Northern Doctor

www.northerndoctor.com

2008-10-08T15:01:00.002+01:00

Now here - northerndoctor.com at Wordpress.

I have moved...

2008-10-04T21:38:00.003+01:00

I have switched over to Wordpress after too many evenings wrestling with the formatting in Blogger. I can still be found here at http://www.northerndoctor.com/ or simply northerndoctor.com as they seem to prefer there. (I am no longer sure of the significance of the www bit.) Or you can of course use the www.northerndoctor.wordpress.com address and you will be redirected to northerndoctor.com.

If you have still been using http://www.northerndoctor.blogspot.com/ then it is all going to go a bit quiet for thee (and also for me) if you don't change your links.

Thank you so much and apologies for the high faff factor.

*Update*
Sunday 5th October. It all seems to work well on my own computers but I am in work at the moment and there is some alarming '404' style action on the PCT computers. They do seem moderately decrepid so I am not sure of the problem here. It all works fine on my Blackberry! Hopefully, it will right itself somewhere in the ether and I will not need to do anything. However, if not then please let me know.

More eleutherococcus

2008-10-03T10:57:00.008+01:00

I am having a bit of a bad science rush of blood to the head after reading through Ben Goldacre's, er, Bad Science book last week.

Budding triathletes
Eladon have been making some suggestions that the use of Eleutherococcus senticosus is supported by 40 years of Russian research and I quote:

"is used to this day by top class Russian athletes being first recommended by the former USSR Ministry of Sport for use by all Russian athletes including the Olympic teams as long ago as 1962."

There does seem to be a lot of literature on this stuff aka Siberian Ginseng from the Eastern bloc and it is not the most accessible in the world. I am not entirely familiar with current trends in Russian high performance athletics so I won't comment further. But I would highlight this systematic review from Canada which found no effect. Predictably the trials which had dubious methodology showed an improvement and those that were more rigorous did not. I am not too disappointed; my triathlon ability is more likely to be improved by a structured programme of regular exercise (ie more than once a week).

Their Elagen Sport capsules also have Coenzyme Q10 in them. Dr Aust can advise you further on this here.

They will supply you with 90 capsules of their Elagen Sport version for £14.95 here. I couldn't help noticing that there are now 50 years of scientific research on this page. It may help as they say - or it may do chuff all if the systematic review is on the button.

Eladon has a very clear statement at the bottom of their home page that they are not making any medical claims. Hmm...

‘Quack’ remedy for bored housewives?
According to Biochemist Dr Nicholas Miller, B.sc, P.hd, health food supplements are often perceived to be 'quack' remedies taken by bored housewives and bewildered hippies, however, few can deny that early 21st century lifestyles tend to be high-stress, high-pressure, performance orientated and plagued with toxins and pollutants of first-world technology. Eleutherococcus with its anti-stress, anti-toxic and stimulatory effects can delay hardening of the arteries, allow for harder work for longer hours without damage to health and can allow people to tolerate higher than normal levels of poisons. Its effect of generally strengthening the immune system combats poor diets and day-to-day viruses and has also been shown to be useful in the treatment of nervous disorders such as depression.
Dr Miller believes it is only a matter of time before the West accepts Eleutherococcus as an officially recognised medicine. “While of undoubted benefit for the sick or convalescent, it is also of boundless value as an invigorating prophylactic to ensure continued good health,” he remarks. “Eleutherococcus is for everybody, especially the overworked or the run-down - the major problem is to tell people in a way as to remove the barriers of cynicism and disinterest.”

The first sentence of this statement is a triumph of misdirection. I can see I am going to have brush up on my Russian and get into some of these papers.

No more anonymity

2008-10-01T20:31:00.001+01:00

Me!

A short announcement - I am no longer blogging anonymously.

I am quite comfortable with being associated with any of my posts and I can see no reason for me to hide who I am. I enjoy ambling my way through the more attack-minded blogs but it isn't the route for me. I plan to continue blogging pretty much exactly as I have been doing.

Er, what's an adaptogen?

2008-09-30T19:53:00.007+01:00

I couldn't help noticing the blurb in this advert in the back of a triathlon magazine I was recently perusing.

Sport Elagen

combining the adaptogenic effects of ES with the anti-oxidant and catalytic
properties of Co Q10

scientifically designed for sportsmen and sportswomen

Phew. I have to admit this is the kind of pseudo-scientific hogwash that really sets my bullshit detector clanging. The advert has a website at the bottom - http://www.elagen.com/

I thought I would start picking the bones out of this advert...

