GP Resolutions for 2014!

GP Resolutions I DEFINITELY will keep up for 2014

• I will tidy my drawers
• I will tell Mrs X that a long hug after EVERY consultation is just not appropriate. And that she hugs a bit too tightly.
• I will log all my CPD activity on the appraisal toolkit calmly and steadily throughout the year rather than at midnight the night before my appraisal
• I shall not dread duty dr days, but will start each one with a deep breath, a smile and a ‘today is going to be fun and interesting!’
• I will not prescribe ciprofloxacin
• I will attempt to read 10% of the email attachments from the CCG
• I will throw out all the broken, and frankly dangerous, old toys in my toy box and disinfect the rest
• I will be better at coding
• I will remove that Cosmo with  the ‘best sex positions for 2008’ on the cover from the waiting room
• I will ALWAYS wash my hands
• I shall try not to retch when examining Mr Y and will ask him if he could please shower before he comes to see me from now on
• I shall try to have a ‘duty dr day’ and an ‘alcohol free day’ on the same day
• I really really really will go on a ‘sports injuries for GPs’ course…
• I shall smile nicely when the patient says ‘well, I haven’t see you for a year doctor so I’ve saved a few things up’
• I will not nod off when I have my therapeutic ‘5 minute mindfulness meditation’ on my couch in the middle of the day (and will set an alarm on my phone just in case)
• I will not text kids, write shopping lists or fantasise about exotic holidays during practice meetings
• I will no longer say to patients ‘you’re not very fit’ (frequently misunderstood)
• I will get smart new work clothes
• I will do NO ‘google-faffing’ during the working day and definitely NO FB/twitter (#needtogetareallife)
• I shall slowly wean myself down to 6 cups of strong coffee a day
• I will check the expiry dates of the drugs in my bag
• When I seem to be the only dr in the practice I shall say to myself ‘I’m glad my colleagues are having a well earned break, they deserve it!’
• I will improve my posture when sitting at my desk, straight back, not slumped
• I will not prescribe benzodiazepines EVER
• I shall keep up with my patient admin as I go
• I will get my equipment calibrated
• I shall not treat ‘pop man’ the same way I treat ‘pop ups’ selling insurance
• I shall write short, brilliantly succinct and pithy referral letters (rather than rambling current ones which could’ve been written by Joyce and Kafka’s love-child)
• I shall embrace revalidation with a positive attitude and a SMILE 
• I will get better with emis web (everyone else says it’s brilliant so I’m obviously doing something seriously wrong)
• I will not have cakes, biscuits or chocolates at coffee time. Perhaps some dried apricots…
• I shall throw all the free GP papers in the recycling without reading them as they just make me feel depressed and want to resign
• I shall tentatively peep into  my ‘non-urgent in-tray’
• I will finally work out how to be clinically thorough, nice and tick all the boxes in 10 minutes and then…(here comes the drum roll…)
• I SHALL RUN TO TIME!!! EVERY TIME!!!

How are you sleeping? Effective self-help for insomnia

CBT based self help for Insomnia

There are lots of different self help interventions for insomnia, and it may not be obvious which one to recommend to patients. This is a brief guide to some of them, based on my personal experience of managing my own insomnia. 

I tried a variety of CBT based books, and though they helped a bit, nothing REALLY worked until I used a website called 'Sleepio'.   The key is to follow the sleep restriction programme to the letter. I hadn't done this until I followed the website. Once I did, hey presto. I am now pretty much cured.

There are several CBT based books available which are useful and easily found in bookshops and online. Professor Colin Espie is a world authority on CBT treatment on insomnia and has produced some of the most helpful tools for patients to try. He has written a fairly long and detailed book called 'Overcoming Insomnia and Sleep Problems'  which is aimed at patients. It is an excellent guide for health professionals to read but many patients will find it too long and complicated. He has written a much shorter and accessible book called 'An introduction to coping with Insomnia and Sleep Problems'. These are both based on well researched principles and are very helpful. 

