Uncategorized – The GP trainee's survival guide

Cardiovascular system, Chronic disease management, Diagnosis, Heart Failure, Uncategorized

Heart Failure – the need to knows

Posted on February 12, 2018 by Emma

Heart failure is a condition we are increasingly seeing as the population ages. According to figures there are approximately 900,000 people in the UK with a diagnosis of heart failure. It is likely many more remain undiagnosed.

Why is it important to a GP? Because it is often our doors that patients arrive at with symptoms of undiagnosed heart failure, or for management of their already diagnosed heart failure. So we need to remember to consider it as a diagnosis, know what other points in their medical history are relevant, how to investigate and how to manage heart failure.

An important learning point – from prior experience – keep heart failure as a differential diagnosis in all patients presenting with symptoms of breathlessness, regardless of age or lack of other risk factors. It is not difficult to include it in your investigations so keep it on the list until you’ve excluded it via tests.

Firstly, we need to think of the way people might present with heart failure. I am not going to cover an exhaustive list of all of the symptoms because you should know this by now. But people often come to see their GP with symptoms of breathlessness ( to differing degrees), fatigue, or very commonly – ankle swelling. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. If it is then your first step is going to be the trusty BNP or NTproBNP blood test.

BNP/ NTproBNP

These peptides are sensitive enough to use as a diagnostic tool for detecting heart failure. But they are not quite as specific. Carrying out a blood test to check the levels of either of these peptides is going to help you both diagnose or exclude heart failure.

But what other factors or conditions can affect the BNP result?

Falsely lower	Falsely higher
Obesity	Tachycardia
Diuretics	LVH
ACE Inhibitors	Hypoxaemia
ARBs	eGFR < 60
Beta- blockers	COPD
	Diabetes
	> 70 years
	Cirrhosis

Note the above features – this is going to influence the other elements of your assessment. In order to help you interpret the result you need further information. You need their medical history, medication list and some examination findings.

Notably you might need to weigh your patient to look for their BMI. You need to know what their pulse is and the regularity of it. In addition, an ECG isn’t going to go amiss. From that you can look for SVTs, LV strain and signs suggestive of ischaemia.

In addition to the BNP you want to get some additional blood results:

Renal function
Liver function
Thyroid function
Lipids
HbA1c

*An off-track learning point – I am pretty tough on trainees at times when it comes to requesting bloods and tests. Why? Because they are expensive and you need to interpret them! When I undertook my emergency medicine rotation I worked in a hospital where the pathology lab was off site. During the induction they told us that we shouldn’t be ordering bloods unless we were planning to admit the patient, because the chances were that the results would not be available before the 4 hour see and treat time was up. Unless you’ve experienced this you will not appreciate how liberating it is to go back to using a history and examination to diagnose a patient. General practice has very much the same ethos. It can be really tempting when requesting a blood test to tick a load of other boxes ‘whilst we are at it’. Don’t. Have a rationale for each test you undertake – what are you looking for and why is it relevant. I’m not going to spell it out for you for the above tests but have a think why they might be relevant!

Interpreting the result

We now have a patient with some symptoms suggestive of heart failure and a positive BNP. What do we do now?

Well we need to look for the cause, unless it is glaringly obvious. The chances are we need an ECHO to help us with this. But how urgently do we need an ECHO? We are going to split our patients into three different categories (as suggested by NICE guidance), and this is going to help us treat our patient within an appropriate time frame:

A very raised BNP (> 400pg/ml) or NTpro BNP (>2000pg/ml) – levels like this carry a poor prognosis so refer urgently to the heart failure clinic for further assessment.
A past medical history of a myocardial infarction (MI) – refer for an ECHO and specialist assessment within two weeks.
Other patients – need an ECHO within 6 weeks of the abnormal BNP result.

The result of the ECHO is going to split our treat versus refer patients even further. Who will we refer?

Patients with a preserved ejection fraction
Valve disease – I think there is some scope to be rational with this group of patients. Read the ECHO report and refer sensibly. A very mild aortic stenosis in an 80 something year old may not necessarily require immediate referral.

So the other patients, i.e. those with left ventricular systolic dysfunction, are the ones we are going to get on and treat.

Mangement principles

Effective communication regarding the diagnosis
Lifestyle measures
Drug treatment
Consider the psychological impact of the disease

Communication – You need to explain the diagnosis clearly and carefully. Heart failure is probably a scary diagnosis to a patient. They are being told their heart is failing. We need a heart to live, and theirs is failing! You need to turn this into a less scary situation with a very good explanation and reassurance that there are ways of helping them. Think about how you might explain this diagnosis, and perhaps try your explanation out in a role play setting.

Lifestyle measures – There are a number of changes patients can make that could help to improve their symptoms and outcomes. Increasing exercise as best they can, stopping smoking, reducing alcohol intake and receiving their annual influenza vaccine.

Drug treatments – Keep this simple in your mind.

