On a more positive sounding note, in our practice doing as much as we can over the phone phone has resulted in all our patient contacts being sorted out the same day. I'm not sure how long we can keep this up for when we have to start doing preventative medicine. However at the moment I think patients are enjoying the same day service. They are enjoying the fact that we don't ask them to come into the surgery just because it makes life easier for us. Patients now don't have to to book half a day off just to spend 10 minutes with us. When we do see patients we do bloods etc at the same time so that they are sorted the same day. Myself and my colleagues work from one list of phone calls. Everyone works efficiently and as quickly as they can to get through the the days work without creating artificial boundaries such as rigid appointment times and the rather silly book on the day routine which has always driven patients mad. The phone lines are relatively free. The patients we are inviting in to see us have significant medical symptoms and require thorough assessment. In our area and possibly most of the UK GPs are working a four day week! I can't believe the press hasn't got hold of this. 20 years ago we used to to have one half day per week on the basis that we were doing our own out of hours approximately one in 4 nights. It's incredible to think that now than normal is a 4-day week with no on call. If anyone is working 4 days a week then I don't think a 10 hour day is excessive as it only adds up to 40 hours.
I would like know if the threshold for diagnosing bipolar disorder is much less than that of what we used to call manic depression? I haven't seen anyone with hypomania in 30 years as a GP but patients are always coming in telling me they are a "bit bipolar". If the conditions are the same the threshold is definitely lower.
The trend to ditch drugs hasn't reached North Wales. I wish it would.
As far as I am aware this is the 2nd met-analysis done in this area. The first one by Irving Kirsch - try Wikipedia, said no better than placebo. So now we have 2 bits of research to go on. Take note of the words "acute" Short term" and "major". These words do not apply to 90% + of my depressed workload which consists of chronic low grade depression and dependency on long term medication. Unfortunately the simple message now to the public and doctors is that these medication "work" . It is much more complex than that. They also stated that they excluded patients with "resistant" depression. I assume that means they excluded those patients where medication failed - bizarre!
There is no evidence that serotonin affects mood - it is a theory. There is no evidence that SSRI actually raise serotonin levels in the brain!
Nearly useless drug. Most chronic pain patients say it "takes the edge off" the pain. When I tell them the cost of "the edge" they look a little sheepish!
Useless drugs. Should never be started in my opinion. Never seem to make much difference apart from initial placebo response. The "take the edge off the pain doc".
By the way. If you are puzzled as to how medicine has got into such a mess with antidepressants read Bad Pharma by Ben Goldacre and you will understand how this has come about it is mass manipulation of the Medical Profession and patients.
Brilliant. I've made several posts on Pulse articles on this subject. You are not being courageous in writing this article however. The science backs you up. Google Irving Kirch's meta analysis. There is no evidence that these drugs work. Not surprising really as there is also no evidence that serotonin plays a role in depression it is just a theory. I am fed up of seeing patients who have been on and off these drugs over many years and they are still depressed. They get the initial Placebo response of course which is satisfying for them and satisfying for the doctor so we continue to prescribe as we are always better at remembering our successes than perhaps our failures with antidepressants. Worse than that I have also read that there is no evidence that these drugs actually increase serotonin levels in any case. It really is laughable if it wasn't so serious. It's a scandal that people are prescribed these drugs in such vast quantities and also the waste of Primary Care time in prescribing and monitoring their effect or lack of.
SSRI s anyone? No evidence. It's just that we are too frightened to admit that we actually don't have a drug that works for this condition
Great blog. Yes the hours in the 80 s were much longer but the teamwork got you through. Doctors mess own room on site and close by off duty pub.
SSRI s should be next.
The SSRI s should be next.
The elephant in the room is the fact that a lot of what we traditionally do has no evidence to back it up. We need daytime triage. Not as tough as the out of hours. It's ridiculous to have a system wherby patients with trivial symptoms are able to see a health care professional as easily as someone with serious symptoms. Out of hours care is now rationed and is safe. We need the same in the day.
Dear jobbingdoc. please don't interpret this chart as meaning antidepressants work. Google Irving Kirsch's met-analysis. No better than placebo. No evidence for the roll of serotonin in depression in the first place - it's just an hypothesis. We have been brainwashed along with the public for decades to believe that these drugs work (better than placebo that is) My local psychiatrist told me the don't work. They are a waste of money and resources and it's a scandal that patients see their issues as serotonin deficiency which means they become to rely on them every time life gets tough. How many consultations are wasted tinkering with patient's serotonin levels? There isn't even any evidence that they actually alter the levels in the first place. As for any trial evidence - go to alltrials.net and you'll see how poor the evidence is that us poor souls have to make decisions. As for the chart - excellent - when you explain to patients that so few patients benefit from so many of our drugs they often decline to take them.
I audited one week's worth of surgery consultations. It would have made no difference to the patient whether they had sought medical advice or not in 48% of the cases. That's not to say they should not have consulted. I wasn't being tough either. Any consultation where I did anything at all (apart from simple reassurance) including defensive antibiotic prescribing for probably viral cough was deemed necessary in my audit. A lot of what we do is traditional cuddly stuff which patients love - the problem is they don't love the system when they want to see us with serious symptoms and find it difficult to do so and those patients potentially have worse outcomes. We should not put up with a system were a sore throat for half a day gets to see us as easily as an elderly patient with weight loss and bowel symptoms. My little audit suggests that nearly half of our time is wasted/used badly. The mainstream media this week reported that it was 20% - not that far off really as the criteria for making such a statement could differ wildly.
We simply don't have time for the cuddly stuff if we have not got time for the serious stuff.
Brilliant. Never heard of imposter syndrome. Now I know how to explain an experienced consultation to my medical student!
Great! Can you look at the benefits of antidepressants copd drugs tight diabetic control with new expensive drugs and mild hypertension? I'm sure the evidence in these areas is patchy too! Questioning the effectiveness of our input in these areas is always met with scorn too.
Just release all the data!
Agree totally. But the biggest issue is how do we stop seeing patients like this. I audited a week's worth of contacts. If you discount reassurance at least 50% of the patients were unaffected in terms of their outcome by seeing a doctor. Why would a taxpayer want to throw more money as a system like this? The money needs to be given to treatments where there are hard outcomes such as cataracts and hip replacements and cancer treatments. Granted we are very efficient but we are efficient at doing stuff that often doesn't matter.
I try not to diagnose ME. I think the label has a negative impact on the patient as there is little if any treatment to access. I prefer to tell patients that all the tests are negative and with a bit of luck they should recover soon. The diagnosis of a chronic long term condition should not be inflicted on a patient without some firm evidence for the existence of the condition in the first place. With all the advanced diagnostic tools we have at our disposal these days as every year passes the the existence of diseases like this becomes more and more unlikely. We can't diagnose everything and where we can't it's best to say so - not to come up with a totally unhelpful label. I have never created/diagnosed a patient with CFS but I have seen lots of patients diagnosed by others and have not been helped. You only have to look at the long list of supposed treatments to realise we do not know what we are doing. If your car breaks down and the mechanic suggests 10 completely different solutions you would probably assume that the mechanic did not know for sure what was wrong with the car.