Best to focus on improving lifestyle education and to tackling the issue starting from Primary School. That is not just "on paper".
I read with some interest the NEJM papers to be then left perplexed.
It is sometimes worrisome observing that papers such as this one are published triggering astonishing attention and general public expectations - intentionally. It has been known for quite some time that calcitonin gene-related peptide (CGRP) is a very potent vasodilator and plays an important role in the initiation, progression and maintenance of hypertension. It is therefore to say at the least naïve to think that, dealing with attacks prevention for a condition lasting most part of the adult life, may not be consequential in terms of blood pressure and cardiovascular risks. I remain puzzled by why data addressing cardiovascular parameters have not been published in detail. Furthermore, not all the subjects responded to the treatment at all. This may well mean that when speaking about migraine, we may be putting under the same umbrella apples and pears, that is same outcome (headache), but different mechanisms (partially, or entirely). Another interesting aspects would be the one of improvement of quality of life being experienced by the patients. I noted with interest a remarkable placebo effect in the 3rd study arm.
I confess, I would have zero suggestions to make to my children other than: “Daughter/Son, just do what you think you may enjoy to do. I am here to help you whatever it may be your choice, if you wish me to” - and as I would like to.
As surely all of you know, the most paid job, on average, is the one of “broker”. Guess what…There are no formal academic requirements, although many employers will require you to possess a degree or equivalent qualification. Training is typically undertaken in-house. Of course, you may prefer to be a CEO or Sales Executive, or a pilot…
On reflection, none of these jobs requires particular academic training…
The average income of medical professionals has dropped over time and so did the “status”. The pay of all doctors has been steadily squeezed by successive pay freezes and cuts, with salaries falling back to levels seen around 10 years ago – despite rising patient demand and declining budgets for patient services. Above all, ourselves and our politicised governing body, have negatively affected job satisfaction and this is just why most doctors would not recommend medicine to their most dear children.
But, we ought to be careful here. All professionals have felt squeezed in many ways and to have lost in terms of work satisfactions. This seems have more to do with politics than with the nature of the job.
Things may change and we should be the ones to promote the changes we want.
A for myself, I would not make a call for a pay raise, but for more freedom and ability to do what I think to be the best for the patients and, sometimes, this may even be to deny something as failing to address the problem and ultimately be a waste of precious time and financial resources (the first being the most important resource of all, for everybody including the patient - to note that after a 10 minutes consultation we all shall be 10 minutes closer to the ultimate, unavoidable, endpoint…).
I am concerned by the amount of debts being cumulated by today’s medical students.
I fear that we are moving towards to a society where slavery is dictated by debts. We have addressed minimum wages, working hours, pay equality, but what about having to work just to pay for fundamental educational needs?
I just can hope we would not change the essence, the spirit, of our job and refuse to be business people. Ultimately, the ideal doctor is the one with no clients as all of them have been healed. In fact, running a surgery with very few patients in the QOF register would not be very profitable at all...
I can see the point being made by Dr Chand and I think it is a correct one. As for Brexit vote, Robert Thaler (Nobel Prize and behavioral economist at the University of Chicago Booth School of Business - not me) considered it to be good example of individuals diverging from this kind of purely rational behaviour. He somewhat forecasted the outcome and said, “most voters aren’t really thinking about it in a very analytical way… The people behind the leave campaign are voting with their guts. There’s no spreadsheet. This is much like a divorce without a prenup. You’re voting to leave, and we’ll take care of all the financial details later.”
That is, NHS spending promises were not really taken in serious consideration. As for my current personal forecast, I can just imagine more struggles in the short and medium term for the medical and nursing profession in the UK. However, markets are and shall remain interconnected. Do not be too surprised if it will be the turn of British doctors emigrating to the Old Continent for better career and training opportunities, higher morale and greater remuneration. In fact, visa restriction may apply at some stage as well as registration barriers. Access and duration of the medial and nursing training may consequently change, but it is hard to imagine a "return to the past".