 However I would like to recommend Prof Espie's website www.sleepio.com as perhaps the best intervention. It is a CBT based 6 week course that is superb. It's beautifully designed, with a simple cartoon layout. As I said, the key is to follow the 6 week sleep restriction programme. This seeks to improve sleep efficiency (proportion of time in bed spent asleep). It does require commitment and some of the changes involved with the initial sleep restriction can seem daunting. It also requires a fee (£6.99 per week , or a one off of £49.99). It includes:

·        weekly online personalised 20min session with 'The Prof', a speaking cartoon character who talks you through each step. 

·        There are online tools and over 100 articles , with email reminders to help you stick to the programme.

·        There is also an online Sleepio community for those that want it. 

It has been studied in a RCT , so has excellent evidence to back up its use (Espie CA; Kyle SD; Williams C; Ong JC; Douglas NJ; Hames P; Brown JSL. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. SLEEP 2012;35(6):769-781.).  

It helped 75% of people with persistent sleep problems, with an average reduction in time taken to fall asleep of 50%, and a 60% reduction in time spent awake during the night. Quality of sleep more than doubled, and energy levels increased by 58%. These improvements with Sleepio were found to be lasting because effects were maintained at the two month follow up point.

I prepared a single A4 summary of options for patients to look at which I give to patients with sleep problems. The other options I include are www.moodjuice.scot.nhs.uk (an excellent website with CBT based handouts on most mental health problems)  and also local counselling services.  It's also useful to staple this handout to those slightly awkward prescription requests for hypnotics- hopefully this reduces reconsultation for sleeping problems and reduces future requests for sleeping tablets. 

 

Dr Ian Kelt, GP Partner, Edinburgh

NB no ‘conflicts of interest’ guarantee: Dr Kelt, Dr Curtis and NB Medical Education have NO financial interest in Sleepio or any other books or products mentioned in our blog or on NB Medical courses.

 

Are you depressed? GP Burnout

How are you doctor?

 I have twice suffered from depression in my medical career. It was horrible, a dark forbidding place I never want to go back to. I felt overwhelmed with fatigue and yet couldn’t sleep. I had profound ‘psychomotor retardation’ (Newton Faulkner has a song Uncomfortably Slow which articulates this feeling perfectly). My brain was so slow my wife could ask me a simple question and I was aware that I was just incapable of articulating a simple response. Just walking felt like wading through wet cement, getting up stairs a Herculean task. I had palpitations, chest pains, every muscle seemed to ache. Simple tasks and decisions became overwhelming. To try to cheer me up one day, she took me out (against my will) to our favourite coffee bar for breakfast. Looking at the pastries (which I knew would all taste of cardboard, as everything did) I just stared and stared and when the waitress gently pushed me to make a choice I was overwhelmed and broke down in tears. My wife had to lead me away, sobbing.

 It was all the more difficult because I was so very deeply ashamed of feeling like this. I had a good career, financial security, a happy marriage, 3 beautiful children – what did I have to complain about? One thing being a GP teaches us is how well people cope with terrible adversity, and yet here I was unable to cope with my ‘nice life’. I felt ashamed, and so hid it longer than I should.

 The first time I had it, I carried on working. I felt able to work even though things outside work were difficult. In retrospect I was on ‘auto-pilot’ a lot of the time and I’m sure I shouldn’t have been working, but one of the curious things about depression is that it changes the way that you think. You can no longer trust your own judgements. You think you can function, and because all your colleagues are stretched to the limit as well everyone colludes that you can. The second time, fortunately, coincided with a ‘between jobs’ period – I definitely couldn’t have worked then. I was helped with support from family, time and space to heal, CBT, exercise and mindfulness. I took sertraline for about 6 months which definitely helped get me re-booted (I really did feel something ‘chemical’ happen after a couple of weeks, just as patients often report), but it caused sufficient niggly side-effects that I didn’t want to take it any longer. However, I’d take it again if it ever came back. A much closer attention to work-life balance, regular exercise, mindfulness and a greater degree of psychological self-awareness, self-knowledge and emotional literacy has kept me well for over 5 years now and I am optimistic that I have beaten it now.

