Alice Shiner

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

Objectives Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. Design Qualitative study in General Practice. Setting UK primary care. Main outcome measures A qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. Design and setting Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. Participants UK based GPs (interview and surveys); European GP trainees (focus groups). Results Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. Conclusions We describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Age-related differential diagnosis of vaginal bleeding in postmenopausal women: a series of 3047 symptomatic postmenopausal women.

Objective The aim of this study is to identify the causes of vaginal bleeding in different age groups of postmenopausal women. Also, we attempt to estimate the incidence of postmenopausal vaginal bleeding and endometrial cancer in a defined geographical area. Study design The study was conducted at a gynaecological oncology centre in the United Kingdom, between February 2006 and May 2009. Patients were investigated according to established evidence-based departmental guidelines. Results During the study period 3047 women were referred with postmenopausal vaginal bleeding. In 1356 women (44.5%) the endometrial thickness measured less than 5 mm on transvaginal ultrasound scan. Benign histology was found in 1144 women (37.5%). Benign endometrial polyps were the cause of bleeding in 10.1% of the cases. The incidence of endometrial cancer in our study population was 5%. The rate of postmenopausal vaginal bleeding during the study period peaks at the age of 55–59 years (25.9/1000 postmenopausal women/year) and declines thereafter. The peak incidence of endometrial cancer during the study period (12.6/10,000 postmenopausal women/year) was seen between the ages of 60 and 64 years and similarly declines with increasing age. Conclusion To our knowledge, this is the first population-based estimation of the incidence of genital tract bleeding and endometrial cancer among postmenopausal women in the United Kingdom. The results of this study showing the age-related differential diagnosis can be used to inform clinical practice when counselling postmenopausal women with vaginal bleeding.

Managing multimorbidity in primary care

Approximately eight in ten of all GP consultations involve a patient with multimorbidity. An average consultation covers 2.5 problems, but those involving a patient with multimorbidity will often be more complex, usually without additional time being available to address the extra problems. As the population ages the prevalence of multimorbidity and the pressures it creates will increase. Although there is little evidence to suggest the best way to deliver care for these patients, it is apparent that the use of single-disease-oriented guidelines without due regard for the individual is often inappropriate. GPs need the confidence and ability to interpret evidence-based recommendations within the context of individual patients. This article discusses the growing phenomenon of multimorbidity, its impact on patients, GPs and the health service, and outlines the skills required of GPs to provide optimal management.

Portfolios and personal development plans

The ePortfolio—love it or loathe it—is an integral part of the workplace-based assessment, it is now a fact of life for general practice trainees. It is also preparation for the appraisal system for qualified GPs, which is heavily reliant upon portfolios of evidence and the creation of personal development plans (or PDPs). Such reliance is only likely to increase with the proposed new revalidation system, which is currently expected to be introduced in 2010–11. Given this context, it is wise for GP trainees to learn how to use these tools to best effect, not only to provide robust evidence of good practice but also to aid personal development. This article aims to describe the way in which PDPs and portfolios can be best employed during your years as a trainee, equipping you with useful skills for a career in general practice. Although the use of tools such as significant event analysis, audit and the consultation observation tool (COT) and case-based discussion, assessments are all important reflective components of the ePortfolio, they will not be discussed in depth in this article.

Ovarian cysts and ovarian cancer

Ovarian cysts and tumours are a relatively common finding among women of many ages, particularly with the wider use of regular physical examinations and ultrasound. Although the finding of an ovarian mass can be a source of considerable anxiety, most of those in younger women are not malignant and may be able to be managed entirely within primary care. However, malignant tumours of several varieties occur and many will require investigation and management by secondary care.

Self-harm in adolescence

Self-harm is a common yet frequently concealed activity among adolescents. GP trainees are likely to encounter young people who self-harm, not only in primary care, but also during placements in Accident and Emergency or general medicine. The type of self-harm seen in each situation is likely to vary and the approach to it may need to change accordingly. However, some themes remain constant and as self-harm is a prevalent phenomenon among adolescents, it is an area with which GPs should be familiar.

Psychosexual medicine: Why me?

This article describes how a particular approach to sexual difficulties allows a useful therapeutic relationship with patients to be developed. Combined with an understanding of the dynamics encountered in the genital examination, it is possible for any interested GP to engage in psychosexual work. The Institute of Psychosexual Medicine has been training GPs and other doctors for over 40 years.

In need of inspiration? Go global!

On a rare sunny Saturday in April, over 100 participants attended 30 Euston Square for the Royal College of General Practitioners (RCGP) Junior International Committee (JIC) Annual Conference. Although most delegates were UK-based AiTs or First5 GPs, some were from further-flung locations, including one delegate who had flown in from Sierra Leone that morning. The wide range of expertise in global health among those present generated a rich experience and a palpable enthusiasm that spread beyond the walls of the College; the conference hashtag was delivered to 158 685 twitter feeds. A truly global event!

Enhanced GP training – creating posts that are fit for the future

Enhanced and extended GP specialty training (EGPT) will require significant changes to be made to the current 3-year GP specialty training (GPST) programme. The proposals for EGPT have already led to postgraduate deaneries reviewing posts within current programmes, with a view to developing appropriate posts and placements for the extra year of training and enhancing those posts which already exist. This article explains how the new programme may be implemented, using case scenarios to illustrate the innovations and changes to training designed to meet the demands of the future.

Global health: time for full integration into GP education

Postgraduate medical training no longer sufficiently prepares UK doctors for the challenges of the 21st century. In 2010, an Independent Commission on the Education of Health Professionals, published in The Lancet , described a ‘mismatch between present professional competencies and the requirements of an increasingly interdependent world’.1 Globalisation, fuelled by a technological revolution and the subsequent mushrooming of social connectivity, affects all sectors of society and hence also each interaction in our consulting room. The recent RCGP conference on Global General Practice is a reflection of the increasingly high profile of global health issues. However, these issues fail to feature adequately in the current postgraduate training curricula of UK doctors.2 The meaning of ‘global health’ has been subject to debate. It has a broad scope, yet can be defined by the basic principle of ‘improving health and achieving equity in health for all people worldwide’ .3 A Global Health Learning Outcome Working Group, consisting of UK academics, medical students and representatives of civil society with expertise in global health and medical education, determined that global health learning outcomes should cover the following areas:4 Some may question why global health is important to GPs who only practice in …