and treat with permethrin. You recommend treating the rest of the family which on further questioning consists of mother and father, two older siblings aged 17 and 18 years and the patients grandmother who is 59 years old and lives with them.
When explaining the need to treat the whole family to the patients mother, she asks you to prescribe all the treatment in the child’s name as the mother wishes to avoid paying the prescription charge. When you explain you cannot do this, the patient’s mother becomes angry, threatens to complain and states that the rest of the family will go untreated unless you prescribe as she requests.
Suggested points for discussion:
  • What would you do in this situation?
  • Is it legal to do as the patient’s mother asks?
  • Do you have a duty of care to ensure the other family members are treated?
  • What other options are available to help the patient’s family?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (February 2018) forum discussion within the OLE:
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Gifts; more trouble than they’re worth?

diamond
Having just had Christmas, I would be fibbing if I didn’t look forward to the odd box of chocolates and bottle of wine from a patient. Although I am aware that I probably received more as a trainee than I do now! I am blaming this on working fewer clinical sessions now, but I am also aware that I don’t have as much time to give to patients. However, should I assess my value as a good GP on the number of Christmas gifts I receive? Probably not.
The scenario below however, is a little more than a box of chocolates. I think I would feel very awkward, but see what you think….and don’t forget to add your comments.
Practice donations
A very grateful patient comes in to see you following a successful procedure to remove an early bowel cancer that you detected. As he gets up to leave, he thrusts a thank you card into your hand. When you open it after he has left, you find £400 in cash enclosed in the card.
Suggested points for discussion:
  • Are there any rules about accepting patient gifts?

 

  • How might you manage this situation?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (December 2017) forum discussion within the OLE:
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Prostate cancer screening. Clinical scenario

This month’s clinical scenario is now available for discussion. This can be included with your reflection to your portfolio/CPD and you can see what others have commented on previously.
Prostate cancer screening
 
An 89-year-old man comes in to see you to ask for a prostate specific antigen (PSA) test. He is very fit and well for his age and has no urinary symptoms. He asks you why there is no national prostate cancer screening programme when there is a breast cancer screening programme. He recently watched a television programme which had concluded that thousands of men’s lives could be saved if there was a national screening programme. He thinks the lack of a screening programme is very sexist.
 
Suggested points for discussion:

 

  • Is it true that thousands of men’s lives could be saved if there was a national prostate cancer screening programme?
  • What are the possible harms that could be caused by PSA screening?
  • If you were this man, would you ask for a routine PSA test?

 

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