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PRIMARY HEALTHCARE STUDY GUIDE Department of General Practice 2006 – 2007 Staff Members Head of Department Professor Philip Reilly Senior Lecturers Dr Keith Steele Dr Drew Gilliland Dr Kieran McGlade Dr Margaret Cupples GP Research Fellows Dr Nigel Hart Dr Katherine MacLurg Research Registrars Dr Naoimh White Dr Waqar Ahmed Departmental Secretary Miss Cathleen Agnew Additional Staff Mrs Claire Leathem Dr Mark Tully Mrs Louise Seaye LIST OF CONTENTS Primary Health Care Teaching Programme 2006/2007 PAGE 1-3 Aims & Objectives 4-5 Learning Outcomes 5-6 Practice Attachments 7-8 Clerkship and Teaching 8 – 12 End Course Assessment 12 – 15 Record Card, Evaluation, Feedback & Attendance 15 - 16 Students in Difficulty 16 Intimate Examination of patients by students 16 Student Support & Guidance Information Sheet 17 Record Card 18 – 22 Practice Experience Questionnaire 23 – 26 Student Mini Curriculum Vitae 27 Self Assessment Questionnaire Information Sheet 28 What is General Practice 29 – 37 The New General Practice Contract 37 - 38 Consultation Skills 39 Consent 40 - 42 Communication in Medicine 43 - 45 Evidence-Based Communication 46 - 50 Audit 51 - 55 Prescribing in General Practice 56 - 67 Common Symptoms & “Red Flags” 68 Medical Records 69 - 71 Management of Common Conditions 72 - 74 Complaints Handling in General Practice 75 - 77 Emergencies 78 Ethics Course 79 - 84 Evidence Based Practice 85 Health Promotion 86 - 94 Child Health in General Practice 95 - 102 Multicultural Issues in Primary Care 103 Modified Essay Questions 104 - 129 DEPARTMENT OF GENERAL PRACTICE, PRIMARY HEALTH DAY TIME Mon 28th Aug 06 = Bank Hol 25th Dec 06 - 5thJan 07 inc = C’mas Hols Mon. 7th & 28th May 07 = Bank Hols a.m. p.m. TUESDAY a.m. p.m. WEDNESDAY THURSDAY a.m. a.m. p.m. FRIDAY a.m. 2006-2007 Mon. 4th Sept - Fri. 8th Sept 2006 Mon. 30th Oct - Fri. 3rd Nov 2006 Mon. 11th Sept -Fri. 15th Sept 2006 Mon. 6th Nov -Fri. 10th Nov 2006 Mon. 18th Sept - Fri. 22nd Sept 2006 Mon. 13th Nov - Fri. 17th Nov 2006 Mon. 18th Dec – Fri. 22nd Dec 2006 Mon. 8th Jan - Fri. 12th Jan 2007 Mon. 15th Jan - Fri. 19th Jan 2007 Mon. 22nd Jan - Fri. 26th Jan 2007 Mon. 26th Feb – Fri. 2nd Mar 2007 Tues. 8th May - Fri. 11th May 2007 Mon. 5th Mar - Fri. 9th Mar 2007 Mon. 14th May - Fri. 18th May 2007 Mon. 12th Mar - Fri. 16th Mar 2007 Mon. 21st May -Fri. 25th May 2007 Mon. 19th Mar - Fri. 23rd Mar 2007 Tues. 29th May - Fri. 1st June 2007 1 MONDAY CARE, TEACHING PROGRAMME Tues. 29th Aug - Fri. 1st Sept 2006 Mon. 23rd Oct - Fri. 27th Oct 2006 2 AGEING & HEALTH INTRODUCTION Venue: D.G.M. 9.15am PRIMARY HEALTH CARE INTRODUCTION DG CONSULTATION SKILLS KS Venue: D.G.P. 2.00pm PRACTICE ATTACHMENTS 3 4 EVIDENCE BASED PRACTICE I MEC, KS, WA Venue: D.G.P. 9.15am AGEING & HEALTH Venue: D.G.M 2.00pm. AGEING & HEALTH Venue: D.G.M 9.15am. (GROUP 2) 9.15am-10.45am CHILD HEALTH IN GENERAL PRACTICE KMcG 11.15-12.45pm COMPUTER ASSISTED LEARNING KMcG Venue: D.G.P. SIMULATED PATIENTS DG/KMacL Venue: D.G.P. (GROUP 2) 9.15 - 10.45am EMERGENCIES JW /AN 2.00pm 11.15 - 12.30pm MANAGEMENT OF ACUTE & CHRONIC COMMON CONDITIONS (GROUP 2) 9.15-10.15am ATTACHMENT FEEDBACK DG & MEC 10.45 - 12.45pm AUDIT Venue: D.G.P. JMcC NW p.m. Venue: D.G.P. CLOSED CIRCUIT TELEVISION CCTV I PATIENT INTERVIEWS I 2.00pm INNER RING PRACTICES CLOSED CIRCUIT TELEVISION CCTV II PATIENT INTERVIEWS II 2.00pm INNER RING PRACTICES Free Page 1 DEPARTMENT OF GENERAL PRACTICE, PRIMARY HEALTH CARE, TEACHING PROGRAMME DAY TIME 2nd Apr – 13th Apr 07 inc = Easter Hols Mon. 2nd Oct - Fri. 6th Oct 2006 Mon. 27th Nov - Fri. 1st Dec 2006 Mon. 5th Feb - Fri. 9th Feb 2007 Mon. 16th Apr – Fri. 20th Apr 2007 Mon. 9th Oct -Fri. 13th Oct 2006 Mon. 23rd Apr -Fri. 27th Apr 2007 Mon. 16th Oct - Fri. 20th Oct 2006 Mon. 11th Dec - Fri. 15th Dec 2006 Mon. 19th Feb - Fri. 23rd Feb 2007 Mon. 30th Apr - Fri. 4th May 2007 Mon. 4th June - Fri. 8th June 2007 Mon. 11th June - Fri. 15th June 2007 Mon. 18th June -Fri. 22nd June 2007 Mon. 25th June - Fri. 29th June 2007 5 MONDAY a.m. a.m. TUESDAY p.m. WEDNESDAY THURSDAY a.m. a.m. Mon. 12th Feb -Fri. 16th Feb 2007 7 8 EVIDENCE BASED PRACTICE II MEC, KS, WA Venue: D.G.P 9.15am. HEALTH PROMOTION Venue: D.G.P. Venue: D.G.P. 2.00pm HANDLING COMPLAINTS MULTICULTURAL ISSUES Venue: D.G.P. DG MC PRESCRIBING Venue: D.G.P. MT 2.00pm EQ 9.15am (GROUP 1) 9.15am-10.45am CHILD HEALTH IN GENERAL PRACTICE KMcG 11.15-12.45pm COMPUTER ASSISTED LEARNING KMcG Venue: D.G.P. SIMULATED PATIENTS p.m. Mon. 4th Dec - Fri. 8th Dec 2006 6 PRACTICE ATTACHMENTS GENERAL PRACTICE ETHICS KS/DG Venue: D.G.P. 9.15am COMMON SYMPTOMS & “RED FLAGS” p.m. 2006-2007 Mon. 25th Sept - Fri. 29th Sept 2006 Mon. 20th Nov - Fri. 24th Nov 2006 Mon. 29th Jan - Fri. 2nd Feb 2007 Mon. 26th Mar – Fri. 30th Mar 2007 Venue: D.G.P. DG/KMacL 2.00pm FRIDAY a.m. (GROUP 1) 9.15 - 10.45am EMERGENCIES JW /AN (GROUP 1) 9.15-10.15am ATTACHMENT FEEDBACK DG & MEC 11.15 - 12.30pm MANAGEMENT OF ACUTE & CHRONIC COMMON CONDITIONS 10.45 - 12.45pm AUDIT JMcC Venue: D.G.P. 11.15 - 1.00pm GROUP B OSCE GROUP A Evaluation/MEQ NW Venue: D.G.P. CLOSED CIRCUIT TELEVISION CCTV I PATIENT INTERVIEWS I INNER RING PRACTICES 2.00pm p.m. CLOSED CIRCUIT TELEVISION CCTV II PATIENT INTERVIEWS II INNER RING PRACTICES 2.00pm END COURSE ASSESSMENT. OSCE, ORAL, EVALUATION, MEQ 9.00 - 11.00am GROUP A OSCE GROUP B Evaluation/MEQ 3.00pm RESULTS AND FEEDBACK Venue: DGP Page 2 PLEASE NOTE: MONDAY, 28th August 2006: BANK HOLIDAY:- Group D PRIMARY HEALTH CARE INTRODUCTION MOVED TO 9.00AM, TUESDAY, 29th August 2006. Dept of General Practice, Dunluce H.C. MONDAY, 7th May 2007: BANK HOLIDAY: - Group C PRIMARY HEALTH CARE INTRODUCTION MOVED TO 9.00AM, TUESDAY, 8th May 2006. Dept of General Practice, Dunluce KEY PMR DG KS MEC KMcG KMacL WA NW JMcC = = = = = = = = = Professor Philip Reilly Dr Drew Gilliland Dr Keith Steele Dr Margaret Cupples Dr Kieran McGlade Dr Katherine MacLurg Dr Waqar Ahmed Dr Naiomh White Dr Jean McClune JW AN MT DW EQ MC = = = = = = Dr John White Dr Andy Nelson Dr Mark Tully Dr Diane Wilson Dr Emma Quinn Dr Mairead Corrigan D.G.M = D.G.P = Dept. of Geriatric Medicine, Whitla Medical Building Dept. of General Practice, Dunluce Health Centre Page 3 4 STUDY GUIDE FOURTH YEAR COURSE IN PRIMARY HEALTH CARE 2006-2007 General Statement of Aims The overall aim of the Fourth Year course is to help you to become a better doctor irrespective of your current career preference or eventual career choice and specifically to assist students to recognise, adopt and develop those clinical skills and values that are fundamental to the practice of good caring medicine whatever the clinical setting. The purpose of this Study Guide is to help you to gain maximum benefit from your time with us in General Practice. Before commencing this attachment you will have completed at least three years of your course and will already have acquired a considerable knowledge base, and skills and attitudes. There are a number of areas in which we would expect you to be competent prior to this attachment. PRE-REQUISITE OUTCOMES 1. To obtain a relevant history from an individual using appropriate questions and responses covering the following systems - cardiovascular, respiratory, gastro-intestinal, genito-urinary medicine, central nervous system, peripheral nervous system, musculoskeletal system and skin. This would include the use of a stethoscope and sphygmomanometer. 2. To assess a patient by examining competently the following systems cardiovascular, respiratory, genito-urinary, central and peripheral nervous system, musculoskeletal and skin. 3. To be able to take a midstream specimen of urine and be able to test for and recognise abnormalities using a dip stick. 4. To recognise the normal ear, nose and throat and distinguish a range of common conditions by history taking and examination including the use of an auriscope. 5. To recognise the normal features of the eye on examination and distinguish a range of common conditions by history taking and examination including the competent use of an ophthalmoscope. 6. To define a list of common gynaecological terminology and to identify by history taking and relevant examination common gynaecological conditions and to be able to suggest specific management options. 5 7. To identify children with a range of common paediatric conditions. To state the various developmental milestones. 8. To understand the pharmacology and therapeutic uses of commonly used drugs and be aware of the particular precautions with regard to prescribing in young children, the elderly and those with liver and renal disease. LEARNING OUTCOMES On completion of this course the successful student should be able to: 1. Identify a patient’s reasons for consulting by relating effectively to the patient. 2. Demonstrate good communication skills. 3. Perform an appropriate physical examination. 4. Define the likely underlying causes of acute and chronic conditions commonly encountered in General Practice. 5. Formulate management plans appropriate to the findings for acute and chronic conditions commonly encountered in General Practice. 6. Determine the impact of a patient’s problems/complaints on lifestyle and interpersonal relationships. 7. Describe the Primary Healthcare team and the role of each individual member. 8. Describe the role of the computer in General Practice. 9. Interpret medical audit and its application. 10. Identify opportunities for preventative clinical medicine and health education in the primary care setting. 11. Distinguish between good and bad medical records. 12. Critically appraise a scientific paper. 13. Develop skills in providing feedback on colleagues’ performance in a clinical setting using Pendleton’s rules. 14. Apply an ethical framework to solve ethical dilemmas identified within the consultation. 6 Common Conditions/Presentations Students are expected to be familiar with the following common conditions/presentations in general practice. These will help direct your learning and may be included in your end of course assessment. 