First line:
- ACE Inhibitors & Beta-blockers – titrate your ACE inhibitors every two weeks (keeping an eye on the renal function) and start with a low dose and gradually increase (perhaps alongside the ACE inhibitor). Make sure you keep an eye on the heart rate when titrating the beta-blocker. If your patient has a home BP monitor then it is worth suggesting the patient check their blood pressure and pulse if they are feeling dizzy or unwell. An ARB is a suitable alternative if the ACE inhibitor is not tolerated.
Second line:
- At this stage you might wish to consider seeking specialist advice but the following medications can be used in the management of heart failure:
  - Aldosterone antagonist (Spironolactone) – for moderate to severe heart failure, or oedema in congestive heart failure.
  - ARB (Candesartan and Valsartan) – mild to moderate heart failure.
  - Hydralazine + Isosorbide dinitrate – moderate – severe heart failure.
  - Digoxin – will improve the symptoms but will not improve mortality. Use in worsening or severe heart failure where patients are already taking maximal treatment with the above mentioned medications.
Diuretics:
- Use for the relief of congestive symptoms and fluid overload.
- They can be titrated up and down as required.
- If a patient is requiring greater than 80mg Furosemide daily then you should refer them onwards.
- Whilst using diuretics you should monitor every six months via a blood test and medication review.

As with all chronic diseases it is important to consider the psychological impact upon the patient. You should address this at their reviews, and manage as required. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This part of the management shouldn’t be under-estimated. You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole.

I hope this has been a helpful summary of how to work up a patient for heart failure, and the basic management approach.

Consultation skills, Diagnosis, Men's health, Uncategorized

Male lower urinary tract symptoms (LUTS)

Posted on February 5, 2018 by Emma

This topic seems to crop up fairly regularly as a tutorial request. It’s funny because whenever we go through it I think it actually seems very straightforward. Yet there seems to be this tendency to over think the subject. So I have put together my approach to the male LUTS consultation. My suggested reading for this topic is the hyperlinked BMJ article and the NICE guidance.

A good way to approach male LUTS are to consider the symptoms as storage versus voiding symptoms. Having this in the back of your mind is helpful for data gathering but also gives you information from which to consider the most appropriate management options.

	Storage	Voiding
Symptoms	Frequency Urgency (and urge incontinence) Nocturia	Hesitancy Poor stream Terminal dribbling Double voiding
Causes	Overactive bladder (if isolated)	Benign prostatic hypertrophy Urethral stricture Meatal stenosis Phimosis
Management options	Anticholinergics	Alpha blockers 5-alpha reductase inhibitors

A mixed picture of symptoms would suggest bladder outlet obstruction, most commonly cause by benign prostatic hypertrophy (BPH).

I take a history of the above symptoms in a systematic manner. I go through all the steps of passing urine to clarify what symptoms they have. It is also important to consider the duration of these symptoms. If these symptoms are acute then you should be considering whether this might be a urine infection, or potentially a bladder cancer.

The other important information you need to know are whether they have (or could have) any other medical conditions that may be causing their symptoms. E.g. is this a presentation of diabetes if they have increased frequency of micturition. Also, the medications that they take for other medical conditions could cause side effects that mimic LUTS. So check with them and check their medication list. You also need to consider taking a sexual history if they have any dysuria or penile discharge.

One of the important questions to ask, as with all consultations:

Why is this man presenting now? What are his concerns?

This is the golden question because it is going to guide your management plan. I often see men who wish to discuss their urinary symptoms because they are concerned about the possibility of prostate cancer. But once this is discussed and investigated they don’t feel the need to take medication for their symptoms. So ask them about expectations – it might save an unwanted prescription!

You need to examine your patient:

Abdominal examination
Genital examination
Digital rectal examination (DRE)
Look for peripheral oedema
Neurological examination – if there is anything in the history that creates suspicion

A note about DRE and Prostate specific antigen (PSA). You need to undertake a DRE at some point during your assessment of the patient presenting with LUTS. Unless the patient is having their blood test very soon after the DRE it is unlikely to impact upon the PSA results. However, you could undertake the PSA testing, advise them they will need this examination at their follow up consultation and then perform it at the review. That is down to your preference. As long as it is completed in good time.

Investigations:

Urinalysis – can look for infection, diabetes, or possibility of malignancy.
An input/output diary – if they have storage symptoms or nocturia. Make sure they note caffeine intake.
PSA – You need to counsel the patient prior to offering a PSA test. I really like this website for providing a man with information about PSA testing.

It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. The man’s scoring on this questionnaire can direct the management plan put in place.

Management:

First line should be information. About their condition and the lifestyle measures they can make that may improve their symptoms e.g. fluid modification. I really like this patient information leaflet from BAUS

Drug treatments. This is where the IPSS can be helpful.

Mild LUTS (IPSS <8)

Enlarged prostate

5 Alpha reductase inhibitor

Moderate – Severe LUTS (IPSS >7)

Normal sized prostate

Alpha blocker

Moderate – Severe LUTS (IPSS >7)

Enlarged prostate

Alpha blocker +

5 Aplha reductase inhibitor

Overactive bladder (isolated storage symptoms)

Anticholinergics

(if fails or not tolerated Beta 3 agonist)

Consider the common side-effects of these medications when explaining them to patients:

Alpha blockers (e.g. Tamsulosin) – reduced ejaculation, postural hypotension (it is advisable to suggest the patient takes these last thing at night)
5 Alpha reductase inhibitors (e.g. Finasteride or Duasteride) – Reduced libido, Erectile dysfunction, gynaecomastia. With this treatment it may take several months for it’s benefit is seen. It is worth explaining this to the patient up front.
Anticholinergics (e.g. Oxybutynin) – dry eyes, dry mouth, constipation, confusion (in the elderly).
Beta 3 agonist (e.g. Mirabegron) – Tachycardia

Organise follow-up:

It is useful to review they patient at 4-6 weeks post initiation of treatment. They you can review at 6-12 month intervals. If it is Finasteride only that you have initiated then you may wish to lengthen the first review to around 3-6 months to allow time for it’s effects to have been seen.