It turns out ES is Eleutherococcus Senticosus - a herb. Elagen capsules are "a highly concentrated pure root extract measured to the correct potency proven to provide maximum effect."

One of the first questions you might ask is what is an adaptogen? I have no recollection of the mention of adaptogens in any physiology lecture I have attended or any textbook I have ever read. Maybe I was snoozing in my lectures but luckily the website is on hand to inform me:

In the 1950's Prof Brekhman of the pharmacological department of the Far East Scientific Centre of the Russian academy of Sciences recognised the potential value of the root and initiated extensive research into its properties. He subsequently classified Eleutherococcus as an 'adaptogen'. An adaptogen is a natural plant substance, which acts to normalise the body's systems in harmony with the normal metabolic, biochemical and immunological processes, as such adaptogens are innocuous and cause no harm. Adaptogens should have a non-specific action, such is the ability of Eleutherococcus to modulate stress and improve performance under a wide variety of stressful conditions.

So adaptogens have a non-specific action that causes the body to work normally. Hmm, never mind the hundreds of thousands of years of evolution that has resulted in the mind-boggling sophistication and elegance of human homeostasis. An adaptogen can make homeostasis even better! It would, of course, be tremendously difficult to prove it wasn't working.

I wonder if this feeds into the psyche of some athletes when it comes to performance enhancing drugs. At one end of the spectrum is the sheer naked cheating of a blood doper. By some artificial means the oxygen carrying red blood cells are augmented. However, at the bottom end this can all get much more woolly. Does taking an adaptogen constitute cheating through performance enhancing substances? The answer is probably no; not unless placebos appear on the international list of proscribed drugs.

The Law of Unintended Consequences

2008-09-16T20:00:00.005+01:00

The substance misuse team I work for had the misfortune to be subjected to a partial tendering process a few years ago. The service was split down the middle and tenders invited for the criminal justice side of the service. This has had some nasty and utterly ludicrous knock-on effects. No one considered the Law of Unintended Consequences...

This takes a bit of explaining but stay with me.

The Intention - Background

The Community Drug Team (CDT) used to look after all heroin users - both on the 'core' service side and 'criminal justice' side.

The criminal justice side of the drugs team looks after those users that come to our attention through the courts, through arrests and after release from prison. They are often subjected to drug rehabilitation orders from the courts or are out on licence with specific probation conditions attached to their freedom. The core service looks after everyone else. The contract for the criminal justice work went to a national drugs charity. The CDT was split with half the keyworkers going to the charity to work and the others staying with the core service.

The core work remains in a NHS Trust and the charity uses exactly the same premises with a different set of staff to see the patients. There are now two entirely separate administrative systems running in parallel when there was previously one.

Still with me?

The Consequences - the Law kicks in

Unfortunately, when some muppet at the PCT negotiated the contract they neglected to include anything on the crucially important business of giving drug users Hep B vaccinations and testing them for blood borne viruses such as Hepatitis C and HIV. A fairly basic requirement for this patient population. Despite discussions this remains at a complete impasse.

The core service lost its full-time lead doctor as it can no longer can justify employing a doctor to cover the whole week. This means in the early part of the week they have no one on site to give medical support to the keyworkers, to give advice, see patients, replace missing prescriptions etc. Innovation in the service has ground to a halt.

I work for the criminal justice side. The absence of a contract for Hep B/C means that despite there being a clear clinical need and the fact that I am appropriately trained and fully qualified to administer vaccines, as well as counsel and then test for Hep C/HIV, I am not allowed to do so. I sit within 2 feet of a fridge full of vaccines and a trolley with the tools of the trade for blood-letting. The contract says no. I am supposed to refer the patients to their own GP. Utterly moronic.

While I sit ignoring this travesty of clinical care the keyworkers from the CDT walk past my room bemoaning the fact they have no GP to get advice from on till the end of the week. I am hamstrung when it comes to getting involved. I am powerless to offer any advice as I am, in effect, working in a parallel medical universe.

No prizes for guessing the losers in this inelegant arrangement.

Joined up thinking? Centrally funded? Welcome to the consequences of a health service where we fragment care. It is a nasty little glimpse of the future where the purchaser-provider ethos overrides common sense provision of routine clinical care.

Shipman's long shadow

2008-09-15T01:07:00.002+01:00

After my shifts at the out of hours this weekend I noticed something about the morphine. In the last week I was the only GP that signed out any morphine to take on home visits.

Now there are a couple of possibilities: either I am the only doctor that has been required to go on any visits in an area that covers an area across three counties in the past week or I am the only doctor who took morphine out when I did it. I am pretty sure I know which it is.