 The reason for this blog is that a recent spate of surveys shows that GPs are under more pressure and stress than ever, and increasing numbers are showing signs of ‘burnout’. I worry how many GPs may be working with depression and risking serious deteriorations in their mental health and addiction problems. A recent Dept of Health Survey shows that job satisfaction in GP is at its lowest, and stress levels at their highest, since 1998. The primary reasons for this are increasing workload and ‘lack of time to do the job justice’. We are working harder than ever, yet GPs are not afraid of hard work (the long working hours of a GP are in 7^th place in the ‘list of stressors’). A recent GPC survey shows similar results, and a Pulse survey revealed this year that almost half of GPs are at risk of burnout.

 Personally, I don’t like the term ‘burnout’. Let’s call it what it is, which is almost invariably depression.  All human beings, indeed all animals in experimental conditions, show the same response on the classic ‘stress-performance’ curve. A degree of stress is good – it motivates us and excites us and we see our performance and energy levels improve. But, eventually our performance starts to plateau and then as stress mounts our performance dips and we exhibit all the classic signs and symptoms of anxiety and depression. GPs show higher rates of mental health problems than other professions; this partly may reflect our personality, partly transference from the suffering of our patients (the ‘wounded healer’ idea) but mostly, I think, just the huge stress of dealing with large numbers of patients, managing uncertainty and shouldering huge responsibility.

 My advice, is that if you are struggling is NOT to trust your own judgement about your ability to cope and continue at work but to seek the help and opinion of others, be that from loved ones, trusted colleagues or other health professionals. And if you feel a colleague may be struggling, please don’t ignore it. Make the time to ask how they really are.

 Being a GP is a tremendous job and a wonderful privilege and I love it,  but it is hard and we are prone as professionals to depression and burnout. If this is you, experience has taught me that with time and treatment not only will you recover fully, but you will come back stronger than before. You will love life, including your job, again. And once recovered not only will you appreciate and enjoy life more, but it will also make you a better doctor. So, be brave and seek help and take some time out to get better. Because you will.

Simon

Resources if you are struggling:

BMA counselling and advice, just call 08459 200 169

BMA links for doctors in difficulty

Doctors & dentists group for addiction problems

Doctors Support Network

The sick doctors trust

Pulse Battling Burnout Campaign

A New Beginning? The 2014/15 GP contract for England.

It’s a big day for GPs in England - at midnight, under the cover of darkness, the government and BMA announced the 2014/15 GP contract for England –believed highly likely to contain sweeping changes in a time of austerity despite a stretched and jaded primary care workforce that would pummel us further in to the ground.  It was splashed all over the TV and in the papers this morning with headline grabbing changes.

Here’s the link to the BMA summary and full report: www.bma.org.uk/gpcontract

 

The reforms actually seem quite positive for what GPs have been saying they want for years: a reduction in bureaucracy to free up time for helping patients.  It helps address many of the issues we have discussed recently on the Hot Topics course such as multimorbidity, end of life care, having time to address complex medical issues and identify and treat malnutrition.

The main reforms are:

• Slashing QOF indicators and removing QP – a total of 341 points will be freed up from QOF
• Amazingly the money will actually be put in to core funding (through the global sum) to pay for the new changes – the contract seems pretty level financially.
• Some QOF targets and timeframes will be relaxed – particularly the removal of HYP003 (the one where BP must be ≤140/90…)

• A named GP for all over 75s
• This seemed to be a big deal for the media and the government – they don’t seem to realise that patients have always had a named GP – but now this will be more formalised with that GP taking responsibility for that patient and co-ordinating care with over health and social care professionals.

• A big section is a new “unplanned admissions Enhanced Service” funded through the money removed from QP. 
•  Older, vulnerable, high risk patients, those needing end of life care or at high risk of hospital admissions will be identified using a risk stratification tool and then pro-actively case managed. 
•  If these patients have urgent queries they will need to addressed on the same day – this can be done over the telephone – and I think most of us try to provide this anyway. 
• Practices will need to have a “hot line” in hours for emergency services and secondary care to discuss patients accessing these services – this doesn’t mean 24hr availability! 
• These patients will need to have a care plan, a named GP and care co-ordinator (evolving roles for our practice nurses?)
• They will need regular reviews and any unplanned admissions will also need review. 
• This will require a change in the way we work with vulnerable patients, but hopefully with the pointless bureaucracy of QP removed we may have some extra time to enable this.  It’s worth noting hese changes have been successfully piloted in Scotland with big benefit to patients and the health service alike (“Anticipatory Care Planning” - BJGP 2012;62;84)

• There’s some sketchy talk about “choice of practice” which basically means forget boundaries but this won’t be in April 2014 and may be “voluntary”.