Who to refer?

Failure of medical treatment after a couple of reviews
Severe LUTS (IPSS 20+)
DRE suggests malignancy
Elevated age-specific PSA
Recurrent UTIs
Persistent non-visible haematuria or any visible haematuria
Urinary retention

This is the British Association of Urological Surgeons (BAUS) age adjusted PSA guide:

Age	Maximum PSA (ng/ml)
40-49 years	2.7
50-59 years	3.9
60 – 69 years	5.0
70-79 years	7.2
80-84 years	10
85+ years	20

If your patient has a raised PSA then this is a really nice web page to direct them to or print off to explain what this means and what might happen next.

I really hope this has shown you how straightforward a male LUTS consultation can be. If you have any questions then just as and I will answer as best I can.

CSA, MRCGP, Uncategorized

Getting stressed about your CSA?

Posted on January 30, 2018January 29, 2018 by Emma

Don’t!

Yes that is much easier said than done. But try not to because it will hamper your preparation. And remember that everyone prepares in different ways and everyone is ready at different times. You might be sitting your CSA on the same day as one of your colleagues and be stressing about the fact that they’re so much better prepared than you are. However, does it really matter? As long as you are ready by the day of the CSA it doesn’t matter if you’ve been ready one month, one week or one day before it. Yes we may feel more confident if we have been ready for a month but the flip side to this argument is that you could just have a really bad exam day and struggle. You wont though because you’re going to consult like you do every day, and you’re going to be great! That is rule one – believe in yourself. If you are doing the day job well (I would hope your trainer has talked to you if you aren’t) then it should be just fine.

How can you prepare for the CSA other than do your day to day consultations? There are many ways:

Role play with your trainer, your fellow trainees and even your family.

Video your consultations and show then to your trainers. Watch them yourself too.

Joint surgeries.

Don’t forget your clinical knowledge – make sure you know your red flags, your guidelines, your management plans.

You can create opportunities every day to incorporate these forms of preparation. Set rules for feedback – you don’t want your confidence to be knocked by lots of negative feedback, but continually sharing only positive feedback, or saying ‘it was fine’ isn’t going to help you get better. My trainees’ might describe me a bit tough and honest where feedback is concerned. Here’s my thinking – I’m going to tell you if it was fine and you might manage a pass. But I’m going to be a bit fussy and excessive too. Why? Because my principle is that when you are preparing you should be aiming for that ‘perfect’ consultation. You know – the one where it all comes together and you send the patient away with an amazing plan! For what reason am I doing this, rather than just making sure you can pass each consultation? For two reasons – the first is that I want my trainee to be a great GP, and I want their patients to see just how good they are. The second is more CSA focussed. There are very few of us who do not suffer from some degree of nerves when we are faced with a pressurised situation. The CSA is just that – it’s the last big hurdle in our training, it’s really expensive so we don’t want to pay for it a second time, it’s a foreign environment (to most of us) and we know that people can fail it. What happens when we are nervous? We are potentially not on our top form. So lets aim for perfection when preparing so that when the nerves hit we perhaps drop a little but not below the pass/fail threshold. So whoever you’re preparing with – ask them to judge you to perfection.

If you’re role playing a patient for a colleague then make it a bit tricky every now and again. Put your peers under a bit of pressure. Again it makes facing the CSA that little easier. From experience I really didn’t find there was a patient there to trip me up, and no one was really terrible to me! But if your colleagues have been a bit tough on you here and there then you won’t be phased if you have a consultation that’s a bit trickier, and most of the consultations will feel like a breeze compared to the practice you’ve been doing.

It may seem a bit odd to suggest practicing with your non-medical family and friends. But it can be really helpful. I recall practicing telephone consultations with my sister who lives 100 miles away. I gave her a rough brief on a topic she might have some idea of what kind of symptoms to have – thyroid, an ill child, etc. Then we would undertake the consultation in ten minutes, and I’d see how she felt it went. Non-medics are also great for practicing your explanations and planning with. However good at role playing you are it is always hard to put your medical knowledge out of your mind. So the explanation might seem fine to a fellow medic, but not so clear to someone with no prior knowledge. So try explaining CKD3 to your partner, or the two week wait to your friend. Genetics is a really good topic to role play with someone non-medical, because you will soon see that you can’t drop into a full description of mendelian inheritance in a ten minute consultation – you have to keep it simple and concise.

Don’t let your theoretical knowledge slip away. This is a really good reason for getting tied up in knots in the exam. When observing, I can tell when someone is starting to question their plan because they can’t quite remember what the guidelines suggest, or they don’t recall the cut off values for this and that. The consultation then just slowly falls apart because the trainee isn’t confident in what they are doing, and they are running out of time to complete the consultation. So know your stuff. The consultation skills get you a long way, but to go the whole way you need to back it up with knowledge.