1. Emergency Contraception 2. Combined Contraceptive Pill 3. Sore Ear 4. Back Pain 5. Sore Throat 6. Headache 7. Fever in Child / recognise sick child 8. “Flu” like illness 9. Proven UTI in a child 10. Vomiting & Diarrhoea 11. Impetigo 12. Acne 13. Scabies 14. Head Lice 15. Shingles 16. Nappy Rash 17. Psoriasis 18. Eczema 19. Gout 20. Dizziness 21. Tired All The Time 22. Abdominal Pain 23. Dyspepsia 24. Rectal bleeding 25. Haematuria 26. Asthma /COPD 27. Cough 28. Shortness of breath 29. Cancer 30. Diabetes 31. Hypertension 32. Coronary Heart Disease 33. Chest Pain 34. Heart failure 35. Atrial fibrillation 36. Chronic Kidney Disease 37. Epilepsy 38. Stroke 39. Depression / anxiety 40. Palliative care 41. Obesity 42. Thyroid disease 43. Osteoarthritis 7 PRACTICE ATTACHMENTS Students are asked to complete a questionnaire about where they want to do their attachment. While we do try to accommodate students requesting specific practices, this is not always possible as there are over 150 individual practice attachments. For reasons of patient confidentiality you cannot be allocated to the practice your family is registered with. Please let Miss Cathleen Agnew, Departmental Secretary, know immediately if this occurs. Usually practices more than 15 miles outside Belfast are residential. You will either stay in the local hospital, in B & B accommodation or occasionally with the general practitioner. If you have a car you can opt to travel daily at your own expense. Please let the practice know if you are not going to need the accommodation. A list of students and their allocated tutors will be posted on the Departmental notice board in August. Please contact your GP tutor at least two weeks prior to your attachment. There is a grant of up to £31.28 per day when using B&B accommodation. Please pay for the B&B accommodation and give the receipt to Miss Cathleen Agnew, Departmental Secretary, for reimbursement. You may be able to ask the proprietor to invoice the Department of General Practice directly and in this case you give the invoice to Miss Cathleen Agnew who will arrange payment directly to the proprietor. This takes approximately two weeks. In addition there is a daily subsistence allowance of £9.96 per day when using B&B accommodation. There is no re-imbursement for those students staying with relatives, friends or in hospital accommodation as they will have access to subsidised food. If the rate is more than £31.28 please get authorisation from Ms Cathleen Agnew, Department of General Practice, 028 9020 4252. In very exceptional circumstances, we may be able to change your allocation. You would need to speak to Dr A Gilliland, Course Co-ordinator, about this. COURSE READING Essential A textbook of General Practice. Edited by Anne Stephenson. 2nd Edition. Published by Arnold, 2004. Available from Miss C Agnew, Departmental Secretary. £6.00 deposit (£5.00 refunded after returning the book). Recommended Fraser RL. Clinical Methods - A General Practice Approach. 3rd Edition. Butterworth 1999. Palmer Notes for the MRCGP. 3rd Edition. Blackwell Scientific Publications. McWhinney IR. A Textbook of Family Medicine, Oxford University Press. 8 Corney. Developing Communication and Counselling Skills in Medicine. Routledge. Reference British National Formulary Khot and Polmear. Practical General Practice Guidelines for Logical Management. 2nd Edition. Fry. General Practice - The Facts. Radcliffe Medical Press. Rubeinstein Wayne. Lecture Notes on Clinical Medicine. 6th Edition. Blackwell Scientific Publications. THE FOURTH YEAR CLERKSHIP The fourth year Primary Health Care clerkship is twinned with Ageing and Health. The block course lasts eight weeks and includes four weeks in each specialty. There are also two Ethics Seminars in Week 5 of the Block. While some of the teaching on this course is factual, most is concerned with skills and attitudes which will enable students to develop coping skills for situations they will be faced with now and in the future. Activity of this sort is experiential and attendance is essential if skills are to be acquired. In your general practice block one week is spent in the department in preparation for the three-week clerkship with a GP in his/her practice. You will come back to the Department of General Practice for the Friday of your first week with your GP. VIDEO SURGERY TEACHING SESSIONS (Two) Students are allocated in groups of 2-3 to General Practitioners in the Belfast area. A surgery of 6 patients is booked by the GP. The patients are not pre-selected and therefore can have a wide range of presenting complaints/symptoms. The student generally has 15 minutes to take a relevant history and examination where indicated. The student is also expected to contribute to how the patient should be managed, eg simple advice, relevant health promotion, advice on how to take medication and how it works and the writing of prescriptions. Each consultation is recorded and afterwards is replayed for analysis by tutor and student. The tape is erased afterwards. This is not an assessment and it allows students to see for themselves how others see them. 9 COMPUTER BASED LEARNING RESOURCES A variety of computer based learning materials are available on a semi-open access basis in the Department’s computer laboratory. See the Department’s secretary for assistance if needed in using the packages listed below. The materials are also available in the Open Access Centre at Mulhouse in the Royal Victoria Hospital. - Introduction to prescribing - Palliative Care in General Practice - Dermatology in General Practice - The computerised MEQ - See separate sheets for a paragraph on each. Dermatology, Prescribing and Palliative Care Tutorials Package Overview Target Audience This package is intended for 4th and final year medical students. “Prescribing in General Practice” and “An Introduction to Palliative Care” may also be of interest to post-graduate students and General Practitioners. Purpose This package consists of three modules “Dermatology”, “Prescribing in General Practice” and “An Introduction to Palliative Care”. The first module introduces students to the diagnosis and management of common skin conditions seen in GP. Students are provided with tuition, practice and assessment on prescribing and in the third module, students are introduced to the concept of palliative care and palliative care services. Content Dermatology A tutorial approach has been adopted to present the characteristic features, known causes, epidemiology and management options for the following conditions: psoriasis, eczema and viral infections. Images are used to illustrate and reinforce teaching points. Three cases are presented to enable the students to assess their ability to diagnose and mange these conditions. A set of revision questions are also included to enable them to assess their knowledge of the material presented. 10 Prescribing in General Practice The module begins with an introduction to prescribing, considering the reasons for prescribing and the issues that should be considered before prescribing any drug. General guidelines which aim to ensure more precise prescribing are outlined. Chapter 3, Writing a Prescription Form, explains the prescription form and how it should be completed. Chapter 4, Controlled Drugs, considers the guidelines for prescribing a controlled drug, Chapters 5 and 6 focus on the issues and guidelines relevant to prescribing for specific groups in the population, namely, children (chapter 5) and the elderly (chapter 6). Chapter 7, Drug Interactions, identifies and briefly explores two types of interactions, namely, pharmacodynamic and pharmacokenetic. Chapter 8, Repeat Prescribing, explores the advantages and disadvantages of repeat prescribing. Five systems of repeat prescribing are outlined and the criteria for a good repeat system presented. Finally, a number of case studies are presented which provide students with practice in completing on-screen prescription forms. A drug database is also available for consultation. Computerised Modified Essay Questions Package Overview Target Audience “CMEQs’ is targeted at fourth and final year medical students. It may also be of use to general practitioners in their continuing medical education (CME). Purpose The package is based on the Modified Essay Question (MEQ) - a paperbased assessment tool which is used in undergraduate and post graduate medical education world wide. It is intended to provide medical students with a self-assessment tool to enable them to assess their ability to define “problem lists” for patients and plan effective management strategies. A wide range of skills can be tested. Emphasis is place on: breadth of knowledge, attitudes, problem solving skills and patient management. 11 Content A series of clinical scenarios, based either in a doctor’s surgery or the patient’s home, are presented. With each scenario the student is asked a number of questions relating to how a particular set of problems should or could be managed. The student answers the questions, either in point or essay form, compares their answers with model answers and marks accordingly. A number of reports are generated providing the student with a profile of their performance on each question and a comparison of their performance with that of their peers. Supplementary information is also provided to enhance the learning value of the CMEQ. 12 PRACTICE BRIEFING Please contact your practice Tutor at least two weeks before your attachment starts. If you are staying in accommodation you will need to check arrangements for getting the key. If you do not have transport and the accommodation is far from the practice the GP tutor will either make arrangements for you to be collected or else advise you on the local public transport arrangements. Please make sure you are punctual, and also if you are going to be absent from any session please let the GP know in advance. This is a compulsory attachment so if you are absent for several sessions you may be required to do an additional elective in General Practice. Your accommodation may mean you are on your own so it is suggested that you bring an alarm clock and transistor radio. If you are staying in B&B accommodation ask if you can use the microwave to heat food etc and bring a supply of coffee and biscuits with you. END COURSE ASSESSMENT This consists of: (1) (2) (3) A short oral examination A modified essay question paper Objective Structured Clinical Examination (OSCE) ORAL EXAMINATION During this session your record card is examined and the assessment by your GP Tutor is considered. You will also be asked about a common clinical condition and about practice management. MOBILE PHONES AND ELECTRONIC TEXT MESSAGING DEVICES 1. Mobile telephones and electronic messaging devices must be switched off during ALL lectures, tutorials, practical classes and clinical teaching sessions. 