Ahmed Rashid

Choosing Together: encouraging person centred care and shared decision making

Like many doctors across the country, I was delighted to see the launch of the UK version of the Choosing Wisely campaign by the Academy of Medical Royal Colleges,1 and equally disappointed to see the associated newspaper headlines …

Making primary care placements a universal feature of postgraduate medical training

We know what you’re thinking having read the title to this article: another desperate attempt to lure new doctors into general practice and then trap them to bolster numbers. In fact, this is not about recruitment at all. Rather, it is about uniting the profession and fundamentally improving the experiences of our patients. The interface between primary and secondary care has long been recognised as problematic, with both patients and doctors frequently voicing their discontent at the care and communication that slips through the cracks. Many suggestions have been made to improve this, varying from shared educational events to better use of technology to plug the gap. The most pertinent, however, is surely to improve the appreciation of the working environment of the other. In the UK, all doctors are required to complete two years of foundation training after graduating from medical school and this is based predominantly (and sometimes exclusively) in hospital settings. Those training to be general practitioners then typically complete a further 18–24 months of hospital placements before completing their training in the community. By the time general practitioners have qualified, they will therefore have completed a minimum of 3–4 years of hospital work, and often much more. There are many reasons why this time is so valuable. First and most obviously, the generalist nature of working in primary care means that experience of all clinical disciplines is necessary. Beyond this, however, these placements also offer an insight into the intricate workings of a hospital, from the emergency department triage, to the preoperative assessment clinic, to the labour ward in the maternity unit. This intimate knowledge helps them to steer their patients towards the right services, strive to organise the most appropriate investigations and send appropriate information across the interface. Moreover, although some aspects of these posts are geared more towards service provision than education, simply being part of the hospital team is useful in raising awareness of the culture, etiquette and stresses of the environment. Yet, in comparison, only a small proportion of specialty trainees will have set foot in a general practitioner surgery as a doctor after qualifying. In 2012, 0% of foundation year 1 placements and 18% of foundation year 2 placements were in general practice. Of note though, general practice placements were reported to receive the highest satisfaction ratings of all specialty placements in the Foundation Programme, with trainees valuing the ready access to senior support and regular, highquality feedback that they received. There is also a strong correlation between training placements in primary care and eventually choosing to work in general practice. While more recent plans to reform the foundation programme to mandate community-based or integrated placements are laudable, this should not detract from the importance of increasing an understanding of primary care in the early years. Hospital doctors may feel that their roles, and therefore their training, end in acute environments. We think otherwise. First and most importantly, the system that their patients are navigating is built on a bedrock of primary care, with most of our patients’ journeys starting and ending here. Indeed, 90% of all patient contact in the National Health Service takes place in primary care, and often in patients’ own homes. Time spent on both sides of the fence helps to inform an understanding of how we can support our patients in their interface transitions.

The importance of ‘Choosing Wisely’

During my first shift as a foundation doctor in a large teaching hospital, I was sent to the emergency department to see a lady who had taken a Paracetamol overdose. Keen to impress the on-call medical registrar, I set about ordering the appropriate investigations according to the latest guidelines. As it turned out, the on-call registrar that day was a senior hepatology registrar. ‘Don’t you know Paracetamol overdose causes liver failure?’ he asked me, patronisingly. He then set about reeling off a long list of tests that I would need to request for a ‘full liver screen’ and I dutifully obliged, ignoring the guidelines and trust protocol that had no mention of these uncommon (and expensive) investigations. As I reflect on this experience years later, I wish I could go back in time and challenge him on this. His reasoning seemed to be that if the patient turned out to have impaired liver function, it would be important to ensure that this wasn’t caused by a pre-existing condition or infection. While that may seem logical, it ignores the fact that the large majority of individuals who take Paracetamol overdoses have absolutely no liver impairment at any stage. Reserving these expensive tests only for those individuals who have been identified as having impaired liver function would therefore save time and money and prevent patients from having to endure potentially unnecessary investigations. These factors were surely considered by the guideline producers, who had not included such a comprehensive routine screen in their recommendations. It’s clear to me now that the reason for making me request those tests wasn’t about patient safety, effectiveness or experience at all. Rather, it was about professional ego. It was an opportunity for him to flex his intellectual muscles and demean a junior colleague. While this is, of course, highly problematic in an educational and pastoral sense, it is also a dangerously careless use of public resources. Professional hierarchies and ‘super specialist’ expertise are important cultural barriers to challenging this kind of behaviour. The recent launch of the UK version of the Choosing Wisely campaign received much interest, and few doctors would argue with the principles of needing to be shrewder about how money is spent in the NHS. However, the decision for it to be coordinated by the medical Royal Colleges is an important one. This means the focus will be on each tribe of doctor self-identifying practices they consider to be of questionable value, and this will require an honest and critical attitude. Those individuals tasked with identifying these practices will need to be brave and challenge professional comfort zones, assumptions and ego. The Choosing Wisely vision is a compelling one, and it would be a huge shame to miss this opportunity to rethink our approach to everyday clinical decision-making. The medical royal colleges need to take this on with the utmost resolution and confront all traces of arrogance and complacency. The perspectives of doctors in training, who are the newest members of each specialty tribe, must particularly be harnessed. They have the capacity to be a powerful force when it comes to developing a fresh approach and must be allowed to realise their potential as ‘agents for change’. Although organisational and political levers are undoubtedly necessary to achieve cost savings in the NHS, there is also a considerable human element to individual clinical decisions. The Choosing Wisely tide has hit the UK from North America, and we must ride it bravely and boldly, challenging practices and egos to remove all traces of paternsalism and doctor-centredness. Holding a mirror up in this way