Be yourself. I remember watching some videos back when I was about 4 months away from the CSA and cringing. I realised that I was consulting completely differently to normal in a bid to undertake the perfect consultation structure. The consultations went terribly and didn’t reflect my usual practice. Once this was highlighted to me I took a step back and started trying to improve my consultation structure rather than start from scratch. You need to be yourself otherwise it will awkward for you, the patient and the examiner. The use of stock phrases just doesn’t work. If this phrase is new to you and doesn’t fit your style or personality then it wont work with the effect it is hoped to. But, by all means take feedback on board and try out new techniques or phrases. Just don’t do it all at the same time! I do advocate being conscious of any words or things you do that you might want to work hard to wipe out of your consultations. Apparently my phrase was ‘I think’. I’m pretty sure I have erased this from my consultations but I know that I use phrase too much in day to day life because my toddler went through a phrase of adding ‘I think’ to the end of most sentences! So just be cautious of repeated words and phrases you use, or those that might make an examiner or patient (who does not know you and will have one encounter with you) think that you are not confident in what you are saying or doing.

I really hope this post has given you some pointers as to how to approach CSA preparation. There really isn’t a one size fits all preparation guide because we all learn differently. If I can answer any questions then please get in touch.

Consultation skills, Diagnosis, Malignant disease, Uncategorized

Referring for suspected cancer

Posted on January 29, 2018 by Emma

This is written following some CSA preparation with a trainee. Let me start with a usual disclaimer – I am no expert in breaking bad news or discussing this topic! I have spent a number of years trialling different methods of approaching this with patients. I’m still not sure I have it right but I wanted to share some thoughts to help you build on your skills.

I don’t know if there are many people out there who do not know of cancer. I would say the vast majority, if not all, have heard of the word. It may be that they don’t fully understand what that means though. But how good are you at using the word in your consultations and saying it with ease? It’s an easy word to stumble over and turn in to the most awkward conversation you’ve had that day. Even with those patients who have a diagnosis of cancer. So practice saying it aloud regularly. Normalise the word.

Here’s where I think the problem lies. Most of us are all a bit too nervous to say the word aloud to someone who doesn’t already have a diagnosis. So when we sit there worried that their symptoms suggest cancer, and we want to refer them, we try to think of every other way of saying it without using the word. We talk about the need to exclude serious, sinister or worrying causes. But none of these words define cancer. They could define any illness that may be more than something minor, or something that someone may have to live with or need an operation for. Some people may not even be sure what sinister means. So here’s the issue – we tell someone we need to refer them to clinic to rule out something serious (or sinister; or worrying) but we don’t tell them we need to exclude cancer. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. Imagine being the patient at this point in time. You’ve trundled along to the hospital, on your own having taken the bus, thinking you might have something wrong that that the GP can’t quite sort out. You’re then faced with someone telling you that you’re in this clinic to look for cancer. Yep, I’d feel pretty stressed too. What if I’ve got cancer? Am I going to have to get home by myself and hold it together? Especially, if they decide you need further investigations to rule it out.

So this is what we need to do – we need to find a clear, yet sensitive, way of breaking this news to the patient. I would like to hope that somewhere along the way in your medical training you’ve been given some guidance on breaking bad news, and had the opportunity to practice this. (I wish someone would have given some guidance in medical school on how to tell a relative their loved one is dying or has already passed away – it would have made my days a junior doctor a little less painful).

We need to model this explanation and planning upon the breaking bad news methods. Because that’s what we are kind of doing. We are introducing the possibility of cancer to a patient, who may not have even considered this as the cause for their symptoms.

Firstly – have you gathered the patient’s ICE (ideas, concerns and expectations)? If you have then you may have already garnered that they are a) worried they have cancer or b) have a completely different agenda. A good example is the consultation regarding a breast lump. On the whole a woman thinks a breast lump = cancer. They want you to tell them it’s not. So they are still a little surprised when you explain you’d like to refer them onwards, but they understand why from the get go. The opposite is bowel or urinary symptoms I find. They think there’s probably something wrong but they haven’t often considered it might be cancer. They just want you to stop them from opening their bowels several times per day for example. So ICE is your starting point for knowing what your opener needs to be.

Use the above knowledge to start the explanation. Here’s the important part – I really think you need to use the word cancer at some point during this stage of the consultation. How you do it is something to work out for yourself, via practice. If I am not truly convinced it’s cancer but they sit within the criteria for a two week referral I usually say something along these lines:

” From everything you’ve told me I think you fit within the criteria for us to refer you urgently to rule out cancer as a cause. I’m not entirely convinced this is the case, however I think it would be wrong not to consider this”

Or if you’re really nervous about telling them you could try:

“For each area of the body there are set symptoms and time frames that have been listed as a reason to refer someone to rule out cancer. From what you have told be you fit into one of these categories so I really think it would be a good idea to send you to the hospital clinic”

If you’ve examined them and you are really worried because you’ve found a mass for example then tell them:

“When I examined your tummy I could feel a lump there. There are many causes for feeling a lump in the tummy. However, when taking the symptoms you told me you have into consideration, I’m worried this could be a cancer. So I think we need to get this looked at urgently”

The same goes for discussing a result that is highly suggestive, or confirmatory for cancer. Speak the whole truth.

Whichever way you decide to drop the word cancer in. Follow it up with a ‘would that be ok?’ and a ‘do you understand?’ or a how do you feel about that?’ You know roughly the answers to these questions but asking them out loud rather than assuming allows you to open up the discussion about how they are feeling and to do some (metaphorical) hand holding. Acknowledge that you understand this may be worrying, stressful, etc.

Discuss the next steps. Confirm that two week wait means they will be seen within the next fortnight. If it’s such they may have investigations first then explain this. If they’re going to the breast clinic or neck lump clinic then tell them it might be a long day and they might want to take a book. Suggest they may wish to go along with someone for company.

