I agree that an improvement in clinical skills, recognition of pathology etc needs incorporated into the RCGP portfolio in a more rigorous manner than the completely arbitrary and useless "CEPS" system which fixates on intimate examination at the cost of a solid CVS/Resp/Neuro/Gastro/MSK assessment - but why do we have to have such a binary approach to everything - it's possible to pride oneself on having both well developed set of clinical skills and communication skills - we shouldn't write off communication skills as "soft skills" as they can be just as tricky to navigate, and I would suggest I see more repeat visits because of poor rapport/explanation/clarity of management plans than missed pathology (though I've seen several missed symptomatic cholesteatomas recently - more so I think because I've got better kit than others rather than better skills) - though that's just my anecdotal impression.
I would suggest more of my meaningful and useful 'pearls' picked up along the way are to do with clinical examination and spot diagnosis rather than new guidelines and management.
I do also worry that in having a set of assessments that means you almost never have to touch a patient, some newer GPs aren't examining people with the rigor and discipline that they should primarily because of squeamishness about human contact rather than time (though this is what is always blamed as we're very good at convincing ourselves we don't have enough time for something).
New contract does nothing to address out of hour shortages. The pay is appalling, and receiving emails weekly that blame me for not being willing to work doesn’t encourage me to do so. They had a charismatic and enthusiastic clinical lead, but even he’s now gone, so it’s just unsafe conditions and poor pay left behind. Also the trainee shifts reinforce how unsupported you’ll be post CCT, so they also need to fix the registrar experience to encourage people to stay on. Even nearby Lanarkshire has better support for trainees on OOH.
Anonymouse - that’s a different user. There’s no space between devil and advocate in his username. I’d made the same mistake and misattributed comments hence the retraction above.
This comment has been deleted
Resilience training. They can't fix the system, so the outcome will be recommendation of resilience training. It's always the same. Systemic faults will get attributed to the individual - they're always just going to blame the canary for not being to withstand higher levels of carbon monoxide.
There is some limited evidence it works for Lennox-Gastaut and Dravet syndrome as an adjunct, with albeit small studies, but most importantly demonstrating minimal risks, and there seems to be a fundamental misunderstanding in most comments here about THC vs. CBD - and the above comment is conflating cannabinoids with cannabis and the associated psychosocial effects. I'd encourage all those w. kneejerk opposition to audit their morphine, oxycodone and fentanyl prescribing with the same conservative morals that they're applying here. Obviously we shouldn't be prescribing, and obviously GPs aren't best placed to do so, but maybe read into it and keep an open mind? I'd strongly anticipate that CBD based cannabinoids will be utilised in mainstream pharmaceuticals in 10-20 years as a useful adjunct to current analgesics/antiemetics/hypnotics.
pretty neat idea, as I'm sure the ease would encourage more reporting - slight concern about how it can safely automatically wipe out confidential/patient identifiable info though...
Inherent implicit bias amongst most, outright racism amongst others? Reform the complaints process, as it's unlikely you're going to be able to reform the hearts and minds of the general public.
Stokes-Lampard...apologies to our revered leader.
Helen Lampard-Stokes did two consecutive days of fairly well reasoned and presented explanation on Radio 4, and their idea of 'balanced' journalism was to then have a montage of phoned-in, emotion laden anecdotal evidence from patients, and an opposing view from a private Urologist. Really makes you despair.
Probably more of a depressing vortex to hell if you're actually a doctor affected by the discrimination associated with identity politics though eh? If the affected group have co-opted the term on an institutional level, identify with it and use it as a heading under which to fight their corner, probably best to respect that, stop quibbling over pedantry and actually listen to the issues at hand?
(DOI: Glasgow based, never met Dr. Krishan)
There’s multiple other criticisms in a massive chain of factors, but what’s ruffling feathers specifically about the enalapril part of the story is the absolute certainty on the part of the judge that it isn’t a novus actus interveniens. I hate the victim blaming side of bringing it up, but it’s daft to a) blame the doctor for not considering the possibility that an in prescribed med would get given when she’s too stretched to communicate it as being withheld but has correctly intentionally omitted it from the kardex which would be a safe practice in most hospitals and b) dismiss its role in causing a septic kid with renal failure to crash. Isobel Amaro has been punished significantly but just didn’t get the public shaming that Dr B-G has received but shouldn’t be dragged through the mud any further as it benefits no one. The whole point in the backlash from doctors is the isolation of an individual as scapegoat for systemic problems and we should avoid committing the same sin as the GMC.