• Practices which have opted out of OOH will need to monitor the quality of their local service – I can think of a few things to say about 111…

• Seniority will be phased out over 6 years and the money will go into core funding for practices.

This is not a complete account of the contract by any means – other areas include IT (providing online access for prescriptions, appointments and the Summary Care Record), a Friends and Family test (patient feedback through a slightly too simplistic question) and a sneaky bit about publishing GP earnings (I can only hope they explain what we get after all the bloody deductions…).

For GPs in Scotland, a minimal change contract is being negotiated for 2014, Wales is trying to reduce bureaucracy and Northern Ireland is looking to reduce QOF.  It seems the UK has become quite the experiment.

From the clinical perspective in England there are going to be changes, but for now, surprisingly, these might be changes for the better.  As ever, the proof is in the eating, the devil is in the detail and of course, no-one knows what next year may bring.

Neal

Statins after haemorrhagic stroke

 

We have been consistently asked why statins are to be avoided after haemorrhagic stroke.

 The 2012 RCP Stroke Guideline states:

 Treatment with statin therapy should be avoided and only used with caution, if

required for other indications, in individuals with a recent primary intracerebral

haemorrhage.’

 

The reason for this is that back in 2003 a seminal meta-analyis by Law and Wald
click here showed an increase in haemorrhagic stroke risk with statins.

 Overall there was a 15% decrease in thromboembolic stroke and a 19% increase in haemorrhagic stroke (including sub-arachnoid hemorrhage and intracerebral haemorrhage). The reasons for this were unclear, and the authors stated there were too few haemorrhagic strokes to be certain it was a real effect.  However since then two subsequent RCTs  NEJM 2006   Neurology 2008 also showed a very small increased risk of haemorrhagic stroke with statins

However, other RCTs have not shown an increased risk and the recent primary prevention Cochrane meta-analysis did not show an increased risk. The most reassuring data however comes from a meta-analysis of all RCTs which have reported stroke as an outcome Stroke meta-analysis 2012 In this study of 95,000 patients statin therapy was not associated with significant increase in ICH. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.

 So what should we as GPs do?

There has been a question mark that statins may increase intracerebral haemorrhage, so in patients who have had a recent haemorrhagic stroke the RCP guidance seems prudent and sensible. However, more recent data is reassuring and given that the benefits of statins are so clear in established vascular disease then in patients with co-morbidity (e.g. previous haemorrhagic stroke and established ischaemic heart disease) individualised decisions will need to be made between you, your patient and the specialist. The most important thing, of course, for both types of stroke is good BP control <130/80.

 

 

Restless Legs Syndrome

 

Restless legs syndrome is miserable for patients and (unlike most things we see!) easy to diagnose and treat. It is common (studies report adult prevalence ranging from 2% to 15%) and recent research suggests that restless legs may contribute in up to 22% of people with sleep problems in primary care.

 ► Just remind me what it is?

 A neurological disorder characterised by an irresistible urge to move the limbs and associated with unpleasant sensations.

 ► How do we make the diagnosis?

 Diagnostic criteria (all must be present) are:

·     Overwhelming urge to move the legs, usually accompanied by uncomfortable sensations or pain

• Symptoms start, or worsen, with rest or inactivity
• Symptoms relieved by movement or other stimuli e.g. rubbing the legs
• Symptoms worse in the evening
• Legs always involved (but it may spread to affect other limbs)
• Normal physical examination, including neurological and vascular

Other factors that support the diagnosis include

• A positive family history
• Frequent involuntary limb movements when asleep or awake

Patients can complete an internationally recognised RLS rating scale to confirm diagnosis and assess severity.

 ► What causes RLS?