2. Students must not bring mobile telephones or electronic messaging devices into examination venues. This requirement applies to all written, practical and clinical examinations as well as class tests. The rule extends to the time during some practical and clinical examinations when a number of students have completed the examination while others are waiting to take it. Students who do not comply with this requirement will be subject to the University conduct regulations as outlined in calendar Book One. 13 MODIFIED ESSAY QUESTION PAPER This is an integral part of the Final MB Examination. It is also used in several membership examinations. At Queen’s the Modified Essay Questions are based on real cases submitted by Hospital Consultants and General Practitioners. Generally speaking a clinical problem is unfolded with the student being asked to comment at various stages on such items as appropriate history and examination, diagnostic possibilities, relevant investigations, ultimate diagnosis and various actions to be taken such as advice to the family, mobilisation of relevant members of the Primary Care Team, and referral, if necessary, to a specialist. The student will also be asked from time to time to prescribe medication and suggest other possible sources of help. The MEQ is not designed to test pure factual knowledge and therefore when setting and marking the paper emphasis will be placed on how the student can apply clinical behavioural and management skills to the various problems which are presented. Although the word essay is included in the title this is a slight misnomer as most questions are just answered as a series of headings and points. This saves you time and also makes for easier marking by the examiners. Concise and legible writing won’t necessarily gain any marks but conversely you certainly won’t lose any! Time is very important and is a major cause of students scoring low marks. Each question scores separate marks and it is important to work out a time schedule and stick rigidly to this. A candidate who only has time to answer 15 out of 20 questions will struggle to achieve a pass mark no matter how well he/she has answered the questions attempted. It is also important to read each question carefully, for example if a question asks for a list of physical signs of head injury, a skull X-ray will not receive a mark since this is an investigation. It is also advisable not to look through the paper before you start as this may distort your answers at various stages which may be geared to the fact that certain information about the case is being withheld to a later time. If in doubt about answering a particular management problem try and think about exactly what you would do, eg if starting a patient on antihypertensives, in addition to writing out a prescription you would also counsel them about smoking, weight, diet, salt and lifestyle etc. These would all be expected to be included in your answer and the marking schedule would be structured accordingly. Sometimes each page of the MEQ is marked independently - you should therefore answer each question specifically even if this answer involves repetition of part of an earlier section. 14 The modified essay paper is in many ways unique but provided the student has a sound basis of clinical knowledge, common-sense and has brushed up on exam technique, this type of problem solving exercise should be looked upon as a useful learning tool and not too difficult a hurdle at Final MB. Some Specimen Modified Essay Questions are included at the end of this Study Guide. OBJECTIVE STRUCTURED CLINICAL EXAMINATION This is part of your assessment and is run jointly with Geriatric Medicine. There are stations covering Ethics, Clinical Skills, Communication Skills, Diagnostic Skills, Prescription Writing and Data Processing. A number of the stations have real or simulated patients to test clinical and communication skills. Students spend 5 minutes at each. Each station is marked using a structured marking sheet. This assessment enables each student to be tested across a spectrum of skills in the different settings of general practice and geriatric medicine. GP ASSESSMENT MEQ 30% Oral 10% GP OSCE Stations 60% ____ 100% ____ The OSCE Stations have been standardised so the Pass mark varies between Stations. The overall mark is re-adjusted to give a pass mark of 50% 15 Students who fail will have an interview and may be asked to repeat part or all of the assessment. Students who perform badly in all areas may be asked to resit the entire examination in September prior to entering final year. The aim of this assessment is to enable students to see for themselves the level of knowledge and skills they have obtained during the course and compare themselves to their peers. FOURTH YEAR RECORD CARD This record card acts as an aide memoir highlighting the learning opportunities which exist during your time in the Department of General Practice and on your attachment to a practice. It contains suggestions for what to do on your attachment. We advise you to show this to your GP teacher and put together a plan for your time when in the practice. This year you are being asked to complete a mini CV and questionnaire to show to your GP Tutor at the start of your attachment (see page 26). It is important to get as much “hands on” experience as possible, eg interviewing patients, prescription writing and doing practical procedures such as venepuncture. For example, if you are spending time with the receptionist try to be “doing” rather than “observing”, eg answering the phone, dealing with queries, pulling charts. We do not expect you to do everything that is listed in the record card but it acts as a guide for you and your tutor. The record card is looked at in your oral assessment and the report from your GP tutor is also taken into account. EVALUATION AND FEEDBACK This is a new course and much of it is in small groups. The more you participate the more you will get out of it. We hope to get to know you well over the eight-week block. If you have any queries please speak to Miss Cathleen Agnew, Telephone No. 028 90 204252. We will ask you to complete a questionnaire at the end of your attachment to enable us to evaluate the course. This is anonymous. Dr Drew Gilliland is the Course Co-ordinator and he would be very pleased to deal with any queries you have about the course or other related matters. He is based in Room 8, 4th Floor, Dunluce Health Centre, Telephone No. 02890 204300, E-mail: [email protected]. There will also be informal discussion about this course after the OSCE Feedback session on Friday afternoon at the end of the 8-week block. 16 ATTENDANCE This is a Clinical Clerkship and attendance is compulsory. A roll-call is taken at the sessions in the Department of General Practice and the GPs are asked to monitor attendance at practice level. The minimum attendance required is usually at least 90%. Students who miss more than this will be asked to provide an explanation. If you have been ill a Doctor’s Certificate may be required. If you have to miss a teaching session please contact us at 028 90204252 and let us know. You have a half day off on Wednesday afternoon in Weeks 1 & 5 and this time should be used for personal matters such as shopping, personal banking etc. STUDENTS IN DIFFICULTY The Course in Primary Health Care is quite demanding. Students have a lot of information and skills to learn. They are also asked to apply what they have learnt in dealing with patients, relations and staff in the General Practice setting. Evaluations tell us that students generally enjoy their time in General Practice and think it worthwhile. However, we are aware that some students, for a variety of reasons, may experience difficulty. They may have personal or health problems. If so, they should consider speaking to their faculty tutor or a doctor in Student Health. Alternatively please feel free to contact Dr Drew Gilliland or any of the other teaching staff. Health related issues are best managed by your own Doctor but we would be happy to give some initial advice. Also if you have had a recent life event such as a death in the family it may be helpful for you to let us know. The information sheet on page 17 gives specific information regarding potential sources of help. Intimate Examination of patients by students The Committee, under the chairmanship, of Professor Neil McClure looked at this area in detail. This Committee has decided that vaginal examination can only be performed by a medical student under the direct supervision of a Gynaecologist. This has implications for General Practice and in the future medical students are no longer permitted to perform vaginal examinations whilst on their attachments in General Practice but are still able to observe vaginal examinations carried out by other healthcare professionals provided the patient has given their consent. 17 STUDENT SUPPORT AND GUIDANCE INFORMATION SHEET GENERAL INFORMATION 1. Head of Student Support Miss G. Silvestri, Head of Student Support and Guidance Contact: 028 9063 3152 (answering machine available outside main office hours) 2. School Tutor If you do not know who your Tutor is or how to contact them speak to Mrs Perpetua Lewis, Department of Ophthalmology Contact: 028 9063 3152 or email: [email protected] 3. The web Student Support and Guidance Website: http://www.qub.ac.uk/fmhs/ssg/ Students News site: http://www.qub.ac.uk/fmhs/news.html Information on Facilities in Hospitals and who to contact for help while on attachment: http://www.qub.ac.uk/fmhs/sumde/Index.htm 4. School Office School Manager: Mrs K Copeland [email protected], Tel 028 9097 3258 Curricula enquiries: Mrs Linda McGuinness [email protected], Tel: 028 9097 1448 Exam Enquiries: Mrs Arlene Stockman [email protected], Tel: 028 9097 5963 Student Support: Mrs Nicola Swenarton [email protected], 028 9097 1451 5. Female Medical Student Counsellor Dr Ann Harper: 028 90263009 or 028 90240503 Ext 2506 SPECIFIC CONTACTS FOR THIS MODULE/COURSE Dr AEW Gilliland – Course Co-ordinator tel: 028 9020 4252; fax: 028 9031 0202; email: [email protected] 18 This section, pages 18 - 26, will be handed in at the Oral Station of the Objective Structured Clinical Examination (OSCE). These pages must be stapled before being handed in. DEPARTMENT OF GENERAL PRACTICE QUEEN’S UNIVERSITY OF BELFAST FOURTH YEAR CLERKSHIP 2006-2007 RECORD CARD NAME _______________________ 19 ACTIVITIES A. 1. 2. 3. 4. 5. 6. 7. 8. Sitting in on surgery consultations. Accompanying GP on home visits. Sitting in with another G.P. Spending a night “on call”. Visiting the local chemist. Writing up notes. “Out of Practice” eg Case Conference, Court, Inquest. Accompany GP to visit a patient with a terminal illness. B. Sessions with other primary care team members. Staff Details of Session Receptionist (s) Health Visitor District Nurse Treatment Room/Practice Nurse Community Psychiatric Nurse Social Worker (if attached to practice) Practice Manager C. Tutorials with GP Tutor 1. 2. Common Paediatric Problems Gynaecology List any other Tutorials 1. 2. 3. 4. 20 Please ask your GP teacher to initial those activities you feel you have carried out adequately. These are only suggestions. You do not have to do them all and you may add more at the bottom. Task Interviewing 5 or more patients on your own. Writing a hospital referral letter on your own. Presenting a case report of a patient you have interviewed at length at home. Familiarisation with appointments, house calls and repeat prescribing systems of the practice. Writing prescriptions. Familiarisation with practice computer system. Treatment Room Procedures BP measurements Urine analysis Ear syringing Dressing wounds Suturing Removing Sutures Taking blood Giving injections Observing cervical smears Follow up of an acute admission. Initial 21 PRACTICE ATTACHMENT Please complete this timetable together with your GP teacher so that time available can be used as efficiently as possible. Opposite are some suggested activities. Week 2/6 AM Mon Tues Wed Thurs Fri PM RETURN TO DEPARTMENT OF GENERAL PRACTICE Week 3/7 AM PM AM PM Mon Tues Wed Thurs Fri Week 4/8 Mon Tues Wed Thurs Fri Please asterisk any evening when you were “on call”. Students finishing their Clerkship in Week 4 stop Friday lunchtime. Those finishing in Week 8 stop Thursday pm. The combined Primary Health Care and Ageing & Health Assessment is on Friday morning of Week 8 at 8.45am. A more detailed Programme will be circulated to you before you go out on your 2nd clinical attachment during the 8-week Block. 