When closing the consultation and planning suggest some follow up so they know they can come back to you. If they don’t have cancer then they will still have the symptoms that need to be managed, and if they do then they might want to talk to you about it. In addition, if appropriate, make sure you offer some management for the symptoms they have in the meantime.

You might have noticed that I have dropped the word cancer into this narrative many time – because it’s an actual word with a definition and we shouldn’t be afraid of it.

It’d be great if anyone else has any good tips to share on how they broach the subject of a two week wait referral.

Administration, Uncategorized

Writing a referral letter

Posted on November 20, 2017November 20, 2017 by Emma

This topic came up in conversation at the practice recently. Disclaimer – I am not the world’s best letter writer, and English was not my favourite topic at school!

This post is perhaps more an opener to think about how you are currently constructing your referrals, and how you can improve on this. Some people take the mail merge literally, and mail merge their last consultation, whereas some people like to write a life story of their patient. I must admit, I have been guilty of both of these in the past.

The most important point when considering referral letters is what are you asking the person on the end of the referral for. This should be the very first sentence of the referral. For example, if you think someone needs surgery then that’s what the referrer needs to know. Plus, you might wish to explain why you think the patient needs the procedure. An example might be “I would be grateful if you would see this 48 year old woman, who has been suffering recurrent episodes of cholecystitis, for consideration of a cholecystectomy”. Thus, the reader knows exactly what you’re thinking, and hopefully what the patient is expecting.

Leading on to the second point – make sure the referral reflects the conversation you had with the patient. If you’ve told the patient you’re referring them for one reason, and the letter makes it sound like it’s for something totally different, it is going to lead to a difficult consultation between the patient and whoever they have been referred to. So keep the story consistent. For example, if there are strict criteria in your area for knee replacements, and you know the patient doesn’t meet them, it is not helpful to tell them you are referring them for this. In reality, you are referring them to a specialist since you’ve exhausted the options, and you need to see if there’s anything available in secondary care that they can try whilst they don’t meet the threshold for replacement. It works in the opposite direction too – why are you referring someone with a hernia to a surgeon, if they don’t want to have surgery? You need to be clear what your patient’s agenda is, and clarify to them what your agenda is when referring.

The above is by far the most important part of writing a referral. The rest is just details, and, in some ways, is shaped by the referral processes local to you. Examples locally are the virtual gastroenterology and neurology clinics. They have been set up to manage the demand for these services locally. The process is simple – you refer to the clinic, they read the letters, they may provide some advice and not see the patient, they may book patients in for investigations first prior to review, or they might see the patient in clinic initially. As such, giving a good history is essential to them making the right decisions. So thats what you need to do. Go back to the days of having to present patients on the post-take ward round, or back in medical school, and present your patient. For example if there is pain – describe the pain. You need to describe the associated symptoms, and the duration of them. You need to include any relevant medical history or medication history. You don’t need to talk about their broken toenail back in 1984! Think about what you’d like to know if you could give patients forms to describe their symptoms in advance of your appointment. Imagine how much easier the consultation may be if you had a nice outline of everything before you saw the patient. (Remember we do have a rough outline as we at least have their medical history, current medications, etc. in front of us)

You don’t want to bore the reader, and you don’t want them to be digging through your letter to make sense of why a patient is being referred. This is why mail merge letters from the relevant consultation are not the most helpful. Your consultation notes are just that – your consultation notes – not you discussing the case with someone else. We often use abbreviations and incomplete sentences, and flit from one part of the history to another. Read the last consultation in the next patient’s notes you open and see if you feel that you know exactly what the writer was thinking, and whether it was an easy read! The other factor here, is a lot of surgeries undertake referral audits, and/or review referrals before they leave the building, which is another reason to make clear why you are making a referral and whether it lives up to peer scrutiny.

Another reason for writing a concise, clear referral is because it helps you. Writing or dictating the referral may prompt you to undertake some further investigation, or ask a few further questions prior to sending the referral off. I like to write my referral as soon as I have wound up the consultation, where possible, as all of the information is fresh in my mind, and I just find it a lot quicker.

Remember I said you don’t need to tell the patient’s life story? You really don’t! I know this because I have, once or twice, received a response thanking me for my ‘comprehensive’ history. Which I am pretty certain means they stopped reading it halfway through! Just give the relevant points!

I hope this is of use when you write your next referral!

Book review, Palliative care, Uncategorized

Book recommendation – Being Mortal by Atul Gawande

Posted on October 18, 2017October 18, 2017 by Emma

This post is not going to teach you anything – it’s a book recommendation. I know you might be thinking ‘when do I have time to read a (non textbook) book?’ but stick with me.

I came to read this book, not through selecting it myself but it was gifted to myself, along with a copy for all the doctors in our practice, by a patient. So, I added it to my growing pile of books to read. I tend to save books for holidays because I am an avid reader – one that struggles to read just a few pages at a time. But I knew I would read it. If someone has taken the time to gift you a book then it’s got to be worth a read.

I wasn’t entirely sure what the book would cover, since I hadn’t read the Amazon synopsis in advance. So to convince you it’s worth your time I will give you a rough idea, and place it into the context of why it was a great read for me.