• in most people it is a primary idiopathic disorder; 50% have a family history suggesting a genetic basis
• The 3 major causes of secondary RLS are:
• Pregnancy (occurs in 20% of pregnant women, usually in the last trimester and usually resolves within a few weeks of delivery)
• Iron deficiency (present in 25% of people with RLS)
• Renal failure (CKD stage 5, occurs in 20% of people undergoing dialysis, often resolves after transplantation)
• There are associations with a wide range of other conditions e.g.
• Parkinson’s, Peripheral neuropathy, Hypothyroidism, Diabetes, Rheumatoid
• Drugs can exacerbate it:
• Antidepressants and lithium
• Neuroleptics and sedating antihistamines
• Dopamine blocking anti-emetics e.g. metoclopramide
• Calcium channel blockers

 What investigations should I do?

• Serum ferritin in all patients
• Treat with iron if <50mcg/ml
• If renal failure or inflammatory disease, ferritin may of course be elevated in which case look at transferrin saturation (<20% suggests iron deficiency)
• Consider renal function, FBC, TFTs, glucose and B12 guided by history and exam

What is the evidence for treatment?

 There is evidence to support lifestyle changes in RLS including:

·         Reducing caffeine and alcohol

·         Taking regular aerobic exercise

·         Regular massage therapy

 For drug treatment, there is evidence to support the use of dopamine agonists for RLS Cochrane Review and also for  levodopa for RLS Cochrane review

Because of the association with depleted iron stores, it is routine practice to recommend iron supplementation if the serum ferritin is low. However a recent iron supplementation in RLS Cochrane review failed to show evidence of benefit.

 There seems to be a lack of evidence for physiotherapy, CBT and mindfulness but we would argue that all of these will be worth trying given their strong evidence-base in other chronic neurological conditions.

 In summary, what approach should I take with my patient?

Œ Make the diagnosis…using diagnostic criteria above

 Is it primary (family history?) or secondary (associated conditions or drugs)?

Ž Investigations

• Check iron studies in all
• Consider U and E, FBC, TSH, glucose, B12

  Consider a treatment trial with iron if ferritin <50mcg/ml

  Assess severity RLS rating scale

 

‘ Management

• Review medication and stop/change exacerbating drugs

• Mild RLS: advice and reassurance sufficient
• Good sleep hygiene
• Reduce caffeine and alcohol, stop smoking
• Increase physical activity
• Simple walking, stretching, relaxation exercises
• Mental distraction techniques and massaging affected limbs

 

• Moderate to severe RLS, consider drug treatment
• Intermittent symptoms (<3 times per week), off-label levodopa taken when symptoms occur or are anticipated
• If frequent or daily symptoms, dopamine agonist is treatment of choice (e.g. ropinirole, pramipexole are licensed for RLS, doses in the BNF). Warn patients regarding the risk of 'impulse control disorders' with these drugs, and best avoided if at risk e.g. current or past problems with behavioural or chemical addiction.
• Gabapentin, taken regularly, is an option though it has less evidence to support it

• Referral to neurologist?
• suggested if doubt re the diagnosis, or symptoms refractory to treatment or if augmentation to levodopa or a dopamine agonist is needed

 Resources for patients:

NHS Information for patients

Useful patient videos from Restless Legs Society UK

UK patient support group

 References:

Causes of insomnia in primary care http://www.ingentaconnect.com/content/rcgp/bjgp/2012/00000062/00000595/art00025

Dopamine agonists for RLS http://www.ncbi.nlm.nih.gov/pubmed/21412893

Levodopa for RLS http://www.ncbi.nlm.nih.gov/pubmed/21328278

Iron therapy http://www.ncbi.nlm.nih.gov/pubmed/22592724

CKS review http://cks.nice.org.uk/restless-legs-syndrome#!topicsummary

AFA review http://www.aafp.org/afp/2008/0715/p235.html

 

 

 

 

Autumn 2013, Course Preview

We are all very excited about our Autumn series of Hot Topics courses, which start in Manchester on September 21^st and end in Cardiff on October 12^th.

·         All the presented Hot Topics will be new compared to 2012 so if you came a year ago, do come back
 

·         We have streamlined the paper book, and included more of our ever popular KISS summaries. Less text, more KISS!
 

·         The electronic version of the book has been developed to become an invaluable resource to use during your working day. It is instantly searchable. Original sources are hyperlinked, and the KISS summaries contain direct links to resources for you and your patients e.g. a KISS section on Achilles Tendinopathy gives a simple management algorithm and a link to the information sheet to give your patient with the appropriate evidence-based exercises to do, cluster headache has a link to the pre-filled home order oxygen form etc.
 