22 To the G.P. Teacher: Please complete this form with your student. This is a means of giving the student some valuable feedback. Student’s Name _____________________________________ Date of Attachment _______________ to ____________________ Poor Attendance Punctuality Enthusiasm Communication Skills Clinical Skills Medical Knowledge 1 1 1 1 1 1 Excellent 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 Please comment on areas that are very good and those that could be improved upon. GP Sig. __________________________________ Surgery Stamp 23 PRACTICE EXPERIENCE QUESTIONNAIRE 1. Name of Student 2. Name of Tutor 3. Address of attached practice 4. List size 5. Percentage of patients Under 5 6. 65-74 Over 75 Practice features (please circle) Health Centre Partnership owned Urban Rural Mixed Dispensing 7. Please comment on any special, social or other features of the practice. 8. Is Child Health Surveillance carried out? YES/NO 9. Is minor surgery carried out? YES/NO 10. What Health Promotion clinics are carried out? 11. What additional clinics/sessions exist within the practice, eg obstetrics, immunisations, police work, factory work? 24 12. What systems of audit exist in the practice? 13. What staff are employed/attached: Nursing/Paramedical: 1. 2. 3. 4. 5. Clerical/Administrative: 1. 2. 3. 14. What special diagnostic, therapeutic or other equipment is available within the practice? 1. 2. 3. 4. 15. What diagnostic facilities are available by direct access outside the practice? Diagnostic 1. 2. 3. 4. 16. Is the practice computerised? If yes, what are its principal uses? 1. 2. 3. 4. 17. How are out of hours duties covered? YES/NO 25 18. Please record number of patients seen during the second week of your attachment. M T W T F With your GP Tutor Interviewed initially by yourself Seen during Special clinics Home visits Night calls (after 6 pm) TOTAL 19. STUDENT’S OWN IDEAS AND LEARNING EXPERIENCE Describe two features (50 words each) of the practice which you have found interesting or stimulating or which have influenced your attitude or helped improve your knowledge and skills. 20. What changes (if any) would you like the practice to make for future student attachments? Your comments will be handled sensitively by the Department of General Practice. 26 21. How do you rate the educational experience you have had during your practice attachment (please circle)? 1 Very good 22. 2 Good 3 Average 4 Below average 5 Poor CLINICAL DIARY Please list 10 cases interviewed by you personally during the course of your attachment. You may be asked about some of these in your oral examination. Date (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Patients Initials Age Sex Reason for Consultation 27 MINI CURRICULUM VITAE Name: ______________________________ Mobile Telephone Number (if applicable): ____________________ Town or City where you grew up: ____________________ Outside interests and Hobbies: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Proposed Elective Destination: _____________________________________ Any special requirements during attachment: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 28 SELF ASSESSMENT QUESTIONNAIRE This self-assessment is to assist students and GP Tutors in order to make the Clerkship in General Practice as relevant and useful as possible for each student. Please complete this Questionnaire which is attached to the front of this Study Guide at the beginning of your attachment and show it to your Tutor. Keep this for reference during your attachment. Please bring this Questionnaire with you on your End Course Assessment day. Obviously it is not possible to cover the list of topics in a 3 week Clerkship but it will give the student and tutor a guide to areas which might be covered. Students at the beginning of the year will have less confidence in many areas but as the year progresses experience and teaching in other 4th year modules should mean that a number of the topics have already been covered in some depth. You will be given a similar Questionnaire at the end of your Attachment. You will have a code number assigned so we can analyse the difference between the two but no individual student will be identified. This is a pilot and we will be interested in feedback from students and GP Tutors. 29 WHAT IS GENERAL PRACTICE This section gives some background information about General Practice. It will describe the role of the GP and members of the Primary Health Care Team and will outline the role and content of General Practice. The definition of a general practitioner by The Royal College of General Practitioners in 1972 is still useful. “The doctor who promotes personal, primary and continuing medical care to individuals and families. He* may attend his patients in their homes, in his consulting room or sometimes in hospital. He accepts the responsibility for making an initial decision on every problem his patient may present to him; consulting with specialists when he thinks it appropriate to do so. He will usually work in a group with other general practitioners, from premises which are built or modified for a purpose, with the help of paramedical colleagues, adequate secretarial staff and all the equipment which is necessary. Even if he is in single-handed practice he will work in a team and delegate when necessary. His diagnosis will be composed in physical, psychological and social terms. He will intervene educationally, preventatively and therapeutically to promote his patients’ health”. Because this role includes psychological and social diagnoses he has to have a much wider information base than previously. By including prevention and education he extends his interest to people who do not call on his services spontaneously and who are not necessarily ill at all. This wider role of the general practitioner places him firmly in the context of Primary Health Care which is the more appropriate term to cover the whole of the team. General practice, by tradition, was mainly concerned with treatment of disease presented by patients, while the emphasis on primary care is on health and its promotion by a healthy life style, by prevention of ill health if possible and by the provision of acceptable first line health care to which all people have access and which they can afford. Factors changing within general practice 1. 2. 3. 4. 5. 6. 7. 8. 9. Increasing interest in performance review (audit) Increasing interest in prevention of ill health Increasing application of computers and information technology with a reduction in information transmitted and held on paper record Working in teams More management education for GPs and staff More practice managers Increasing use of district and treatment room nurses Social-Skills training in consultations Patient Participation groups * He/She is interchangeable 30 10. 11. 12. 13. 14. More female general practitioners Increasing/changing workload More effective treatments available in general practice Consultant led clinics in general practice Near patient testing eg blood investigations Factors for change from outside general practice 1. 2. 3. 4. 5. 6. 7. Financial cuts in the NHS Few hospital beds Shorter hospital stay Day Case Surgery Emphasis on Care in the Community Longer waiting lists in certain areas Super specialisation Social changes 1. Population changes. In the past 20 years the number of people aged more than 65 years has increased by 1/3. They now constitute 15% of the population and the proportion of elderly is set to rise further. There is also an increasing Ethnic Minorities population. There is increased unemployment, more work-related stress and a tendency to stop work earlier. 2. Technical advances in coping with disability. PRIMARY AND SECONDARY CARE One of the major differences between primary and secondary care is the nature of presentation of illness. In secondary care patients are usually referred from another practitioner, their illness has been categorised, and by the very nature of their presentation in hospital, social and psychological causes for their illness have usually been excluded. In primary care patients present to both nurses and doctors with largely unsorted problems. Primary care is not the sum of a range of secondary care specialities performed to a lesser degree, it has knowledge and skills peculiar to it. These skills relate to the work of a clinical generalist, and focus around problem definition and solving. A clinical generalist is able to understand the illness, the patient and the context, bringing together physical, psychological and social causes of disease. Generalists use their skills in the consultation, both in communication and examination rather than advanced technology to identify the nature of disease. Investigations are kept to a minimum and tend to follow a progression rather than a battery as seems to occur in secondary care. Perhaps the most important feature of the clinical generalist is their ability to use a hypothetico-deductive model to identify disease. Using their knowledge of the patient, their social context, including their working environment and home surroundings, the 31 common illnesses in the community and their wider knowledge of disease, a generalist will identify a priority list of likely causes for a patient’s symptoms. He will then ask discriminating questions to exclude or include possibilities from the list. Although this process may occur from start to finish in one consultation, more commonly the generalist allows the full picture to unfold over a series of planned consultations. The use of information collected over time is a special feature of general practice in the United Kingdom and enhances our generalist role. An example might be a child who presents with a cough. A child whose relatives have asthma, and who has been seen with hay fever or eczema would make a diagnosis of asthma likely; discriminating questions might focus on the effect of exercise or winter viruses. Examination might concentrate on listening for wheeze or checking the peak-flow rate. A child of the same age who had recently returned from visiting grandparents on the Indian subcontinent would raise the possibility of tuberculosis. Discriminating questions might focus around fever and weight loss. A chest x-ray would be a high priority. A child of the same age who appeared well, perhaps even disruptive in surgery and whose mother had a previous history of postnatal depression might be the presenting symptom of a maternal depressive illness. Questions in the last example may need to move from inquiring about the child’s health to asking about the mother. A clinical generalist is usually skilled at picking up small verbal and non-verbal cues, they will have a range of skills which will help them reach the most likely diagnosis quickly, excluding serious illness and creating a safety net if their original hypothesis is incorrect. They also have skills in sharing with the patient their thinking and their proposed management, listening and asking for the patient’s ideas and anxieties about their illness. These skills help the patient to understand the nature of their illness which increases the cost-effectiveness of any treatment. Clinical generalists also have to anticipate and deal with acute life-threatening illness: the child with the cough might present acutely, either during the day or at night, severely ill and at risk of respiratory arrest. They also need a range of skills to manage health promotion and disease prevention, perhaps drawing a parent’s attention to the effect that a smoky atmosphere might have on their child’s cough, or being aware that the child with a cough has not been immunised against diphtheria. Managing illness in primary care has its own special skills. Patients have total autonomy, once they have left the consulting room they are free to follow advice or ignore it. There is evidence to suggest that about one third of prescriptions are not presented to the chemist. Successful management of disease requires a negotiated plan in which the patient has ownership and understanding; it will usually involve pragmatic compromise over a theoretical academic clinical ideal in favour of what is feasible in the patient’s social context and understanding. Each management plan in primary care must address the three aspects of illness: the disease, the patient and the social context. 