I have had a lot of discussions with colleagues recently about using and carrying morphine. Many are deeply anxious about using a drug that has been demonised by Shipman and been the object of such severe scrutiny by the authorities. If anything goes wrong with morphine and it is highly likely you will be suspended pending a full police investigation. And things can go wrong. Even with the greatest care in the world, morphine, just like any other drug, has potential side effects. One of those side effects being that the recipient stops breathing. There is an excellent drug, naloxone, that reverses the effects of morphine. And it works just like this Trainspotting clip - a magical, instant recovery.

But the fact is that most GPs do not see the benefits of morphine to their patients outweighing the potential disadvantages to themselves.

However my opinion doesn't square with the evidence. The Healthcare Commission annual report on 'The safer management of controlled drugs' suggests that opiate use actually increased by in 2007. (Thanks to NHS Exposed for highlighting the report in this post last month).

Perhaps I could agree that I have seen an increase in prescribing of morphine and other opiates in palliative care in the past few years. I am also aware that amongst GPs that do prescribe 'core drugs' in palliative care it is common practice to prescribe a whole box to leave in readiness as the patient gets to the end stages. These often go unused and the data says nothing about actual morphine usage.

From the report:

"I am very pleased to hear the post-Shipman tighter governance arrangements have not been a barrier to patients receiving opioid treatment.
I suspect that the increased use of Schedule 2 controlled drugs is partly due to their increasing use in the management of persistent non-cancer pain "

Dr Roger Knaggs
Specialist Pharmacist - Pain Management
Nottingham University Hospitals NHS Trust

My practical experience as a GP is that there very much is a barrier to some patients getting morphine. Most GPs are not carrying it and that is a pretty sizeable issue to overcome. Of course, a doctorate pharmacist in a secondary care hospital would remain utterly ignorant of this.

It is encouraging that opiate prescribing hasn't dropped through the floor but I remain highly sceptical that morphine use has increased as a primary care drug for patients in acute pain or having a heart attack. While one can still expect morphine if one is dying or in chronic pain it is being eradicated as a drug for the acutely unwell in their own home. I wouldn't expect this to show up in these statistics - it is always going to make up a fraction of the total morphine prescribed.

The report doesn't go into these details but it does note the relatively greater increase in drugs such as oxycodone. I asked a palliative care specialist last year why oxycodone is a better drug than morphine and he freely admitted he couldn't give any clinical reasons. Perhaps it is the placebo effect of fancy packaging or perhaps simply because it is not morphine. (I also noticed the increased prescribing of benzodiazepines by nurses but that is a rant for another day.)

The Healthcare Commission's report should not lull anyone into complacency. It is very possible that we are leaving patients in pain on occasions and inadequately treating life threatening conditions as a consequence of a state noose of controlled drug regulation around the necks of clinicians that use morphine in patients' homes.

We need some further research into the actual patterns of use of morphine post-Shipman and and exploration of GP attitudes to this group of drugs. Any potential collaborators please feel free to email.

The GP bag - or mine at least

2008-09-14T07:00:00.001+01:00

While I was on the subject of the doctor's bag I thought I would share mine. It makes me look more like I a plumber than a GP. Despite media reports to the contrary, as a salaried GP, I am not quite as expensive as a plumber per hour at weekends.

It is a touch redolent of a Gladstone bag as favoured by those GPs more inclined to the 'Grand Old Man' image.

G.O.M. isn't really my preferred style...

Giving it all up

2008-09-12T10:37:00.009+01:00

One of the most insidious changes in 2004 that the reorganisation of out of hours care has precipitated is the way that GPs now approach the treatment of emergency medical problems. A minority of GPs including principals work shifts out of hours and most GPs get significantly less exposure to acutely unwell patients than they did in times past.

I do a number of appraisals for the PCT each year when I get to sit down with fellow GPs and have a blether about the state of the nation. As well as artfully facilitating their self-directed educational processes we, as appraisers, are encouraged to introduce an element of challenge. I like to ask what emergency drugs they carry nowadays.

Increasing numbers do not carry anything. No penicillin in case of the dreaded once-in-a-career case of meningococcal meningitis, no adrenaline for severe allergies and certainly no morphine for pain or heart attacks. Nothing. Not even an aspirin. Even in a relatively rural area oop north most GPs prefer to have a mobile phone and the ambulance control emergency line on speed dial. (And that is the conscientious ones; the rest ring 999 and suffer the callhandler protocols.)