·        New to 2013, you will be emailed pre and post course MCQs so that you can test your knowledge and demonstrate your learning
 

·        For the first-time we have developed some of our own patient information sources to reflect current evidence for you to give your patients e.g. for patients requesting a PSA test, on low salt/high potassium diets in hypertension, low FODMAP diet in IBS etc
 

·       As ever, a broad range of topics will be discussed which reflect the incredible diversity of things we have to deal with primary care from the very complex to the seemingly simple….highlights will include new research, evidence reviews and guidelines on:

o   How best to manage patients with multimorbidity

o   New Vitamin D guidelines

o   Treatment resistant hypertension

o   New evidence and guidelines on TIA and stroke

o   Dementia

o   Depression

o   Eating disorders

o   Social anxiety & OCD

o   PSA, LUTs and prostate cancer

o   Headaches

o   Chronic non-cancer pain

o   Common sports injuries & MSK problems e.g. shin splints, plantar fasciitis etc

o   Gout

o   Detection of melanoma

o   Psoriasis

o   IBS

o   Liver disease

o   Obesity

o   Common infections

o   New vaccinations update
 

·         An extensive range of other topics, from the seemingly simple (e.g. acne, erectile dysfunction, polymyalgia….) to the very complex (e.g. medically unexplained symptoms, end of life care…) and are all fully updated and included in the book, all with invaluable links and resources
 

·         As ever we want you to have a relaxing and fun day out of the practice, so we will keep the atmosphere light, with some good new funny clips and we really hope you have an enjoyable day

With GPs being so busy, we are convinced that this model provides us the best way of practising patient-centred evidence based medicine. So, do come along and we look forward to seeing you next month!

Simon, Zoe, Neal and Gail

Patient advice Diet and IBS

Dietary Advice for IBS

 Research is increasingly showing that most people can control the troublesome symptoms of IBS through modification of their diet. This takes some commitment and trial and error, but the results can be very rewarding.

 ►Step One:

 Follow the dietary advice from the British Dietetic Association, by following the guidance in their BDA Food Fact Sheet on IBS

 This advice includes:

·         Cutting down on rich and fatty food

·         Cutting down on some high fibre foods, and especially those which produce a lot of gas such as beans and pulses

·         To eat soluble sources of fibre, such as golden linseeds

·         To try lactose-free dairy products

·         To try some probiotics

 Keep a symptom and food diary, looking to identify the triggers. If no significant improvement after 4 weeks then move to….

  ►Step Two

 This involves paying close attention to altering your diet to reduce your intake of FODMAPS

 FODMAPs are types of carbohydrates which are poorly absorbed and rapidly fermented by gut bacteria to produce gas and other symptoms of IBS. Recent research shows that 86% of patients can control their symptoms by cutting down on FODMAPs, and benefits are seen within 4 weeks.

 

However a low FODMAP diet is not simple to follow, as FODMAPS are found in a wide range of food sources. For example….

Food Group	High FODMAPs examples	Suitable alternatives
Fruit	Apples, Peaches, pears, plums	Banana, grapes, oranges, strawberries
Vegetables	Mushrooms, onions, garlic, cauliflower, asparagus	Potato, tomato, carrot, green beans, lettuce, peppers
Protein	Legumes and nuts	Fresh chicken, pork, lamb, beef, eggs
Breads and cereals	Wheat, rye, barley	Corn, oats, rice
Dairy	Milk, yoghurt, cheese ice-cream	Butter, lactose-free dairy products
Other	Honey, sorbitol, fructose	Golden syrup, regular sugar

 

Ideally, your doctor should be able to refer you to a dietitian trained in this approach. If this is not possible, then the team at Monash University in Melbourne who have developed this research have produced a range of  Information materials on FODMAPS which you can follow. This includes a book you can order, and also an excellent low FODMAP app for iphone and ipad, which can instantly tell you whether any food is high or low in FODMAPs.

There is also an American diet book available Amazon link

 If your symptoms continue, then obviously go back to your doctor.

This approach takes commitment, but if it works (which for most people it will) your IBS will be controlled without needing to take any drugs. Good luck!!