The book covers the issue of death, and how we get there. Atul Gawande is a surgeon in the USA, and he wrote this book after reflecting on his experience of caring for older people – professionally and personally, and looking after those with terminal diagnoses. It is a personal reflection of his journey to improving the care of those people in the later stages of their life, and in the terminal phase. He looks at ageing (briefly), and how that impacts upon physical ability. Then puts this into the context of care of older people – in hospital and beyond. He looks at how modern medicine impacts upon mortality, and the choices available to people of all ages when they are given an end of life diagnosis. Finally, then looking at the change from managing at home to needing nursing home care, and how this has changed with time. He has spoken to palliative care specialists, those who have worked within the social care setting, colleagues, and most importantly patients.

All of the above is why I urge you to read this. How many of you have spent much time in your medical education and work, to date, dealing with end of life care directly? I recall my time as a trainee in the hospital recognising that people were moving into the terminal phase of my life, but not having the seniority to ‘make the call’. Sometimes I’d be given the responsibility of having discussions with relatives, to pass on the decisions made by senior colleagues. Sometimes I would watch as colleagues made seemingly unfathomable decisions that we must continue aggressive treatment of patients. I actually found some of my hospital shifts extremely upsetting as a result of this. I felt helpless watching management plans unfold, and being complicit in seemingly irrational management plans. The hospital is a busy place, and often understaffed at weekends. This could lead to a more senior doctor not having time to review your patient, and thus see in reality their situation. As such this sometimes seemed to prompt them to make management plans that would serve as a ‘holding plan’ until they could get to see the patient. My issue with this process was that by undertaking and ABG, or a portable CXR, you are suggesting to the family members who are watching their relative get sicker, that there is a way back from this. Yes, sometimes this is the case, but in one particular experience (I recall the scenario vividly – it happened 7 years ago) I knew that they would make no difference, but I followed orders. I remember thinking at the time I would rather spend my time talking to the family, and making this death something they wouldn’t remember as traumatic in any way. I didn’t get to do that. I felt really unsatisfied with my job when I got home that day.

This book, didn’t solve anything for me, but it made me think of how it could help hospital colleagues. It made me consider how I could potentially help my patients avoid being in this position when they reach the hospital. It opened up the idea of very frank and honest discussions. I thought I was trying to do that already, but this book gave me some tips on how to refine this.

It didn’t take too long to read. I also found there was no part of the book that I felt the urge to skim read. It was all interesting, and pertinent to the role of a GP. I encourage you to read this book, because I think it will improve your care of those patients reaching the later phase of their life, and making that time a positive experience for themselves and their family.

You can find a link to the authors website, and more information on the book here

Cardiovascular system, Chronic disease management, Consultation skills, Diagnosis, Hypertension, Uncategorized

Hypertension – the diagnosis

Posted on October 4, 2017October 18, 2017 by Emma

I’m covering this as it’s a common reason for consulting in primary care. What do you do when you pick up a high blood pressure as part of an examination for another presenting complaint? The answer should not be ‘ignore it and hope it goes away’!

As always, you can read the NICE guidance for all the ins and outs of hypertension diagnosis and management. What I’m going to do is give you some tips on what might be helpful during a consultation where someone has a raised blood pressure but no diagnosis of hypertension.

What I will say (and I can imagine this will become a familiar phrase) is that it is not easy to complete all of this in one 10 minute consultation. So it’s worth planning how to tackle this over a couple of consultations.

Most importantly, you need to know what raised blood pressure is. Here are the definitions to guide you:

Stage 1 Hypertension – clinic BP 140/90mmHg or higher AND subsequent 24h BP or home monitoring BP 135/85mmHg or higher
Stage 2 Hypertension – clinic BP 160/100mmHg or higher AND subsequent 24h BP or home monitoring BP 150/95mmHg or higher
Severe Hypertension – clinic systolic BP 180mmHg or higher OR clinic diastolic BP 110mmHg or higher

I think it’s fair to consider their reason for attendance, and whether this may be impacting upon their BP reading. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s a good time for you to complete your documentation. It can be hard to convince a patient to sit and say nothing! Also – make sure you’re using the correct cuff size – this really does impact upon the measurement.

If the BP is high on the first reading then measure it on the other arm also. You should have at least two measurements of BP if the initial one is >140/90. You may take a third if there is a significant difference between the first two. Document the lowest reading taken.

Your first consultation is likely to go as follows if you note a raised BP:

You will need to organise 24 hour (ambulatory – ABPM) BP monitoring OR home BP monitoring (HBPM). You might want to discuss these options with your patient. The ideal is ABPM.
You can also introduce the idea of hypertension and the lifestyle factors that might impact upon the patient’s BP. It gives them a bit of information to digest in the meantime, and it may allow them to consider how they can alter their lifestyle to make improvements.
You can also organise further investigations required to assess for target organ damage (kidneys, heart, eyes), and perform a cardiovascular risk assessment:
- Bloods – renal function, lipids, HbA1c, liver function (if considering statin)
- ECG – look for LVH, and REALLY helpful to have a baseline ECG
- Urine – for albumin: creatinine ratio
- Fundoscopy – you can look yourself but signposting them to an optician for a detailed check is helpful.
To complete a CVD risk assessment (a Q-risk in our case) we will need some information regarding family history of CVD, their height and weight (to calculate BMI), their smoking status, and checking their pulse for AF (which should ideally have been done prior to BP measurement since it can affect electronic BP recording)

You can see that after you’ve taken a history and reached the point of diagnosing a raised blood pressure (which may not have been their reason for attendance) there is quite a lot of explanation and planning to get on with! Don’t forget to address their actual reason for attendance if it wasn’t related to blood pressure.