According to the ONS: "Average life satisfaction, worthwhile and happiness ratings reach highest levels since 2011". Who should we believe to? My impression is certainly echoing the findings highlighted in this short article.The sample size of the ONS is of sample size of approximately 158,000. Quite small, may I say, particularly when we ignore the distribution, social status, age, response rate, etc. I could not find the number of people claiming benefits due to mental disorders, and specifically depression, for the year 2016-2017. However, we know that mental disorders have become the most common cause of receiving benefits, with the number of claimants rising by 103% from 1995 to 1.1 million in 2014. I am likewise aware that is is more likely that people on benefits and unemployed are suffering from depression.
As for the GP role, this should be framed within the above context of increasing number of patients being diagnosed with depression, increasing number of antidepressants being prescribed, yet not decreasing number of patients claiming benefits due to a reduced burden of depression on work capability for instance. Hence, we should be questioning if we are really making a difference and/or enough difference.
We are also aware that double-blind, randomized controlled trials have shown that antidepressants are, on average, only marginally superior to placebos. One might reasonably ask, however, whether there might be a sub-set of patients for whom antidepressants are highly effective. This is certainly possible, but to date no one has been able to reliably predict which subset of patients will respond best.
Moreover, because average antidepressant efficacy is small and not clinically significant, if there is a sub-set of patients for whom antidepressants are highly effective, there must also be a sub-set of patients for whom antidepressants have no effect, or are even harmful.
We know for certain that they are not a cure, but - in the best case scenario - a treatment.
My humble opinion is that we should reflect deeply as a society on the causes of the increasing burden of mental health issues.
As physician, we should improve our understanding of depression, and how to identify an effective treatments for a given patient, if any.
I do not think this study demonstrates a causal relationship between PPI and gastric cancer. The association between atrophic gastritis (AG) and gastric cancer (GC) has been known for a long time. AG represents the end stage of chronic gastritis, both infectious and autoimmune. In both cases, the clinical manifestations of atrophic gastritis are those of chronic gastritis, but pernicious anemia is observed specifically in patients with autoimmune gastritis and not in those with H pylori–associated atrophic gastritis. The latter has been perhaps more often associated with diagnosis of GC. It is therefore hardly surprising that, among all the people - many - taking PPI consistently for a long time there should be a good proportion with AG, hence at increased risk of GC. If PPI were to be blamed for GC, then I would have expected an increased prevalence of GC when compared to the '80s. The opposite appears to be true. That being said, I find concerning for the very same reasons that patient on regular PPI are not reviewed regularly.
Following a paper (N Engl J Med 2017; 377:411-414) which highlighted concerns about their prescribing, coupled with "new evidence" that their effectiveness as a treatment for chronic backache was to be questioned, I wrote elsewhere:
"That is sad news as I for sure have been quite strongly under this impression for many years, that is more than 10 years. I cannot refrain from thinking that the price drop of those medications may have reduced the interest in highlighting benefits we should have been more cautious about. Also, worthwhile exploring other mid and long term downsides on the CNS, including mental health and addiction, or other forms of impacts. Co-prescribing with opiates and coexistence of drug abuse and hyperalgesic states appear to be of common observation. Perhaps "negative" studies should have a louder resonance to avoid similar, too late, "discoveries".
Ever since, a heroin addicted trying to detox shared his knowledge of them. He had known for many years too well first hand about them and why they should have been controlled drugs, in his humble opinion. However, it has to be said that making a drug controlled does not necessarily limit its diffusion. The opioid epidemic can just confirm my consideration. It is our prescribing and the way we explain what we know about pros and cons of any prescription that may make a significant difference. Often, a 10 minutes consultation may not be long enough. Furthermore, we should be most mindful of the unknown unknowns for any new drug, particularly if acting on the CNS.
It is perplexing that we are still suggested to be looking "for people confirmed as being at high risk of DM because of a fasting plasma glucose of 5.5–6.9 mmol/l or HbA1c of 42–47 mmol/L". It seems that a blood result is what we should need to raise concerns about DM. DM is endemic and it would not be shifting a sign-post to 5.5 mmol/L (which has been the case for a while now) to make the difference. If we really want to make a difference instead, we should not wait for that long and for a blood test result. As a matter of fact, observation and just using a simple weight scale could be an immediate, cheap, and helpful starting point. It can be argues that when blood tests start to show some degree of derangement, something is already going "wrong". We have known for many years that lifetime diabetes risk at 18 years of age increases significantly with BMI. It has been suggested that this varies from 7.6 to 70.3% between underweight and very obese men and from 12.2 to 74.4% for women. The promise of early intervention is that not only does it mean providing effective, timely support to those at risk to prevent poor later life outcomes and the intergenerational cycle of disadvantage, but it delivers savings to both local and national agencies at a time of increasing budgetary pressures.