32 What is a team? A team is defined as a group of people who make different contributions towards the achievement of a common goal. Gilmore et al (1974) described four essential characteristics of teamwork in general practice. 1. The members of the team share a common purpose which builds them together and guides their outcomes. 2. Each member of the team has a clear understanding of his/her own functions and recognises common interests. 3. The team works by pooling knowledge, skills and resources and all members share responsibility for outcome. 4. The effectiveness of the team is related to its capabilities to carry out its work and its ability to manage itself as an independent group of people. The Primary Health Care Team is an organised group of professional workers, each of whom is directly available to people in a defined community. The Primary Health Care Team 1. 2. 3. 4. 5. 6. 7. Permits division of labour and prevents dysfunction of work. Improves interdisciplinary understanding. Extends individuals’ capabilities. Makes communication easier. Provides a basis for the appraisal of individuals’ performance. Allows specialisation. Permits changes to be made. Those who make up a Primary Health Care Team vary but usually include the General Practitioner, Health Visitor, District Nurse, Practice/Treatment Room Nurse, Social Worker, Receptionist and Practice Manager. The Health Visitor The Health Visitor is a state registered nurse with a post-registration qualification who provides a continuing service to families and individuals in the community. He/she has a broad potential brief which includes:1. Postnatal home visits This is a statutory duty from the day the midwife stops attending (usually day 10). 33 2. * Regular follow-up at home or surgery continues until the child attends school. There are routine assessments at 6 weeks, 7 months, 18 months, 30 months and pre-school at 4 years. The function is to educate and support the mother in basic baby care, common postnatal problems, minor childhood illness and developmental milestones. The visits also include child developmental and screening work including tests of sight, hearing and development. Specific surveillance and support of at risk groups single parent families cases of potential non-accidental injury the handling of children with emotional and behavioural problems or physical and mental handicap marital counselling 4. * * * Preventative work and Health Education immunisations health education visits/screening of elderly 5. * Advisory and liaison work advice on local resources eg mother and toddler groups, day nurseries, self help groups. 3. * * * The District Nurse Broad potential overlaps with other members of the team but main duties are:1. * * * * * * * * * * 2. General nursing care including prevention of pressures sores bowel and catheter care treatments, injections and dressings post op assessment and care of patients discharged early from hospital venepuncture rehabilitation Stoma care management of incontinence care of patients with diabetes care of the terminally ill including the use of a syringe driver to provide symptom relief Mobilisation of resources, incontinence aids, commodes, ripple beds, bath aids. The district nurse co-ordinates the nursing care of the terminally ill and involves the Twilight Nursing Service, the Marie Curie Nursing Service and help from the local hospice whenever appropriate. 34 3. * * * Preventative work monitoring at risk groups health advice administration of influenza and pneumococcal inoculations. The Treatment Room Nurse/Practice Nurse The role of this nurse depends in part on the personal interests, confidence and experience of the nurse. It is also depends on the needs and requirements of the Practice. A Practice Nurse may share district nursing duties. Commonly performed tasks include:a. Basic nursing procedures dressings, venepuncture, injections, immunisations, basic observations (weight, BP, urine testing), suture removal, ear syringing, taking swabs for culture and sensitivity and recording ECGs. b. Management of minor accidents. c. Special Clinics - Wart Clinics (application of liquid nitrogen), Diabetic Clinics, Hypertensive and Well Woman/ Well Man Clinics. d. Taking cervical smears (if trained to do so) e. Organising the monitoring of patients on warfarin and cytotoxic agents f. Assisting the doctor in various procedures (eg fitting of intrauterine contraceptive devices (I.U.C.D.s), minor surgery) and acting as a chaperone g. Regulation and maintenance of treatment room supplies and equipment h. Completion of paper work for audit and items of service payments. i. General health education and advice. The Community Psychiatric Nurse Community Psychiatric Nurses (CPN) are usually based in a Health Centre or premises belonging to the Community Trust. They provide care for people suffering from severe and chronic mental illness and for those suffering from less severe but nevertheless disabling mental health problems. 35 The care provided includes assessment of the mental state, monitoring the mental state, administration and monitoring of medication including compliance, supportive psychotherapy and rehabilitation. They also provide support, advocacy, information and advice to sufferers’ relatives and carers. User and Carer participation is encouraged and valued. The Reception Staff They are key workers as they are the usual initial contact for access to any service offered by the Practice. 40% of their workload involves patient contact, face to face or by phone. Reception duties * * * making new and repeat appointments receiving and directing patients taking requests for visits. Filing and record duties * * * * * * locating patients’ records and re-filing dealing with post registering new patients filling in claim forms updating clinical records administering the repeat prescribing system. * secretarial duties including typing letters, organising clinics and patient recall. The Social Worker Some practices have attached Social Workers, others do not, so the student may not meet a social worker during their practice attachment. Their work load covers three broad areas A. * * * Individual case work counselling individuals and families with financial and personal problems marital and bereavement counselling follow up and support for the mentally ill. 36 B. Advice and allocation of resources. * * home help, meals-on-wheels social service day centre places * advice to impoverished, disabled and homeless, home adaptations, telephone installation grants, social benefit allowance, legal housing rights, voluntary and self-help groups. C. Statutory responsibilities* * * * * * supervision of children in Care supervision of adoption, fostering and child minding management of child abuse care compulsory admission of patient under the Mental Health Act 1983 responsibility for the handicapped under the Disabled Persons Act 1970. Any one social worker could not possibly deal with all of the above. Duties such as the supervision of children in Care is specialised and requires additional training. However, a practice based social worker can be the first point of contact. If s/he cannot deal with this work it may be referred appropriately to another social worker. *A practice based social worker would generally have less statutory responsibilities to deal with. Practice Manager Most practices now employ a Practice Manager, even the smaller practices may employ someone on a part-time basis. Many of their duties can be delegated but they retain an overall responsibility for 6 broad categories. 1. * * * * * Staff hiring and firing induction and training rotas and holidays contracts grievances and problems 2. * * * * * Finance monitoring and maximising sources of income monitoring all outgoings paying staff salaries record keeping accounts preparation 37 3. Administration, organisation of basic administration tasks. 4. Premises and supplies, organisation of security, equipment maintenance. 5. Future planning. 6. * * Liaison work staff, doctors, hospitals, Health Boards organisation of meetings. Additional Reading, pages 1 -24 “Clinical Method”, Fraser. 3rd Edition. Pages 1 - 67, “Notes for the MRCGP”, 3rd Edition, Palmer. THE NEW GENERAL PRACTICE CONTRACT This contract was introduced in April 2004 and replaces the previous contract which was introduced in 1990. From a patient’s perspective, the two major differences are that patients are no longer registered with an individual GP but with a practice and practices can now opt out of providing out-of-hours cover. Out-ofhours provision will now be organised by Health and Social Services Boards in Northern Ireland and Primary Care Trusts in England, Scotland and Wales. There are a number of clinical domains where the quality of care the practice delivers is looked at and individual practice incomes are adjusted accordingly. CLINICAL DOMAINS Heart failure Palliative Care Dementia Depression Chronic Kidney Disease Atrial Fibrillation Obesity Learning Disabilities Smoking Coronary Heart Disease 38 Left Ventricular Dysfunction Stroke and TIA Hypertension Diabetes mellitus COPD Epilepsy Hypothyroidism Cancer Mental Health Asthma Practices can also decide to perform additional services called “Enhanced Services”. This involves the practice developing specific programmes to look at, for example, alcohol misuse, anti-coagulation monitoring, IUCD fitting, drug misuse, intermediate care, care of the homeless, sexual health services and minor surgery. Practices also receive support for providing premises and the provision of information technology. You will not be expected to know details about the Contract but this basic information should be useful to you when you are attached to your Practice. 