It is a further worrying erosion of our professional position but it's one that doesn't have to happen. As GPs we do all have the choice to keep up those skills, to keep ourselves equipped and not shrug off care to the nearest paramedic and A&E department.

Playing with fridges

2008-09-07T09:02:00.005+01:00

I was watching the Tweenies with my children recently and they have a 'Be Safe with the Tweenies' mini-series. Most of these are about relatively obvious risks such as the dangers of walking in front of swings or running out into the road. This episode was all about the risks of getting stuck in old fridges and it seemed unnecessarily macabre to my mind. The kids didn't seem too bothered and I didn't dwell on it further other than to consider how tricky it might be for a 6ft high polyfoam Tweenie to get into anything but a drive-in fridge you might see in the USA.

At work, I have been doing some digging into the literature for an old paper related to the problems of reducing people off benzodiazepines. There has always been some concern that stopping benzos suddenly could cause seizures. The 'paper' was in the British Journal of General Practice 20-odd years ago. This oft-quoted piece of the literature turned out to be a letter in the back pages of the BJGP detailing a fairly gung-ho trial where a number of patients prone to fits had their benzodiazepines dropped like a stone. Thankfully, all was well for those patients but I was left reflecting on the ethics of research from a bygone era.

You may wonder how ethically dubious research and child fridge misadventures are linked. Take a look at this remarkable 1958 paper on how children behave when locked in fridges. I picked up on it via this blog entry highlighted on badscience.net. Yes, they did actually lock children in a simulated fridge and then observed their response.

A classic of medical research. Now trying getting the consent form for that signed these days.

Floods cause chaos

2008-09-06T20:11:00.004+01:00

No, not here. In India 56 have died and there have been 3 million affected in over 1700 villages in the Bihar region and Nepal has also been affected. The WHO page is here and gives an update on the crisis.

The information available on the WHO site is remarkable. The South East Asia Regional Office have detailed reports (India and Nepal) on the current situation. It goes as far as to list individual camps with numbers of people, those pregnant or post-partum and also any disabled refugees with how many wells and toilets to which they have access.

One of the hardest things about absorbing information on the WHO site is that the numbers de-humanise the suffering. I guess it is the same with many of these situations. Of course, television pictures help but it can be hard to raise an emotional response. Reading the names of schools being used as camps helped me bring it back a little. Try substituting your local primary school name and then imagine your entire local population sheltering there.

The first things these people need is clean water, somewhere to crap and the kids need an emergency measles immunisation programme. And food and shelter of course. This is a standard response to a humanitarian crises but it is interesting as most people would not immediately think of the measles. It can tear through the child population and I have commented before on the potential for measles to kill. I always finds the WHO helps give me a bit of perspective and this damp week is no exception.

Incidentally, I am not aware of any evidence that our MMR catch-up programme and an increase in measles cases is in any way related to the sodden British summer.

Never trust a GP in a leather trilby

2008-09-06T10:41:00.003+01:00

The Jobbing Doctor comments on The Mail's malignant article this morning. Let me draw attention to one aspect.

Compare and contrast:

The Mail September 5th, 2008

"Their [principals] pay has shot up 58 per cent to an average of £113,164 but they are seeing fewer patients and working seven fewer hours a week."

BMA News September 6th, 2008

"Average pay of a salaried GP as of of 2005/6 was £46,905 but this was because many worked part time: 23.8 hours a week on average according to the NAO... This would make a pro-rata average yearly salary of £74000..."

It would be easy to see how it might be a great idea to employ salaried GPs as part of large private enterprises. Please see Rules 1, 2 and 3 below on some of the issues that have to be addressed if we go anywhere near this sort of model.

Incidentally, I am not surprised that The Mail have attacked Dr Gupta - have you seen his hat?

If I were in charge... Rule No.1

2008-09-05T14:00:00.000+01:00

I thought I would spend some time reflecting on what changes I would make if I were in charge.

Just complaining about the system could start to wear people down.

I think there are some fundamental principles that need to be embraced in primary care. Some of these are already being achieved and some of these are pure aspirations, some are being eroded and are now in serious danger of falling off the edge.

Here are my first thoughts:

Rule 1. Every person in the UK is entitled to care from a named GP.

This seems simple but in practice it is easily eroded. What is indisputable is that people value continuity. They may also need to access Walk-in Centres and NHS Direct but when you have any kind of illness that can't be resolved completely in a single contact then it is stark-staringly obvious that it helps to see the same GP again.