About 100 years ago, at Harvard, Dr. Cabot said that although medicine does not offer advantages to a lazy or money-seeking man, it does appeal to a strong man who wishes to do a man's work, and fight a good fight, and help humanity.
Other times and wording that would not resonate well today. Quoting KingFund resources, "In 2011, 43 per cent of all doctors in England were female, exceeding 100,000 for the first time with numbers increasing at a faster rate than male doctors. Women are expected to outnumber men at some point between 2017 and 2022, accelerating demand for flexible, part-time and salaried posts raising the prospect that more doctors may be required to provide care in future years".
But, I have seen clinicians moving from the bedside to management roles, some mixing the 2 roles, and quite a few leaving the profession. This is something that appeared to me as obvious about 2 decades ago, but that I have seen becoming increasingly popular over the last 15 years.
Overall, it may be fair to say that a difficult profession is becoming less appealing, but the financial rewards - or the lack of it - are not necessarily what is playing a pivotal role.
However, further income cuts in relative or absolute terms (such as a result of the spiking indemnity fees), may be what could trigger a retirement decision for those who can. For the younger or us, I hope they could find what they have studied for.
I agree with S Cabbabe thinking: "For future physicians to succeed, they need to be freed from the tyranny of ideas imposed upon them by those not working at the bedside of the patient.". Unfortunately, this will not depend entirely on them, but largely on the political winds.
Then, let us not being anymore the gatekeeper, but the expert adviser and advocate of our patient instead. Please, let the Pharmacist accept new roles and duties. Also, please, let Pharmacists dispense antibiotics without GP prescription, privately. I am not so sure the number of prescriptions will increase much. And should it do it instead, I would be less than surprised to see a drop later on. As for the hospital referrals, in truth, it seems to me that a decreasing amount of people is willing to pay a visit to the local hospital. Actually, I should say local hospitals. I have observed that patients do learn from our actions. And yes, the raise of anti-claim/defensive medical practice has helped no one at all. A practice which has been indeed underpinned by medical reports we have generated. So, we cannot complain about that either. I am grown to believe that prevention is much better that cure. I would love to spend my 10 minutes, starting from a very early age, educating our patients in what to do and what to avoid instead, to keep our bodies and mind healthy. Perhaps, we could have a 20 minute appointment, which could be more productive in many ways. I would like to focus on early detection of important and progressive diseases to increase the chances of cure. I would like to have direct access to imaging. I would like to help patients to fully understand what is going on in an always more complex, multi-disciplinary, medical management, without losing their ways and remaining in charge of what they want to do with their bodies and lives. I would like to have the time to speak to the Consultant and to read their correspondence. I want the GP to be the most experienced and educated figure within the healthcare system. Perhaps, one day soon, most will accept that coughs and colds do get better without medical intervention. And maybe, one day, we will be in a position of saying that using a spray and smoking 40 cigarettes a day at the same time is an absurd that cannot backed up by a GP working for the NHS. The NHS is struggling. GPs are struggling.
At 46 am I past sell-by date, or still relatively young? I don't know, but I know that I have worked now for 21+ years and I have seen how much the profession has changed. As such, I would suggest to all the new graduates to look very much around and learn "entrepreneurial venture skills". I am sure they are "top" graduates, plenty of drive/will and energies. You can do anything you wish to, but get prepared for alternative routes.
It would be interesting to make a distinction between cases when the GP advises refraining from work, and cases when the patient is requesting a sick note as he or she feels unable to work whatever this may be the cause. From this subgroup, the DWP should -without the need for a referral- assess promptly those who have been sick for a significant amount of time (4 weeks or more). I am sure many GP would agree on probably all the cases where refraining from work would be beneficial to the mental and physical health of the patient.
I would avoid the fallacy that recruiting more doctors in OOH/A&E would mean better outcomes. This apply also to the 24/7 Consultant on duty. We will continue to prescribe, operate, fill more hospital beds, order more diagnostic tests — in short, spend more money. But the NHS resources (and of our society overall for that matter) would be better directed toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease.
