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:

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?



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.

Close-up of man's hand

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.


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?


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?


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.


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.
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.

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.


Career + Parenting = Guilt

I remember my mother telling me that being a parent involves a lot of guilt, whether it’s not breast feeding for long enough (if at all), not going to the right groups, or, as they get older, not going on such wonderful holidays as other children. Well I can add to all of that. The guilt of also having a career.
I read one of the popular parenting books a few years ago and within the first couple of chapters it became clear that the author felt very strongly that children shouldn’t be in childcare before the age of 4. Huge waves of guilt ensued. My eldest then was only 3 and already I had completely failed him?!
I was ambitious throughout school and university and enjoyed doing the extra bits and pieces where I could. I started my VTS and went on to have 3 children in quick succession. Suddenly I realised I didn’t have the time (or energy) to be quite so keen. I welcomed into my life this new world of Guilt and felt attacked by it on all sides. I was now unable to do those extra audits, CPD sessions or organising (let alone attending) the social nights out.
There was the heavy guilt of dropping the children at nursery at crazy o’clock knowing that they would probably be the last ones to be collected at the end of the day. There was also the mad dash to get there before nursery closed – an extra dollop of guilt towards work colleagues who were still there as I rushed off.
Don’t get me wrong; I can clearly remember the joy of eating my lunch in the canteen undisturbed when I went back to work after number one. There is also some freedom in having another purpose to who I am, earning my own money and being able to walk around unattached to an infant – but then there is the guilt for feeling like that too.
I have found that the children starting school has helped with the guilt slightly.  It isn’t my fault that they have to be at school – I have the law to support me here, (as I have explained to the children vociferously). Although some other mothers have scuppered this by becoming teaching assistants at the school, so even this small bit of support waivers. ‘Mummy, why can’t you be a teacher?’ Well, darling, hmm…..during the summer holidays I think they may have a point.
But this is exactly where being a locum GP can come into its own – due to one word – flexibility. I can fit work around life, not the other way round. When at work, I work hard, I do my best for the patients, I keep up to date, but if one week I want to go to sports day – I can, without the guilt of asking colleagues to swap. Most days, I can start my sessions after school drop off and finish so that I can be back at the school gates at pick up. This has really helped with another portion of guilt – this time towards my husband.  As he works full time too, expecting him to fit in school runs takes a toll on him just as much as me.
As the children get older, I fear the guilt doesn’t stop. The days of tearful nursery drop offs (me mainly) may be gone, but I am sure there will be lots of new ways in which I can let my children down, and never be as committed or quite as involved as I aspire to be at work. I am told the feeling of never doing anything 100% doesn’t leave, but I hope I am getting better at managing it.
Currently I am having a dilemma whether to go to a meeting which I really ought to attend or to make it to collect my children on time from school….probably best to stop writing now so I can let all that guilt set in for whichever I choose not to do.
This article was first published on Networklocum.com

Catch Up Treats

In case you haven’t had a chance to look inside your Great Green Magazine from last month, here are some sneaky treats.

There is a helpful article outlining the essential info about Postmenopausal bleeding and Endometrial Cancer. One of my learning points was that any significant bleeding change in a woman over 40, should also be considered at a similar risk for referral, alongside other risk factors such as obesity or PCOS. I also hadn’t appreciated the increased risk from tamoxifen use and it was useful to read about strategies for prevention of endometrial cancer.

The next article is on Testicular cancer with a really simple, handy guide for how to differentiate the types of scrotal swellings. Did you know that being taller is a risk factor for testicular cancer?

If you are starting to prepare for your AKT it would be worth reading the short summary of where to begin by Virginia Head who is an ST3.

It’s that time of year again when antibiotic requests are ever present – unless that is, you have a very well-trained patient group! I have tried hard to search through the evidence base that’s out there so I can confidently justify why I am not issuing them. We have had several great AKT questions on this subject in InnovAiT. I also came across this summary table of infection guidance for primary care, endorsed by the RCGP, which includes details of clinical criteria. Having your local CCG guidance to hand is also helpful.

As a trainee it can be tricky if the GPs in your practice have different prescribing habits. However, it can be really constructive to discuss these with your trainer so that you feel comfortable in what you are prescribing.