Yep, I agree completely, sorry if wasn’t clear. (FYI it’s point 15 on this court document: http://www.bailii.org/ew/cases/EWCA/Crim/2016/1841.html )
@10:52: It comes from the court documents. A lot of verification from many sources on Twitter who've read various accounts. The paediatric consultants version on 54000 doctors doesn't attribute the administration to anyone in a rather loaded way (as they understandably don't want to be seen to victim blame). The criticism of Bawa-Garba is that she didn't tell the family not to do so, not that she prescribed it or forgot to omit it. Emphasises the unrealistic expectation for her to be in all places dealing with all things at once - hospital docs don't often have to consider what might get given by family/friends as to most, the kardex is gospel. Likewise, no way nursing staff would risk giving unprescribed meds.
You're misrepresenting the case somewhat in saying that she omitted to document suspension of enalapril, the implication being that it was left on the kardex and this was why "Jack was subsequently given his evening dose of enalapril around 7pm" - enalapril wasn't on his kardex (ie. was intentionally omitted) and this dose wasn't given by medical/nursing staff but rather by family. Might be worth clarifying in the timeline for the sake of fairness.
Not enough people seem to know where the 'unprescribed dose of enalapril' came from but it's worth looking up to provide even more depressing context to the story.
The Body Keeps The Score by Bessel van der Kolk is the best exploration of PTSD I've read and shows how the USA are leaps and bounds ahead of us in terms of trauma management (mainly because of the Vietnam war, 9/11 etc). I've struggled to manage PTSD well because EMDR and t-CBT simply aren't available locally, despite their proven benefits. I'm sure a lot of our demographic have issues w. complex trauma and would benefit more from the above recommendations that the ineffective depression/anxiety pathways they get filtered into. Trauma centres as per USA practice would be a fantastic development.
Great article, prompted a purchase - just FYI, the PUL15 code doesn't work, think it might be because it's currently on sale for 19.99 from RRP for 24.99 and that discount exceeds the 15% reduction.
Safe medication - yes - but shame we'll miss out on cases where it's a first presentation of undiagnosed peripheral vascular disease, diabetes, etc. They say they won't give to those with high CVRA risk - this depends on this having been calculated, requiring info from primary care. Erectile Dysfunction also increasing in incidence in younger men due to psychosocial issues, unrealistic expectations etc which need a whole different type of management - framing ED as a simple condition with one unifying panacea of a small blue pill seems narrow-minded.
My view is that first assessment - doctor - subsequent prescribing etc - pharmacist.
Thanks for your comprehensive response - much appreciated. I've now had a chance to read the whole document and agree with all your points. Replaced my cynicism with scepticism and a bit of hopefulness.
My main concerns are that we're going to be woefully untrained/unsupported in managing a team of noctors employed by someone else, and I also dread the extra work they'll inevitably generate. Just as one example, the roles specified in the document for the pharmacist are completely unrealistic - how can a pharmacist navigate the 50+ special requests, when a lot of them require a nuanced and intimate knowledge of patients (eg. antidepressant or hypnotic prescribing) or an unspoken contract between patient and doctor that comes through mutual history with each other - it's just not practical and obviously a suggestion made by someone who isn't currently a jobbing GP.
Even if they reduce actual workload by some arbitrary amount, the amount of menial supervision, handover, communication, tasks, extra work to support the uncertainty/portfolio projects/training of ANPs, pharmacists, paramedics etc will just replace the stress of being overworked with the stress of losing job satisfaction and ennui. By being restricted to 'complex' patients as well, we'll lose the satisfying cases (a quick reassurance something isn't a melanoma, that they do indeed have an ear infection, an easily fixed rash, etc etc) and who on earth is going to even determine who is simple and who is complex before they walk in the door?
I think maybe this is good for others following, but that I've already got one foot out the door at the end of this training and there's not enough specific, defined benefit in this contract to justify staying on unfortunately.
Thanks again for taking the time.