Better coordination of care is also worth investment. Small GPs groups in disconnected offices often provide fragmented treatments, while multispecialty practices integrated with hospitals may well be associated with lower cost and higher quality of care.
We hardly speak anymore with consultant/hospital colleague.
I am not alone thinking this way. All these strategies have been shown to improve patient outcomes without adding physicians to the workforce. Instead of training/recruiting more doctors, or make them work longer hours, let's make better use of the ones we already have.
It seems to me that more doctors than ever are considering retirement and who is familiar with the work/compensation curve, it does not take long to understand that a slightly higher pay shall not be an incentive. In fact, it may do something in the very short run, making indeed things worse as to this shall follow a workforce shortage.
I hope this helps...
I would be most cautious with the interpretations of the results. The Authors say: Sertraline was the most commonly reported SSRI, but none of the five previously reported birth defects associations with sertraline was confirmed. For nine previously reported associations between maternal SSRI use and birth defect in infants, findings were consistent with no association. High posterior odds ratios excluding the null value were observed for five birth defects with paroxetine (anencephaly 3.2, 95% credible interval 1.6 to 6.2; atrial septal defects 1.8, 1.1 to 3.0; right ventricular outflow tract obstruction defects 2.4, 1.4 to 3.9; gastroschisis 2.5, 1.2 to 4.8; and omphalocele 3.5, 1.3 to 8.0) and for two defects with fluoxetine (right ventricular outflow tract obstruction defects 2.0, 1.4 to 3.1 and craniosynostosis 1.9, 1.1 to 3.0).
First point: I am taken back by the fact that the Bayesian analysis did not take into consideration use of alcohol, or folic acid. Needless to say, all the drugs taken by the patients should have been likewise considered, particularly in the first trimester.
Second point: there are countless number of genes that may be involved in the process and we know only very few of them. Surely we are not sure if we are comparing and associating apples with pears or if we are not. I do feel that the study has very low power and it would be interesting to know if a similar study reporting a negative association (reduction of the odds of malformations) would have been published. I am herein referring not only to SSRI, but anything, including H20...My position remains that in pregnancy avoiding medications/drugs unless strictly required should be the best course of action.
Quite a few negative comments and skepticism. Being mindful of Galton’s intuition about the wisdom of the crowd, I feel to highlight the merit of looking into when, where, how and how much money was spent. Could it be possible that money was invested and that the RCGP is expecting a positive return in the years to come? Personally, I would love to see the University being in charge of the exams rather than the Royal Colleges. But, this is just me…
There should be more cohesion among GPs, of this I am sure.
The RCGP has not helped much. Anyone who is working as GP, and who has been revalidated - or appraisals - should be a member of the RCGP at a nominal fee.
The RCGP should have a catalytic role.
I have seen GPs remaining isolated in their very own Practice.
The above has been coupled to unachievable targets such as “pleasing everybody”, yet acting as a “filter” without upsetting anyone.
GPs are often confined to their consulting rooms.
You are a GP in the first place because you love helping people and you are passionate about healthcare. Now, you are left wondering about your role.
The financial reward was made to be your prize, but this was never meant to be. You feel that it is time to leave as your pension bucket is, anyway, already full.
The assumption that QOF are/were going to have (positive) impact on the population's health requires for us to postulate that GPs were not looking after their patient's according to basic general practice healthcare principles -because of whatever reason.
Moinuddin Kapadia, you make a good point and - sadly - UK is not hold the black shirt. This link may help to clarify what I mean when I say that UK is not the worse of the league: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3284
However, I strongly believe we should be given more "medicolegal protection" and more tools for rapid diagnosis (test kits). There is a well routed culture in the general population, which has been created with decades of antibiotic prescribing for self-limiting - as a rule, infections. Vaccinations have made no difference to our prescribing, which seems to be odd. However, alike for CO2 emissions, you have to do what is right, no matter what others may be doing.
Another option would be the introduction of a prescription ticket on antibiotics. Antibiotic over-prescribing is deeply rooted in the UK medical practice. Delayed antibiotic prescriptions have been adopted by many GPs, but with limited benefit. Perhaps, the introduction of a £7.98 ticket on antibiotic prescriptions (the cost of a pack of cigarettes to be precise), could have a place. The income so generated should be invested into pharmachological research.