39 CONSULTATION SKILLS (WATCHING YOU, WATCHING ME) Sessions during Course Week 1 Mon 2.00pm Dept. of General Practice Week 1 or 5 Thurs 2.00pm Dept. of General Practice Week 1 or 5 Fri 2.00pm Teaching Practices Week 2 or 6 Fri 2.00pm Teaching Practices AIM: How to develop an effective consulting style. OBJECTIVE: 1. To demonstrate ineffective consultations. 2. To provide evidence that quality consultations can be related to positive health outcomes. 3. To describe health belief and task based models of the consultation. 4. To present a series of five tasks which can be used to practice and teach effective consulting. 5. To demonstrate how students can identify their strengths and weaknesses by videotaping their own consultations. 6. To enable students to practice the use of recommended techniques for discussing videod consultations in terms of evaluating them and giving and receiving feedback. CONTENT One introductory tutorial followed by one practical using simulated patients. Two CCTV sessions when students will consult with both patients. TASKS 1. How would you define clinical skills, communication skills and consultation skills. 2. What factors make a successful consultation. 3. What are (a) the doctor (b) the patient barriers to effective consultations. PRESENTATIONS 1. Evidence for poor consultations. 2. Evidence that consultations can be effective. 3. Clinical Interviewing Skills. 4. Consultation Models. 5. Performance Tasks. 6. Discussing video consultations. 40 CONSENT It’s a general legal and ethical principle that valid consent must be obtained before starting treatment or physical investigation or providing personal care for patients. This principle reflects the right of patients to determine what happens to their own bodies and is a fundamental part of good practice. A health professional who does not respect this principle may be liable both to legal action by the patient and action by their professional body. With regard to medical students written consent is not normally required for a patient either to sit in on a consultation with a GP and patient or interview and/or examine the patient themselves. However whenever possible patients should be informed at the time of booking the consultation that the medical student may be present. If this is not possible they should be told when they book in with the receptionist and should be given the choice of asking the student to wait outside. It is a sensitive area and GPs and students need to tread a fine balance between getting the student exposed to a range of important medical conditions during their training but at the same time ensuring patients do not feel compelled to take part in consultations or procedures involving a medical student. Intimate examinations involving examinations of the female breasts, the genitalia and the male and female rectal areas should only be observed or carried out by a student under supervision by a general practitioner or health professional with a chaperone if needed (see medical school guidelines). A student must never perform any of these examinations on his or her own or without consulting the health professional supervising the teaching session. CONSENT TO VIDEO RECORDING. There are two video recorded teaching sessions in the fourth year general practice course and patients are booked for a video recording consultation with a fourth year medical student with the general practitioner in attendance. Box 1 sets out the GMC basic principles for making and using visual and audio recordings of patients (2002) and Box 2 shows the patient consent form for video recordings which is used for fourth year teaching. It is important in this process that patients are aware beforehand that the consultation will be recorded by video camera by the student undertaking the interview. The GP and other students will be watching either through a one-way mirror or using a television monitor. Patients are aware that they have the right for this tape not to be subsequently used in a teaching session. They are also told that the tape is wiped at the end of the teaching session after being played back to the student, the other students in the teaching session and the teacher. If the recording is to be kept this would require more detailed written consent such as the RCGP consent form and the medical student would also have to give their written consent as well. 41 Box 1 GMC basic principles, taken from Making and Using Visual and Audio Recordings of Patients, 2002 ________________________________________________________________ 1 When making recordings you must take particular care to respect patients’ autonomy and privacy, since individuals may be identifiable to those who know them from minor details that you may overlook. The following general principles apply to most recordings (exceptions are explained in the GMC guidance). Seek permission to make the recording, and obtain consent for any use or disclosure. Give the patient adequate information about the purpose of the recording when seeking their permission. Ensure that the patient is under no pressure to give their permission for the recording to be made. Stop the recording if the patient asks you to do so, or if the recording is having an adverse effect on the consultation or treatment. Do not participate in any recording that is made against a patient’s wishes. Ensure that the recording does not compromise the patient’s privacy and dignity. Do not use recordings for purposes outside the scope of the original consent for use, without obtaining further consent. Make appropriate secure arrangements for the storage of recordings. 2 If children who lack the understanding to give their permission are to be recorded, you must obtain permission to record them from a parent or guardian. Children under 16 years of age who have the capacity and understanding to give permission for a recording to be made may do so. You should make a note of the factors that were taken into account in assessing the child’s capacity. 3 If a mental disability or mental or physical illness prevents the patient from giving their permission, you must obtain agreement to recording from a close relative or carer. In Scotland you must seek agreement from any person appointed under the Adults with Incapacity (Scotland) Act 2000 who has an interest in the welfare of the patient. 4 People who agree to recordings being made on behalf of others must be given the same rights and information as patients acting on their own behalf. 42 Box 2 Department of General Practice – Queen’s University Belfast Patient Consent to Video Recording for Undergraduate Medical Teaching Date ……………………. Patient’s name ………………………………………………………………………. Dr ………………………………., whom you are seeing today is hoping to video 4th year undergraduate students consulting with patients. The purpose is to enable students to improve their communication and clinical skills. The tape will be played back to the student with 2-3 other students who are part of the teaching session and will be interviewing other patients. The tape will be erased at the end of this teaching session. The video is ONLY of you and the doctor or medical student talking together. The camera will be switched off at any time if you wish. All video recordings are carried out according to guidelines issued by the General Medical Council. You do not have to agree to your consultation with the doctor being recorded. If you do not want your consultation to be recorded, please tell the doctor. This is not a problem, and will not affect your consultation in any way. To be completed by the Patient I have read and understood the above information and give my permission for my consultation to be video recorded. ………………………………………. Signature of the patient BEFORE THE CONSULTATION Date ……………… After seeing the doctor I am still willing for the recording of this consultation to be used in this teaching session. ………………………………………. Signature of the patient AFTER THE CONSULTATION Date ……………… To be filed in the Patient’s Notes 43 COMMUNICATION IN MEDICINE An Age-Old and Essential Component of Medical Care “I observe the Physician, with the same diligence, as he the disease; I see he fears, and I fear with him: I overtake him, I overrun him in his fear, and I go the faster, because he makes his pace slow; I fear the more, because he would not have me see it. He knows that his fear shall not disorder the practise and exercise of his Art, but he knows that my fear may disorder the effect, and working of his practise.” John Donne 1572-1631 CLINICAL INTERVIEWING SKILLS INTRODUCTION The interview process is a key component of all medical consultations. History taking notes commonly list specific questions to be asked to identify common symptom patterns and characteristics. It is essential to have mastered and internalised these questions. However, a clinical interview is not the administration of a questionnaire. There are basic skills which have applicability to all types of interviews and are important irrespective of the nature of the patient’s complaints, whether physical or psychological, and irrespective of the discipline of the interviewer, whether social worker, general practitioner, psychiatrist, surgeon or physician. The basic skills will be described below but it should be remembered that such skills are acquired and maintained by practice. Diagnosis and treatment begin with the interview. Communication is about gathering information as efficiently as possible in the time available and learning to define as precisely as possible the patient’s problems and why he or she may have chosen to come to the doctor. Knowledge and experience of communication must be blended with knowledge of medicine and clinical reasoning to produce an effective interview process. INTERVIEWING STYLE A. BEGINNING THE INTERVIEW Non verbal cues contributing to the development of a supportive atmosphere. Introduction: RELAX - not too formal FACE PATIENT SQUARELY 44 EYE CONTACT SMILE/FACIAL EXPRESSION PROXIMITY - remove barriers if possible TOUCHING PATIENTS - may be appropriate TIME - always limited B. INTERVIEW PROCEDURES Appropriate use of the following: 1. 2. 3. 4. 5. 6. 7. 8. Listen carefully to the patient. Attend to both verbal and non-verbal cues. Facilitate using both verbal and non-verbal responses. Control the interview by encouraging the patient to keep to the point. Clarify by appropriate use of questions, repetition, summarising. Avoid jargon. Avoid premature focus on the initial problem. Appropriate use of questions: Use open questions before going on to ask specific questions. Use single questions. Avoid leading questions. A positive and supportive atmosphere can be enhanced by informality of style, a pleasant and warm manner, good eye contact, avoidance of physical barriers, proximity. C. ENDING THE INTERVIEW 1. 