Yonder: GP trainers, menopause, shared decision making, and coroners’ reports

GP trainers. Rarely does a week go by without an unpleasant newspaper headline about GPs overprescribing antibiotics. Having recently had a patient swear profusely at me and refuse to leave my consultation room after I’d explained that they had a viral infection that wouldn’t improve with antibiotics, I find myself wondering whether policymakers really understand the work we do in primary care. A recent French study took on the divisive issue of antibiotic prescribing, comparing rates between GP trainers and non-trainers.1 They looked at the prescribing patterns of 860 GPs over 1 calendar year, 102 (11.9%) of whom were GP trainers. Prescribing rates were adjusted for various GP characteristics, including sex, age, location of the practice, number of visits per GP, and the case-mix. Being a trainer resulted in a significant difference in antibiotic prescriptions compared with non-trainers, corresponding to a relative reduction of 23.4%. Although a noteworthy finding, it’s difficult to know what the policy implications might be. An interesting follow-up question might be: what is it about being a GP trainer that makes you less likely to prescribe antibiotics?

Yonder: Doctor emigration, vitiligo, canes, and self-harm pictures on Instagram

Doctor emigration. It’s all well and good to announce increased medical school places to deal with the massive doctor shortages in the UK, but it’s pretty clear to NHS staff that there is also a big leak that needs to be fixed. A large number of colleagues I trained with are now practising abroad, and it is a trend that is regularly reported in the medical and lay press. The esteemed UK Medical Careers Research Group in Oxford recently reported a study that investigated the reasons why doctors are considering leaving medicine or the UK.1 They received over 5000 responses to their questionnaire survey. Among those considering working in medicine outside the UK, the most commonly cited reasons were to gain wider experience, that things would be ‘better’ elsewhere, and a negative view of the NHS and its culture, state, and politics. The authors conclude that, if policymakers want to retain doctors, they need to introduce real improvements to resources, staffing, and working conditions. Hear, hear.

Prescribing for ADHD in primary care

Attention deficit hyperactivity disorder (ADHD) is the name given to a condition characterised by inattention, hyperactivity, and impulsivity. Although there are many historical descriptions of these behaviours in children,1 definitions of ADHD as a disease emerged in the 1980s, when the practice of classifying mental disorders became popular and the DSM-III and ICD-9 diagnostic systems shifted the scientific focus on mental illness from aetiological debates to finding practical and reliable disease descriptions. The term ADHD, drawn from the DSM-III, was initially used only in North America. In Europe, the term ‘hyperkinetic disorder’ was used and was initially reserved only for the most severe cases. The broader definition afforded by the DSM eventually led to a corresponding rise in diagnosis rates in Europe, although they were still dwarfed by the much higher rates seen in the US. This historic diversion in practice has been partly explained by differing diagnostic criteria, but also by the power of the pharmaceutical industry, advocacy groups, and the internet.2 A comprehensive 2015 meta-analysis included 175 ADHD prevalence studies and suggested an overall pooled estimate of 7.2%, although few included studies were from outside of Europe and North America.3 Prescribing rates are naturally closely linked to prevalence and have also received much attention. A 2016 study explored prescribing patterns of ADHD drugs in children in the UK using primary care records, finding a dramatic increase in use from 1992 until around 2008, with stable levels of use since then.4 Indeed, ADHD drug use in children aged <16 years increased a staggering 34-fold overall in that 16-year period. The steadying of prevalence in …