Pulse reported on this in the past month. There is something of a paradox here in this survey but extending hours doesn't tend to do much for continuity when the evening/weekend clinics are share out. The ideal continuity of care would mean you could access the same GP 24 hours a day 7 days a week. This is clearly not likely to result in a very happy and effective GP workforce. We tried it in the past and it ended up with a singular lack of GPs. I have been that GP and it is Officially Miserable.

I think the named GP should work a certain minimum number of sessions to be eligible to be a 'named GP' and be reasonably accessible to the patient. I don't think that person has to be a principal and they could easily be salaried (but see Rule 3). I don't have a huge problem with the accessibility being measured in some way. However, previous methods of measuring accessibility to GP appointments have, if anything, damaged continuity of care as practices have offered same-day appointment systems and other dubious innovations to ensure access targets are met.

There should be special protection under this rule for the housebound, elderly, disabled and residents of nursing homes etc. It might even be worth measuring continuity in this group of patients. How many different GPs have they seen in the past 12 months? I would wager that quality of care is inversely proportional to that number. One large practice near us has a 'duty doctor' who will do visits on their designated day for the whole practice. In a practice of nearly 20 GPs it can be a while before you see the same GP again...

That named GP should be actively involved - not just the 'registered GP' so often quoted that has never met the patient.

So it is simple: one patient, one genuinely responsible GP.

If I were in charge... Rule No.2

2008-09-05T13:41:00.007+01:00

Rule 2. The 'named GP' should have a maximum number of patients on their list.

Pulse report on this today - in a situation of economic constriction one way of maintaining income is to keep patient lists high.

However, I haven't added this to my list because I am concerned about greedy principals. GPs only let this slide out of desperation. We all know it is bad for care but if the money ain't flowing, they can't take on staff and they just have to absorb the work. It's nasty for everyone.

The main reason for adding this is to give a measure of protection against the corporatisation of medical practices. Setting a maximum number of patients would make it harder for practices to shrink partnerships and employ nurses, salaried GPs etc while they adopt a CEO GP role and absorb the profits. It helps maintain Rule No. 1 as a reasonable prospect. The maximum number could be altered from region to region depending on factors such as deprivation, health care needs and geography. It should never be open to manipulation on pure economic grounds.

It would also protect patients against these same excesses from cold-blooded private organisations with profit motivated agendas. It might have the unintended effect of capping GP salaries but most GPs don't want to get rich, they just want a fair salary for a fair day's work.

However, these first two rules don't exclude a different model for general practice. If a big company makes sure that there are named GPs active in looking after a reasonable number of patients then that's fine as long as Rule No. 1 and Rule No. 2 are observed. So I thought we needed a Rule No. 3...

If I were in charge... Rule No.3

2008-09-05T13:15:00.000+01:00

Rule 3. The 'named GP' must retain a measure of control over how that clinical care is delivered.

This is more nebulous and needs further refining. Fundamentally, this is to protect patients against the worse excesses of top-down central government control over patient care and retain the capability to meet local need.

I think this control could vary from model to model. I think that there are very few models of primary care in this country that work as well as the democratic medium-sized practice with a strong primary health care team all contributing to the care of patients. The input of clinicians in this model is readily apparent. However, I do not think it is necessarily the only model of care that could work for the whole of the country.

A salaried 'named GP' in a larger company would still have to have an input. The company would be expected to demonstrate, as part of its contract to deliver primary care, that it is responsive to input from clinicians.

People complain about a 'postcode lottery' but local variation in care is essential to meet local differences in health care need. I think there is scope for variation in the delivery of care and (shh, say it quietly) there may well be some areas, perhaps severely deprived urban areas, that will benefit from a polyclinic. If they met these three rules then I would be more relaxed about Darzi.

A positive choice

2008-09-04T19:53:00.005+01:00

I am a big believer that being a non-principal GP (not to be confused with an un-principled one) is an incredibly positive choice for a GP to make. I love my job. I don't want to be a partner.

There is still a considerable hangover amongst the profession that salaried GPs are principals 'in-waiting' and that locums are simply unemployable wasters.

I do work weekends, as do lots of salaried GPs and lots of principals. And most importantly, I really enjoy it. The administrative burden of daytime general practice is stripped away and you are left with a patient, their problem and one's own clinical acumen. It feels like real medicine with real medical problems rather than Big Pharma medical manipulations. (Motto - an ill for every pill). I reckon I examine almost every single patient. How often can you say that in daytime practice? When I am out visiting I spend as much time as is needed to sort the patient and our out of hours service supports that approach to patients.