2. Summarise the problem. Ask if there is anything else troubling the patient. Would he/she like to ask any questions. Empathy of manner and tone of voice are often significant 3. COMMUNICATION SKILLS - A LIST OF BEHAVIOURS THAT CAN BE OBSERVED IN EVERYBODY THE CLINICAL INTERVIEW SETTING A. “SOCIAL” SKILLS The beginning Body posture Eye contact Attentive listening Use of facilitation Style of questions 45 Absence of jargon Keeping patient to relevant matters Picking up verbal cues Presence of empathy B. “PROFESSIONAL” SKILLS Use of confrontation Use of silence Appropriateness of interrupting Picking up non-verbal cues Covering psychological aspects Covering personal issues Covering social aspects Ability to clarify NOTE In senior medical students and junior doctors the so-called “social” skills listed above are likely to be used. Some training is required to ensure that these skills are used effectively. Again in senior medical students and junior doctors the so called “professional” skills are not likely to be effectively used and definite periods of small group training are needed which should be repeated at regular intervals over an extended period of time (several years). 46 EVIDENCE-BASED COMMUNICATION? This session is written as a literature review, clustering around a number of subheadings. These sub-headings may themselves be used as the starting-point for discussion, but participants may need to be persuaded to stay as close as possible to the evidence. Does doctor-patient communication need to be improved? Complaints against doctors have increased dramatically since the introduction of the health reforms, although there are many factors other than the doctor’s consultation skills that may account for this (eg under-resourcing, consumerism, political ideologies that increase public expectation beyond what the service can deliver, the recession, a general culture of whinging, scape-goating and distrust of authority). However, in 80% of cases, dissatisfaction with health care services is deemed not due to clinical negligence but to some form of dysfunctional communication eg inadequate information giving, misunderstandings, perceived insensitivity, lack of control over decisions and treatment, discontinuity of care and general disorganisation of the service (this, however, hinges on a definition of communication so broad that it includes most things). A 1995 study into information-giving prior to prostate surgery unearthed a clear need to improve the comprehensiveness, relevance and intelligibility of information given to patients. There are a number of reviews of doctor/patient communication which are good starting points for those with a serious interest in the topic. These include Pendleton, the Toronto statement and Stewart. Can communication be measured objectively? If so, what process and outcome measures are chosen? Studies of medical communication have been disappointingly restricted in their approach. There are a few full-length qualitative studies eg Fisher and Todd (eds), West, and Mishler - the last named is perhaps the best: all are similar in approach. The great majority of the work undertaken, however is quantitative. A fair number of these studies, it must be said, are scientifically elegant and linguistically naive, and there is a disconcerting tendency for considerable resources to be elaborately spent on the obvious (“Being nice to your patients is a good thing” - “Grass is green’ - boffins’ amazing claim!”) This at times is enough to make any rational humanists fall on their swords, but at least it can be said that there is now a very considerable number of objective studies which conclude that making the effort to communicate well makes a difference. Some process measures which have been used include: the time doctor and patient spend talking and listening, the number of open questions asked, the amount of information given, and the extent of opportunistic health promotion. 47 Outcome measures include: Patient factors eg satisfaction, psychological state, recall and understanding of the consultation, symptomatic improvement, quantifiable improvement in pathological state. Doctor factors include: self-confidence, self-worth, job satisfaction, psychological state. What evidence is there that good communication improves outcome? There is now some evidence that the quality of clinical communication is related to positive health outcomes. Reduction in blood pressure is significantly greater in patients who, during visits to the doctor, have been allowed to express their health concerns to the doctor without interruptions. Concordance between doctor and patient in identifying the nature and seriousness of the clinical problem is related to improving or resolving the problem. Explaining and understanding patient concerns, even when they cannot be resolved, results in a significant fall in anxiety. Greater participation by the patient in the encounter improves satisfaction and compliance, and outcome of treatment (eg control of diabetes and hypertension). The level of psychological distress in patients with serious illness is less when they perceive themselves to have received adequate information. In surgery, beneficial clinical communication results in less pre-operative anxiety, reduced post-operative complications and quicker and less stressful recovery. In radiotherapy, beneficial clinical communication results in greater treatmentrelated knowledge and less emotional distress. Beneficial clinical communication results in increased compliance with medical instructions and prescribed medications, leading to improved functioning in everyday life, particularly for those with chronic illnesses. A recent systematic review of 10 analytical studies and 11 randomised controlled trials indicate that, in 16 studies, more effective communication was significantly related to improved health outcomes. Can good communication be taught? Is it retained and used in real life? Beneficial clinical communication can be taught, is feasible routinely in clinical practice and can be achieved during normal clinical encounters, without unduly 48 prolonging them, provided that the clinician has learned (and is motivated to use) the relevant techniques. What are “the relevant techniques”? These are communication skills which, when taught to and used appropriately by doctors, have been shown to improve the outcome of consultations. They read like a combination of common sense and good manners: but the techniques may not always be applied in the heat of everyday practice. These skills include such things as using a judicious mix of open and closed questions; permitting silence to give the patient time to talk; checking understanding; offering negotiated management; and also such things as ensuring a quiet and comfortable environment for consultations to take place. Such matters are fairly easy to teach and learn. Poor communicators, however, are more likely to be poor because there is something wrong at the level of attitude rather than skill. Problems, in other words, may be “deep” rather than “surface”. A self-image which includes a sense of one’s own importance and the value of one’s time can easily surface as brusqueness and indifference, for example. These matters are more difficult to put right, and communication skills teaching must offer the opportunity to bring out the attitudes which underpin performance in individual consultations. Evidence suggests that the effectiveness of communication teaching is much enhanced if participants are able to reflect on and discuss a video/audio recording of their performance. Feedback is essential to changing attitudes and behaviour. This can also be powerfully provided by interacting with role players who, after the consultation, can provide the doctor with accurate information about how s/he made the patient feel, how competent and empathic s/he appeared to be, what might be done to improve certain areas etc. This is perhaps the only time in a doctor’s career that such detailed insight into his/her effect on patients will be offered. What aspects of communication do patients complain about? The commonest complaints in both hospital medicine and general practice are: Time factors (too long waiting, too short seeing the doctor) Not enough information Poor quality information (not clearly written or spoken, not what the patient wants) Adequate information communicated poorly (given too late or rushed or given insensitively or when the patient was alone) Inconsistent or contradictory information from different sources. 49 APPROACHES TO THE CONSULTATION The various general approaches to the consultation are - as here - often loosely referred to as models, but in fact they are of very different status. Remember that some are the result of intuition, some of empirical study - though the empirical studies are themselves of mixed value. All, at least, are attempts to capture some element which either does or should take place in the consultation. Note in particular that these are not really competing models aimed at describing the same phenomena: rather, they are all complementary...... and imperfect. THE BIOMEDICAL MODEL: 1. 2. 3. 4. 5. Take an accurate and relevant history (OBSERVATION) Perform an accurate and relevant examination (OBSERVATION) Make a provisional diagnosis (HYPOTHESIS) Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING) Make a definitive diagnosis (DEDUCTION) Notes: This is the classical medical diagnostic process. “Hypothetico-deductive” thinking of the kind described here is still central to the doctor’s task in a consultation. In any single consultation, the doctor may form, test and discard a large number of diagnostic hypotheses based on the information (cues) s/he received from the patient. This is, however, a very incomplete account of the consultation. It is reductionist: the patients are seen and treated in terms of signs, symptoms and diagnoses, and labelled accordingly It is doctor centred: there is no mention of the patient’s feelings, beliefs and opinions, of any sharing of information or agreeing of a management plan It flounders when no objective physical disorder is unearthed It does not recognise the importance of non-verbal communication It omits the therapeutic use of the doctor-patient relationship It fails to recognise that a consultation can be one of a series - as is often the case in general practice It over-emphasises the importance of decisions based on personal clinical experience: these are apt to bias because of the limited number of patients that any one doctor can experience It is in response to these criticisms that other possibilities have developed, all broadly holistic and all perceived as more modern in approach. 50 Here are a couple of the more important ones. Pendleton et al From observation, seven tasks were detailed which together form comprehensive aims for the consultation: 1. 2. 3. 4. 5. 6. 