Working with colleagues and great curry!

Another good GP meet up last night, we shared fantastic curry and current dilemmas. As one of us has had to let go a partner and another has resigned from her partnership. Both had issues to do with being able to work with colleagues in practice. Tough decisions but we all agreed both had done the right thing.

Shingles vaccine and norovirus vaccine on the horizon, nursing homes and home visiting.

We covered a lot of ground!

Austerity and NICE

The GP group were in decidedly sombre mood, talking about austerity cuts and effects on patients. We discussed effects of diet poor mental health and effect on kids of the budget cuts. We discussed what we could do about it and how to raise awareness of the plight of our already disadvantaged patients.

There was more throwing hands in the air at current NICE guidance regarding tamoxifen for at risk women. Several of us had heard the Inside Health article about the recommendations and agreed with the GP on the show.

We also managed to share dilemmas regarding colleagues and partnerships. A productive if rather depressing couple of hours.meeting in July , accidentally not recorded until september as it hadnt saved

Psychiatry and Anti-Psychiatry

It's the summer holidays so I think I should get double points for any intelligent thought at the moment!

Luckily there is lots in the media about psychiatry with the publishing of the latest DSM V manual, a couple of articles gave me pause for thought.

In the Guardian review there is a long piece by Will Self, asking what the point of Psychiatry is and criticising Psychiatrists for essentially being state-sponsored drug pushers.

http://www.theguardian.com/society/2013/aug/03/will-self-psychiatrist-drug-medication

It's certainly an interesting article, although not a balanced one. What is equally interesting is the huge number of shares and comments the article has generated since it was published 4 days ago.

 An item that is less controversial and not quite so interesting there is an in the London Review of Books of the manual itself. It's by another non-medic Ian Hacking

http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest

It also seems to have generated alot of comment in a short time. The article expands on the idea that really this manual is not for clinicians, as it is virtually inusuable. It's role is largely in the US for bureaucrats to decide how and who to provide medical care to.

Both articles give plenty to think about. It's interesting to compare the message of Will Self's article with Ben Goldacre's Bad Pharma. Both men want clinicians to be more thoughtful in thier prescribing I think. One has the medical back ground the other is well read and educated on the subject but not a prescribing clinican themselves.

Thinking fast and slow

A while since I last wrote anything on here!

A crazy few weeks have been and gone, with poetry festivals school hols and trips across the country and abroad to see family.

I read an excellent book by the Nobel prize winner Daniel Kahnemann 'thinking fast and slow' about the mental short cuts we all make to cope with the sheer volume of information the human brain receives every second of the day.

It makes a lot of sense to me and I'm sure any GP trying to convey information regarding likelihood and risks. I'm sure it will influence my practice and I would recommend it as a good read, whatever your walk of life.

http://books.google.co.uk/books?id=oV1tXT3HigoC&printsec=frontcover&output=html_text&source=gbs_ge_summary_r&cad=0

Diets and Psychopaths

Firstly some listening, a helpful follow on from Inside Health as ever. Looking at the evidence for the Fast Diet 5:2 etc the opinion is there isn't enough evidence yet to support its recommendation beyond other 'move more eat less' diets, but as one helpful comment from a listener the following week pointed out, the idea of only dieting 2 days per week is both new and more achievable, so what's the harm? I'm recommending the Fast Diet which is a few quid on Amazon and written by a GP. It's top of the best sellers list bit I don't think I can take credit for that!

I've zipped through Jon Ronson's excellent Psychopath Test, lots to think about regarding diagnosis if psychiatric illness, the use of checklists to define illness and the use of medication.

Francis Report & all calories are not equal

A  cold snowy morning! Time to get things done that don't involve leaving the house!

So, I've been following various reports about the Francis Report before I decide what I think and how it should affect me and my practice. Yesterday I listened to the BMJ round table podcast with Mr Francis himself and various other senior figures in the health service. Only one piece of journalism in the mainstream press gave me pause for thought. It was by Roger Taylor who also has a book coming out about the NHS.

He described how a successful hospital can still have thousands of adverse events reported including serious injury and death due to medial error and still be thought of as a good hospital. So, for people working in a system and there being more than an 'acceptable' number of errors not spotted, isn't so surprising really.