NOTE – If you diagnose someone with severe hypertension, you need to consider starting an anti-hypertensive there and then. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. unless you have a recent renal function it is good to get one taken prior to starting an ACE inhibitor, since we need to monitor renal function after initiating said medication). You must also consider referral for same day specialist input if they have signs of papilloedema and/or retinal haemorrhage, or if they have symptoms to suggest an underlying cause e.g. phaeochromocytoma, or referral for investigation if this is possibly secondary hypertension.

The follow-up consultation is hopefully going to be straightforward if you have completed all of the above.

You are going to have the BP monitoring results and be able to diagnose hypertension, and which stage. You will also have the investigation results. This, in turn, allows you to manage the condition appropriately.

What are the lifestyle measures patients’ can take to reduce blood pressure? Did they have a think about these after the last consultation? Are there any changes they think they can realistically make?

Diet and exercise (including reducing salt intake, and reducing caffeine intake)
Quitting smoking
Reducing alcohol intake
Relaxation therapies

Who are we giving drug treatment to?

Stage 1 hypertension and < 80 years old with:
- target organ damage
- established CVD
- 10-year CVD risk > 20%
- Diabetes
- Renal impairment
All stage 2 hypertension

Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. We need to be looking for a secondary cause in these individuals and offering detailed assessment.

Hypertension should be monitored through clinic readings (unless they have white coat hypertension, in which case home monitoring can be used).

Target BP in clinic is <140/90 if <80 years old or <150/90 if 80 year or older. (home monitoring is <135/85 for < 80years and <145/85 if 80 years or older).

I’m going to stop here.

Do you know which antihypertensives should be used in which groups?

Do you know the stepwise treatment for hypertension?

Do you know how different drugs should be monitored, and what common side effects you might experience with the different medications?

Please use the comments section to try answering some of these questions, or if you have any questions regarding what has been discussed above!

Contraception, Physiology, Sexual Health, Uncategorized, Women's Health

Contraception – the basics

Posted on September 27, 2017October 18, 2017 by Emma

This is one of the most common tutorial topics. Why? Because there’s so much to know, it’s a common reason for women consulting, and it’s something that we don’t spend much time thinking about during our hospital jobs – even Obstetrics and Gynaecology posts!

It’s daunting because there are so many options, and so many situations. Who can have what, and when? What are the side effects? How should it be used?

I am not going to talk about all the methods in-depth here. I thought I would start with a quick overview of the options available, and a fact or two about each to get us started. My knowledge is derived from the Faculty of Sexual and Reproductive Healthcare (FSRH) guidance and the online learning modules that comprise the DFSRH.

One thing I like to do when learning is relate clinical knowledge back to anatomy and physiology. I find that by doing this, things just make sense, and tend to stick in my mind better. So you might notice that this post relates back to the physiology of the menstrual cycle!

So what’s available?

Barrier Methods:

Male or female condoms
Diaphragms
Caps

I’m not going to discuss barrier methods any further!

Combined Hormonal Contraception (CHC):

Pills
Patch
Ring

Progesterone only methods:

Pills
Injection
Implant
IUS

Non- hormonal:

Copper IUD

You can see why it’s so confusing for both the patient, and the doctor! Within these methods – there are so many brands!

But who are the main players, where hormones are concerned, in the reproductive cycle?

Well we need FSH and LH release from the pituitary gland. These hormones are working on the ovaries to ensure maturation of oocytes occurs over the cycle, and to facilitate the release of one each month. As this is occurring there are changes occurring within the uterus to prepare for potential implantation, and subsequent pregnancy.

Why is it useful to know this physiology? Because it lets us work out how the different contraceptions might be working to prevent pregnancy, and how they may impact upon the woman’s bleeding patterns.

Thus, progesterone within combined hormonal contraception (CHC) impacts upon the feedback cycle of these hormones to eventually prevent the mid-cycle LH surge, along with it’s affects on cervical mucus. Oestrogen within CHC is acting upon the endometrium, and preventing follicular development.

Progesterone only methods are slightly more complex, because it depends a little on the specific progesterone, and how it’s given, as to how exactly it affects the cycle:

The injection suppresses ovulation
The progesterone only pill’s (POP) main action is via effects on cervical mucus, but may or may not suppress ovulation (desogestrel, found in brands such as Cerazette and Cerelle, suppresses ovulation in approximately 97% of cycles)
The implant often suppresses ovulation but this is not absolute, and certainly not towards the end of the 3 years.
Progesterone emergency contraception prevents the LH surge thus arresting follicular development and delaying ovulation
The IUS (e.g. Mirena) has it’s greatest effects on the endometrium and thickening of cervical mucus. It inhibits proliferation of the endometrium, thus making it thin and atrophic.

The Copper IUD, as a non-hormonal method, works by producing a foreign body reaction. It can also affect endometrial enzymes, and copper has a direct toxic effect on sperm and ova. It’s primary mechanism of action is the prevention of fertilisation. However, it can be used as an emergency contraception to prevent implantation.

With perfect use, all methods of hormonal contraception are very effective at preventing pregnancy. However, methods that require patient action (pills and the injection) tend to have higher pregnancy rates, and greater discrepancy in typical versus perfect use. The most effective method at preventing pregnancy is the implant. The Mirena IUS and the implant have a greater impact upon pregnancy prevention that female sterilisation.