I recently signed up again with the National Association of Sessional GPs. They are working had to look after the interests of non-principal GPs. Ludicrously simple things like getting the current BNF have been a challenge in the past and the NASGP has helped in all sorts of areas:

We're a voluntary non-profit making membership organisation currently with 1,700 members, and our aim is to unite all general practitioners through an agenda of quality and equality. Yes we agree - it all sounds very ambitious but in fact we've been very successful in doing just this. We were founded in January 1997 by a group of enthusiastic GPs (nearly all Sessional GPs), and we've energetically campaigned to improve the status and representation of Sessional GPs through our handbook, regular newsletters, national conference, code of good practice, local groups, practice induction pack, website and the media.

I'll also continue to support principals as I believe every person in the country needs a named GP. Much as I love being salaried, being a locum, being a teacher and whatever else I choose to do I also recognise the need for an appropriate framework for primary care.

Free car parking for some...

2008-09-02T13:22:00.004+01:00

One of the frustrations I feel at being a GP is that it seems impossible to do one's job without a car. Home visits are a normal part of the working day and in the more rural setting oop north it is unimaginable to manage without a vehicle.
I often think some practices should invest in a very cheap runaround or maybe some kind of hybrid/electric car. It could live at the practice and the GPs could cycle/walk/get the bus into work and there would still be transport to do the visits. Everyone's a winner.

A minor irritation with visiting hospitals is the need to pay for parking everywhere you go. I do not have a big problem with paying for parking in town centres. I think of it as a bit of an extra tax on car ownership and it rightly encourages me to thick twice about these visits and I get on my bike when I can.

The charge for car parking at hospitals does not fall into this category and has always raised hackles.

Interestingly, Scotland have chosed to abolish charges. While it hardly constitutes a major rift in health provision across the UK and I don't think anyone will be using the standard 'postcode lottery' argument here it does highlight how the management of the NHS is diverging.

Even more interestingly, the Health Secretary Nicola Sturgeon has been powerless to influence the situation at PFI hospitals. Jobbing Doctor has had a word about PFIs already today. They may not show up on the public borrowing but we have certainly mortgaged away a huge slice of future NHS spending. Thin end of the wedge anyone?

Royal College of (London) General Practitioners

2008-08-30T20:21:00.008+01:00

I have recently become involved with the local faculty of the college but there is clearly a problem with encouraging young blood locally. The old-fashioned image is one of a gentlemen's club with red-faced GPs agreeing to bestow fellowships on one another as they pass the port. The stale aroma of these smoked-filled rooms lingers on in provincial faculty meetings.

It is difficult to be critical of the College - they are fundamentally about improving the quality of general practice. They explain their role further here.

It might be difficult to be critical but I am going to try anyway.

Firstly, I should warn anyone tempted to browse their site that it is a god-awful example of a website. It is bland, tricky to navigate and given that websites are really the shop window for these organisations, deeply uninspiring.

Website aside, I am not convinced that the College has grasped all its opportunities to engage a wider audience. Of course, almost all GP registrars, or Associates in Training (AiTs) to use the jargon, are now members of the college as Membership of the Royal College is now mandated as the basic qualification for a GP. It used to be known as MRCGP but has now been snappily re-branded as nMRCGP.

To be fair, there have been substantial and fairly impressive changes to the nMRCGP examination. I have been around long enough that I could apply to be an examiner with the College and this is something I would be interested in. The College runs a Clinical Skills Assessment (CSA) component to the exam. (Still with me on the acronoyms and abbreviations?) This is a impressive construct with candidates being examined in 13 'mock' consultations where the full spectrum of their skills as a GP can be assessed.

This is all a great achievement. And it has all been comprehensively tainted by the location of the examining centre. Every single candidate in the country has to travel to the CSA centre. In, ahem, East Croydon. So it is south of London and a total nightmare to get to unless you are based in London itself. Your best bet if you live in the north of England or Scotland would probably be to fly to Gatwick. I feel it is only right that I register my utter disgust at the choice of location.

To be an examiner they ask for a commitment of 12 days and you are expected to spend some of this time in 3 day blocks at the CSA. (Add travel to that and I would probably be away from home for 4-5 days.) Good grief. It is difficult to imagine any more barriers to a GP with a family who works for a living in the north.

While I understand the need for consistency and reliability with examiners is the College managing to recruit any assessors in the north of the UK at all?

Anonymity of bloggers

2008-08-29T21:10:00.003+01:00

I have been giving this some thought for the past few days since I read the excellent post on NHS 'Behind the Headlines'. I am a mere babe in GP blogging terms but I have been giving serious consideration to 'de-anonymising' my blog. Many bloggers including, amongst others, Jobbing Doctor, The Witch Doctor, Dr Grumble, Dr Crippen and Dr Andrew Brown are anonymous and some have been hammering at the doors of the great and good for some time with righteous indignation.

