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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