That was an initial introduction to contraception. It gives you an idea of whats out there, how they work and how they link into the physiology of the menstrual cycle.

There is much more to know, in order to allow women to make informed choices, and help us consider what might be right, and safe, for the woman.

Let me know if you have any thoughts on the above – and through your comments give me an idea of where we should move on to next within the subject of contraception.

Administration, ARCP, eportfolio, ESR, MRCGP, PDP, Uncategorized

A smart PDP

Posted on September 20, 2017October 18, 2017 by Emma

I attended a joint trainer and trainee meeting, and the focus of the afternoon was how to develop and keep an active PDP during your training and beyond.

I thought I’d share some learning from this because I know that this is not the best part of my appraisal process, and an area that I have spent very little time thinking about previously.

This session really helped change my thinking and knowledge of the process.

What is a PDP?

It’s a personal development plan. It’s a way of showing your supervisor that you are considering your learning needs and how you plan to meet these needs. This is by setting an action plan that details what you will do to address this learning need, how you will evidence that this has been completed, and a timeframe for this learning.

Why is it important I hear you ask……

……because we are learning all the time. A good PDP will focus your learning, and allow you to prioritise your time and learning needs. There is large amount to cover during GP training, and it’s going to seem daunting at times. So setting some aims and making plans might just make it a little easier.

Also, being MRCGP focussed, apparently some ARCPs have flagged up a poor PDP, or with nothing ‘active’ within it. This has held up some trainees’ progress to certification. In addition, the PDP you have at the end of GP training will form your PDP for your on-going appraisal process. Having an active PDP is mandatory for appraisals, and completed appraisals, are mandatory for revalidation.

How do I get started?

Firstly, how many entries should we have on our PDP? The golden number is three, however you may more or less! You need enough to show you’re addressing your learning needs, but not so many that you cannot keep up with the learning. Some might be more straightforward than others, and some more complex. Some may have a relatively short time frame, and some longer.

What shall I include?

This is where it gets difficult. It’s a ‘personal’ development plan. So you are the only person that can answer this. You need to look at your learning needs (lets talk about learning needs assessment/analysis another time). Perhaps they will relate to the current job you’re undertaking. They may relate to where in your training you are. For example, if you are preparing for AKT they may be related to knowledge development, or preparing for the CSA they’ll perhaps be more specific to consultation skills. They might be related to developing an interest you have, or managing your work life balance. If you can justify the reason for including it at this time, then go for it.

Creating the perfect PDP item

It needs to be ‘SMART’

S – specific

M – measurable

A – attainable

R – realistic and relevant

T – timescale

I’m going to use an example from my current appraisal, which I have now refined to reflect the above learning! I think if I use an example to talk through it, it will make more sense.

Specific – ‘To become accredited as a full trainer’. This is a specific aim, as opposed to something along the lines of ‘develop my training skills further’. The latter could include anything, and doesn’t necessarily have an end point, whereas the former has a defined end point.

Measurable – I can evidence that this has been completed via being approved as a full trainer. I can link to areas in my learning log that show the things I have done to support and facilitate my application.

Attainable – Can I get this done? Well I know there is a trainer panel in February time. I have been attending the right meetings, and undertaking the appropriate work in anticipation of this, so it is definitely possible!

Realistic and relevant – The work I need to complete to achieve this is already part of my workload, so I am not adding more work to my plate. I do need to factor in some time to complete the paperwork though. It is relevant, because we have an ST3 currently, and without being a full trainer I cannot be a named supervisor for an ST3, which I would really like in order to further my position within the practice where training is concerned.

Timescale – Well I shall aim for the end of March, as this gives me time to complete the application, attend the panel and hopefully receive confirmation that this has been achieved!

By laying out the objective like this I have focussed my learning, I know what I need to do, and I am telling whoever’s reading it what I’m going to do and how.

I have added a link to a good RCGP document on completing a PDP, with some good examples of real PDP entries, and what makes them work well or not so well. Follow this link and then click on the PDP pdf.

Why don’t you sit and write a PDP entry now and see if it’s a bit easier. Feel free to share some ideas or ask questions in the comment sections below!

Administration, MRCGP, Uncategorized

Welcome

Posted on September 20, 2017October 18, 2017 by Emma

This is a blog I have set up to share information about GP training with trainees. It might be or interest to trainers and fellow GP colleagues also.

I have been a trainee. Sometimes you just don’t find the answer you’re looking for about how to get things done. Sometimes you just need a snippet of information rather than a whole essay. Sometimes you’re just thinking ‘how do I explain this to a patient’.

I’m going to try and help! This is new for me, and I’m going to figure out what to add in as I go along. That’s where I need my readers’ help and interaction – If you give me ideas, based on what will help you I will shape this to meet your needs!

I’m an associate trainer, and I do weekly tutorials with my trainees’. I will take some inspiration from what they suggest as topics, and share some of these with you too.

I also hope it’s a place for support – if you work with me and use the comments section to share ideas, tips and thoughts, it develops a network of trainees beyond your local area potentially.

The only thing I wont be doing, and I really don’t want you to do, is put anything that is patient specific on here. Any ‘cases’ I use for learning will be ones that are made up. They will be those patients that make the ‘perfect’ CSA case, or ones that allow us to consider and practice our communication skills. They are often the brainchild of active imagination that I bring to role-plays – I do have an A* in GCSE drama don’t you know!!