He also mentioned a consultant in Mid Staffs who was running an exemplary department and managed to do so through the crisis, but unfortunately this wasn't expanded on. It strikes me he is the has something valuable to contribute to the debate.

The round table was interesting, but didn't really come up with anything above and beyond what has been extensively written about. It seems a pity to me, with so many senior figures in one place they couldn't come up with some answers.

Much more interesting was a San Franscisco Medic on another BMJ podcast, discussing how all calories are not equal and how processed foods trigger insulin release and further cravings for more calorie dense fattening foods. He went pretty fast and I found it hard to keep up so I might have to listen to that one again! The basic message was cut right down on processed foods, high fibre foods help digest sugars hence whole fruit and whole grains being preferable to anything in a packet.

This is useful to me and my family personally as I have time and resources to cook good food. Helping my patients? I guess it's a question of encouraging people to buy fruit and veg and eat more home cooked food. Although with no fresh fruit and veg shop locally and many of my patients having no cooking skills at all, I'm not sure how far I will get with my more deprived patients.  

Cochrane collaboration podcast and Inside Health

I listened to my first Cochrane podcast and can report it was pretty good. Compared to the slick production of Inside Health it's about dry and the speaker obviously less experienced at broadcasting, but still engaging and I'll listen to some more.

The podcast I listened to was about the use of SSRIs after stroke and although not directly relevant to my daily practice, I enjoyed hearing about a novel use of a well known drug.

Inside Health continues and one good item on Parkinson's disease but I was less impressed with an article by a family planning specialist about continuing use of the combined pill in older women. The specialist highlighted all of the benefits of taking COCP but didn't mention the possible side effects once. If I was a patient I would have been left thinking there was no possible side effects and would have a very biased opinion of the class of drugs.

Lots of listening and reading.

So, Inside Health is back on the air and as usual has lots to discuss and think about! I'm up to date with the episodes and have particularly appreciated the article on dry mouth and current cancer treatments.

I'm proud to announce I finished Bad Pharma last week, within the 3 weeks of the library book loan too! I talked about it to a friend and colleague and she asked if reading it had changed my prescribing. I think that is a really hard question to answer quickly!

The book is pretty forthright about my responsibility as a doctor regarding prescribing and Ben Goldacre really knows his stuff. He also makes good points about getting the right information to GPs to be able to make a good decision when prescribing.  

He highlights the arbitrary nature of some of our decisions and how easy it would be to fix indiscrepancies by entering all patients into trials as a matter of course as opposed to the current state of affairs.

So, how will it change my prescribing? I would like to think I prescribe mainly tried and tested generics based on current best evidence already. I hope it will make me more enquiring about prescribing decisions from secondary care. I hope I will share the vagarities of some decisions with my patients where good evidence isn't available more openly.

The book is very critical of medical journals and editorial decisions and champions the Cochrane Collaboration throughout the book. I guess the CC wouldn't be my first port of call for day to day decisions, but maybe I should look at it more- i shall subscribe to their email alerts and have a listen to the podcasts they do.



   

Measles

First things first, Happy New Year! Resolution number 1, record more of my learning!

So, the spotty 20 year old I saw before Christmas had Measles confirmed on a viral swab. I've reviewed her notes and she missed her MMR, despite it being clearly recorded she was safe to have it and should do so.

The girl has epilepsy and learning difficulties so we think that's why her carers chose not to give it. She's been registered her whole life with the surgery.

A quick look at the Medscape App reminded me of all the points I had forgotten about Measles.

The girl presented with a florid rash , I was reminded of the 3 C's, which I hadn't asked about and learnt Vitamin A can reduce symptoms but I'm not sure if that's only for deficient individuals.

I also learnt that Measles directly suppresses immune response, making secondary bacterial infection a risk, not just viral sequelae.

So learning points?

Check childhood immunisations when reviewing patients with learning difficulties, consider diagnosis in unvaccinated individuals with 3 C's

My senior colleague saw 1 case in the 80s and none since so hopefully it will be a long time before I see another!