It is not really my style, tempting as it is, to launch such attacks and I have been questioning the need for anonymity at all. I am not particularly concerned by the consequences of my posts - they are relatively milky mild and unlikely to provoke offence. Why not 'fess up and show my cards?

However, the prospect of these bloggers being forcibly de-masked and facing GMC castigation is a worrying one. For the moment I am going to stay anonymous; a change now feels too much like a knee-jerk reaction and if for no other reason but to show some solidarity.

Pain. A philosophical question.

2008-08-29T16:04:00.005+01:00

Paracetamol is an incredibly safe, remarkably effective, cheap and easily available painkiller. I realise it can be a bit nasty in overdose and cats definitely wouldn't agree with me. But in a world of overrated treatments which are distinctly toxic and with dubious benefits to humankind it is just about one of the best that exists.

But some patients just do not want to take painkillers. So let me ask: If you have a headache and you take paracetamol and the headache goes, do you still have the migraine? Have you somehow masked a problem which is still there?

It reminded me of the philosophical chestnut - Does a tree falling in a forest make a sound? Now I am not much of a philosopher but health beliefs are important to patients. The pragmatist in me is infuriated at the contrariness of the patients who would rather be in pain than try a simple remedy. Of course, I realise that what is needed is to appreciate their perspective in a little more depth and root out their concerns.

A pocket watch - the perfect present for the squeaky clean GP

2008-08-28T21:29:00.010+01:00

It's been a busy week in university-land. All the students that have had to resit exams have been given their results. It must have been a pretty tough week for an unfortunate few as they have to decide whether they can face repeating a year or they may even be looking at an entirely different career to medicine.

I did some sessions as an OSCE examiner this year. OSCEs are Objective Structured Clinical Examinations and are now accepted as a fairly standard method for assessing the clinical skills of students.

It is interesting to watch students show off skills that I, along with generations of doctors, had to learn on the job, at ungodly hours, with no supervision and scant training. I am young enough to have done a rudimentary OSCE as a student but old enough to remember the squeaky bum terror (apologies to Alex Ferguson) of doing a lumbar puncture after reading it up in the ever-faithful and well-thumbed Oxford Handbook of Medicine. Our first years can do all sorts of practical procedures that I have never been taught formally. The old and bold may moan about the molly-coddling of students but I like to think we are now molly-coddling the patients rather than the junior doctors.

Our Trust has imposed a 'bare below the elbows' policy. No rings, no watches, no ties, no nothing. At the OSCEs it was quite striking how all the students wear their wristwatches on their belt loops or some of the females have a nurse-style upside down watch thing (do they have a name?). They all practice perfect Ayliffe technique handwashing and (again, I have never been taught that either - you can see it here) are quite the little infection control wallahs.

How many GPs do you know that follow this policy? I gladly gave up my bug-ridden tie on the slightest sniff of evidence of a problem but I feel some reticence to give up my watch and wedding band. I have yet to examine the evidence for this policy but I can't find any mention it on the Health Protection Agency site. However, it is one of those policies that it is tough to rail against at first glance. A second glance may be merited but the benefits of handwashing are pretty clear cut.

Still, I am trying to be positive and I am considering indulging myself with a pocket watch as I feel sure they could be due for a revival in the medical profession. I am not sure if I will be able to pull off a waistcoat to match but potentially I could look quite the dapper country GP gent.

Bank Holiday Blues - moan, moan, moan

2008-08-25T13:50:00.008+01:00

I wish we would give some serious consideration to abolishing Bank Holidays. I have been out visiting some patients in a more rural part of the county this morning.

One of the issues with Bank Holidays we have around here is the pharmacies being closed. None of the local pharmacies in the smaller towns and villages seem to open. Inevitably the elderly and disabled patients (the ones who need visiting) have no way to get their medications. Any immediate treatment has to be provided from the back of our car. It limits therapeutic options, is messy, and GPs are rubbish at following dispensing guidance when doling out tablets. So clinical risk is ratcheted up.

The hospital frequently ends up with no beds on the Bank Holiday so we get a message advising us not to admit. This is fairly unhelpful (if not a touch insulting) advice if, like most GPs, you don't admit unless people need a hospital.

And to cap it all, I am sure there are plenty of GPs and patients out there who will testify to quite how miserable their life will be on Tuesday as practices try to squeeze a quart of patients into a pint-pot of clinics next week.