Peer influence as a driver of technological innovation in the UK National Health Service: a qualitative study of clinicians’ experiences and attitudes

Background Accelerating innovation to improve quality is a key policy target for healthcare systems around the world. Effectively influencing individuals’ behaviour is crucial to the success of innovation initiatives. This study explores UK clinicians’ lived experiences of, and attitudes towards, clinical peers endorsing healthcare innovations. Methods Qualitative interviews with UK-based clinicians in one of two groups: (1) clinicians working in ‘front-line’ service provision and (2) clinicians in strategic leadership roles within health institutions. Participants were identified through purposive sampling, and participated in semistructured telephone interviews. Thematic analysis was used to identify and analyse themes in the data. Results 17 participants were recruited: eight clinicians from front-line UK healthcare settings and nine clinicians in leadership roles. Two major themes were identified from the interviews: power and trust. Participants recognised and valued peers’ powerful influence, exerted in person via social networks and routine work-related activities. Peers were implicitly trusted, although often on condition of their credibility and deservingness of respect, supporting evidence and absence of conflict of interest. While the groups shared similar views, they diverged on the subject of institutions, felt to be powerful by strategic leaders yet scarcely mentioned by front-line clinicians. Conclusions UK clinicians view peers as a powerful and trustworthy source to promote innovative technologies. Policies that aim to support this process should seek to control the wider conditions that nurture peer-to-peer influence. Further research into interpersonal influence in health settings may improve implementation of change initiatives.

A theatrical approach to multimorbidity consultations

Doctors often get compared to other professional groups. It is easy to see, for example, how doctors may be likened to car mechanics – they diagnose and (try to) fi x problems, perform annual checks and have specialists in particular systems or types of car. Similarly, patients having a wound sutured in an emergency department might compare their doctor to a tailor or to a seamstress. Doctors are also often compared to actors, and improvisational acting may provide a particularly useful metaphor for the way doctors engage in the demanding consultations of modern clinical practice.

Yonder: Suicide, rhinosinusitis, urgent care centres, and favourite patients

Suicide. Suicide continues to be a frequent and tragic cause of death across the world that can be devastating for families and loved ones. Given that suicide is commoner in those with physical and mental health problems, it would be reasonable to suggest that suicide attempts may be preceded by contact with primary care services, thus providing opportunities for intervention. A research team from Northern Ireland recently sought to examine predictors of contact with healthcare services in the 12-month period prior to suicide. 1 They retrospectively analysed deaths recorded as suicide by the Northern Ireland Coroner’s Office, linking with data from GP records. They found that, in 87% of cases, there had been contact with GPs in the year prior to suicide, with frequency of contact particularly high in those with psychiatric conditions and substance misuse issues. However, they also found that, for 40% of individuals, there was no history of mental health conditions and suggest that GP alertness to suicide may perhaps be too narrowly focused. Rhinosinusitis. In addition to nasal symptoms, chronic rhinosinusitis is associated with reduced quality of life because of the impact on sleep quality, work productivity and mental health. In order to explore the experiences of patients with this condition, researchers from Norwich interviewed 21 adult patients that were recruited in an ENT clinic.

Yonder: Rosacea, youth mental health, diagnosing arthritis, and telephone triage.

Rosacea. Rosacea is a common, chronic skin condition in adults. As it predominantly affects the face, it has the potential to cause significant psychological and social distress. The internet has provided opportunities for patients to access information as well as interact with peers and experts. A US research team recently analysed posts on an online rosacea support forum to obtain insights into patients’ educational needs. 1 They found that patients primarily sought advice about treatments, triggers, diet, and skin care. Perhaps unsurprisingly, there were also a large number of queries about the efficacy and adverse effects of therapies. The authors suggest that doctors should make more attempts to include patients in their rosacea care and suggest that one way of doing this is to have them take pictures to track progress and keep a diary of potential triggers. They also suggest that proactively providing resources could help reduce confusion about the disease and treatments. Youth mental health. Youth mental health is increasingly recognised as a priority area in health systems around the world. In particular, there has recently been an increased focus on early intervention and an Irish research team recently sought to examine the role of the GP in providing early treatment in this population. 2