Patients that lose/forget/their dog eats their medication.
We get loads of these calls every weekend but the Bank Holiday is always worse. One thing I have noticed today is that there is an interesting dichotomy here: on one hand we exhort our patients to continue to take their medications every day, no matter what. However, how many medications are there really where it would make much difference if a patient missed a day or two? Anti-epileptics, warfarin and insulin maybe but many other tablets don't come into these categories. This leads to some reluctance by GPs to prescribe over the telephone to patients they don't know. They are reassured it won't matter if they miss a day or two and are told to speak to their GP on Tuesday (see above).

No wonder some patients get confused.

Bank Holiday - where are all the GP principals?

2008-08-24T09:59:00.003+01:00

I have been working in the local out of hours organisation this weekend. I always find it a bit of trial working over the bank holiday. The NHS is quickly exposed as a Monday to Friday and 9-5 organisation. Of course, many in the NHS, including GPs, work longer hours on occasions but the fundamental rub is that if you are ill outside of normal working hours then we are down to a no-frills bare bones service. By the end of the weekend there will be no beds at the local hospitals and a backlog of problems for GPs on Tuesday.

I had a scan of our GP rota this weekend and out of some 105 GP shifts there are only 25 shifts filled by principals. I know this is a difficult point but why is there is so little engagement with principals and working out of hours?

There is a fundamental problem here because we can't have it both ways. Across the profession, we can't claim the moral authority of being the guardians of primary care, the patients' advocates and yet kick our shoes off at the weekend, light the barbeque and celebrate a job well done as we crack open a beer. The patients still need us at all hours. The best GPs, I think the patients would suggest, are the ones who make themselves available.

I am not advocating a return to the bad-old-days of working all day and being on call all night but one of the most galling aspects is the simmering discontent that many partners seem to have for their local out of hours organisation as if it is some malign government scheme. Principals gave up their 24hr commitment with huge relief in in 2004. What did they think would replace it?

Those same principals may now feel thoroughly embattled with their daytime commitments and now we have a ludicrous situation of GP evening and Saturday morning clinics ('Gordon' surgeries as The Jobbing Doctor would call them) while the out of hours organisations run in parallel!

For me this raises the question: Is it impossible for practices and principals to reengage with out of hours care in a more constructive fashion?

You think it's bad here...

2008-08-20T16:32:00.001+01:00

There has been the usual kerfuffle this week about getting medicines on the NHS. Terry Pratchett has been banging his drum about Alzheimers and Big Pharma has been copping a bit of flak for their usual merciless approach to pricing.

We continue to indulge in the usual handwringing for drugs that, in some cases, can extend life for a few weeks and are so expensive it makes my hair throb. Meantime at least a third of the rest of the planet can't get the very basic essential effective medicines. If you think drugs are too expensive for us then pause for a second to consider the ramifications if you live on a dollar a day.

Medicins San Frontier have the Campaign for Access to Essential Medicines and it pretty much does what it says on the tin. They seem chuffed with UNITAID and said as much back in July. UNITAID (a new organisation in 2006 with some interesting funding) have done some work to address one of the bigger issues. The 20-year patent rule holds it all up and until that runs out it is tricky to make cheap drugs for all (ahem) but before then there is nowt but trouble. UNITAID have taken steps to establish a 'patent pool' which will go some way to reducing these problems.

MSF said:

“UNITAID has shown great vision and understanding of what needs to be done - this could potentially have a big impact, both for access to medicines and for medical innovation”, said Ellen ‘t Hoen, Director of Policy at MSF’s Access Campaign. “Whether this works or not now depends on the willingness of patent holders to share, in exchange for royalties, the relevant patent rights in the pool.”

Jolly good stuff and well done to all of them but the patent holders are presumably Big Pharma. I won't hold my breath.

Superdoctors!

2008-08-20T16:20:00.001+01:00

I will look forward to this on the box tomorrow. I feel mildly hysterical at the wildly oscillating fortunes of doctors these days so some levity seemed in order.

How do you hide a £10 note from an orthopaedic surgeon?

Put it in a textbook.

What is the difference between God and an orthopaedic surgeon?

God doesn't think he is an orthopaedic surgeon.

What do you call two orthopaedic surgeons reading an ECG?

A double-blind trial

Hee hee. There is a lot more in that vein here. I am only jealous that I can't do my shoe-laces up without bending over. But in all seriousness: Anybody that can devote themselves to working in Blackpool for 2 weeks out of every month has to be a bit of a hero...