7. To define the reason for the patient’s attendance, including (I) the nature and history of the problems (ii) their aetiology (iii) the patient’s ideas concerns and expectations (iv) the effects of the problems To consider other problems: (I) continuing problems (ii) at-risk factors With the patient, to choose an appropriate action for each problem To achieve a shared understanding of the problems with the patient To involve the patient in the management and encourage him/her to accept appropriate responsibility To use time and resources appropriately (I) in the consultation (ii) in the long term To establish or maintain a relationship with the patient which helps to achieve the other tasks. Health Belief Model The decision to consult depends on: 1. The individual’s general interest in health matters, which may correlate with personality, social class, ethnic group etc 2. How vulnerable or threatened a patient feels him/herself to be to a particular disease 3. The individual’s estimation of the benefits of treatment weighed against cost, risks and inconvenience 4. Trigger factors such as alarming symptoms, advice from family or friends, messages from the mass media, disruption of work or play. This will be covered in more detail in the Health Promotion Session. Additional Reading: Textbook of General Practice, Stephenson. Pages 17-29. “Clinical Method”, Fraser, 3rd Edition. Pages. 25-108. “Notes for the MRCGP”, Palmer, 3rd Edition. Pages 68 – 74. 51 Weeks 2 & 6 Fri 10.45am – 12.45pm Dept. of General Practice AUDIT AIMS To acquire the knowledge and skills necessary to successfully perform audit. LEARNING OUTCOMES To define audit and understand its purpose. To outline the stages of the audit cycle. To describe the importance of topic selection and setting clear objectives. To design a simple audit. To demonstrate an appreciation of the potential benefits and difficulties of performing an audit. To interpret data relating to audit. To differentiate between audit and research. To recognise the importance of teamwork and ethical principles in relation to audit. TEACHING METHODS Small group teaching. Practical exercises involving examples of audit. Additional Reading Pages 27 - 29, “Notes for the MRCGP”, 3rd Edition. Palmer Pages 194-206, “Textbook of General Practice”, Stephenson. Pages 1 – 14, “Medical Audit and General Practice”, Marinker Pages 9 – 59 Principles for Best Practice in Clinical Audit [NICE] www.nice.org.uk There will be additional written material provided at the beginning of the session. 52 AUDIT BASICS Place of Audit - part of being a professional is the responsibility for maintaining high standards of care. Audit is an integral part of that and is expected of both Hospital Doctors and GP’s. Professionals are increasingly accountable to the public... actions may have to be justified. Professionals are aware of the need to maintain high standards of care; audit is a tool used to improve clinical care. It should function to encourage genuine efforts to understand what has happened in practice. It should promote learning and shape change in the light of the reflections made. Definition Clinical audit is the attempt to improve the quality of clinical care by measuring the performances of those providing that care, by considering the performance in relation to desired standards and by improving this performance Purpose of audit It is to improve the quality of patient care Audit is ... confidential educational systematic relevant Audit involves ... change time working together Audit needs ... enthusiasm structure a commitment to change if indicated integrity (honesty) consent of those participating Research is about determining or verifying what constitutes best practice. Audit determines how well that best practice is being implemented. Clinical Effectiveness involves applying the best available knowledge (derived from research, clinical expertise and patient preferences) to achieve the best possible outcomes of care for patients. Audit is an essential part of the process to ensure that patient care is being delivered as intended. Clinical Governance is the framework through which NHS organisations are accountable for safeguarding high standards of care and improving the quality of their services (it is a system of corporate accountability). 53 INTRODUCTION TO AUDIT DESIGN Topic must be useful and feasible Objective what do you hope to achieve keep it short and simple (KISS) Criteria markers of good practice that are measurable Standards what should be happening? expected % of cases where criteria should be met level chosen may be arbitrary - for ideal care - for reasonable care - for minimum acceptable care Often 100% standard is chosen, and then exclusions are made. identification of “cases” –who belongs in the group? selection of “cases” without bias appropriate size of sample / is sampling necessary? Data availability and collection - What is happening?- decide what information is needed to measure criteria Pilot - Ensure it will work Method Sample Analysis of data – Collate information into meaningful groups, comparison of data with original criteria and standards set Discussion - How do we get there? i.e. meet the standards set? Outcomes – What have we achieved? What changes are to be implemented as a result of the audit? Review - consider again – Have we improved? What Should be happening? Change Introduced What is really happening 54 SAMPLING Why Sample? To get an overview of the group of interest To save time To reduce the cost Collecting data about every patient in a group of interest may not reveal any more information about the group than a well-designed sample. You have to decide if you want to review every patient individually (i.e. do a census) or if you wish to study a sample of the group. When might sampling not be helpful? If the information you want / need comes from a computer search, and is readily accessible, there is no real value in sampling – it takes no longer to do the whole group. A sample must be Representative so that valid conclusions can be drawn i.e. without bias Large enough to give realistic measure of performances. It is important that the register / group of patients is as complete as possible. Studies would show that patients not included are often not as well cared for as those on registers. Dealing with results after sampling If you sample, you must apply your changes / improvements to the whole group; i.e. not just ‘fix’ the sample. 55 AUDIT FORM Rationale - why the audit is being done Topic Objectives Target Standard % Criteria Method - data - what is to be collected, is it available, in what form? - identify patients - how/how many patients will you sample? - who will carry out audit? - pilot - will it work? Data collection Analysis Outcomes / Action Re-audit What Should be happening? Change Introduced What is really happening 56 Week 5 Wednesday, 9.15am Dept. of General Practice PRESCRIBING IN GENERAL PRACTICE INTRODUCTION Prescribing of drugs is one of the few legal rights conferred by registration as a medical practitioner and with the considerable expansion in the pharmaceutical industry in recent decades has become a more important mode of treatment than ever before. Prescribing by general practitioners in Northern Ireland accounted for expenditure of approximately £366 million in 2005/6. This expenditure is increasing at a rate several times greater than the general inflation rate. Every year sees the introduction of 30 to 40 new drugs. Evidence of the effectiveness of old drugs is constantly changing. Newly qualified doctors will, during their professional career, see a complete change in the nature of therapeutics and pharmacology. Doctors must learn to keep up to date with the changing evidence and learn rapid and effective ways of updating themselves. The volume of prescribing is also increasing. Each GP issues approximately 70 prescriptions per day, most of which are repeat prescriptions. The task of recording, monitoring and issuing these prescriptions imposes a considerable administrative burden on practices. AIMS The session aims to introduce the student to the principles of good prescribing, the process of writing prescriptions, the availability of common references sources and the treatment of common conditions in general practice. OUTCOMES The student should be able to 1. 2. 3. 4. 5. Write a NHS prescription for a condition commonly encountered in general practice. Locate information to assist in the prescribing decision. State the particular requirements for prescribing different legal categories of drug. Be aware of the potential influences on prescribing. Be aware of the common causes of medication errors and adverse drug reactions. Recommended Reading “Guidance on Prescribing” - Pages 1 to 25, British National Formulary. Additional Reading Pages 137 - 160, Textbook of General Practice, Stephenson. Pages 75 - 85, “Notes for the MRCGP”, Palmer. 3rd Edition. 57 58 59 60 61 62 63 64 65 66 67 68 COMMON SYMPTOMS & “RED FLAGS” Week 5 Mon 2.00pm Dept. of General Practice AIM To introduce students to a range of common symptoms seen in General Practice. OUTCOMES 1. Describe the causes of a range of common symptoms. 2. Differentiate between common and less common medical causes of these symptoms. 3. Prioritise “Red Flag” associated symptoms or clinical findings which would alert the student to a more serious problem. TOPICS OF STUDY Acute Abdominal Pain in Adults Acute Confusion Acute Shortness of Breath Blood in Urine Chest Pain Headache Rectal Bleeding Sore Throat Swollen Glands Tiredness Handouts will be given out in class during this session. Reference: Symptom Sorter (1999) Authors: Keith Hopcroft and Vincent Forte Publishers: Radcliffe Medical Press 69 MEDICAL RECORDS High quality medical records are important in providing a good standard of healthcare for patients. In the past records were often kept by each professional group with little or no sharing of information. Medical records are now increasingly multiprofessional and this is of benefit to the patient. Guidance written for doctors by the GMC in “Good Medical Practice states” that ‘medical records should be clear, accurate, legible and contemporaneous’. Patient records should report the relevant clinical findings, the decisions made, information given to patients and any drugs or other treatments prescribed. This guidance also states that medical records must keep colleagues well informed when sharing the care of a patient. When faced with a serious complaint or litigation, many doctors wish that they had made more complete records. Complaints can be difficult to deal with when records are incomplete. Similarly the successful defence of a claim may be seriously hampered by records that are illegible, inaccurate or incomplete (or indeed missing altogether). It is essential therefore that doctors keep medical records to a high standard with complete information both for the benefit of patient care and also to protect themselves. What should good medical records contain? Good medical records should allow another medical practitioner to make a clear reconstruction of a consultation. They should be recorded in a logical way, whether they are written or computerised records. Records should include the following: HISTORY – a summary of why the patient has presented including details of symptoms, time-scales, associated illnesses, allergies and relevant social history. EXAMINATION – record any important findings, both positive and negative. Always record details of measurements (eg. blood pressure “140/80”, not blood pressure “normal”) DIAGNOSIS –not only should a clear record of a diagnosis be made if possible but also a record of how the diagnosis was reached. If differential diagnosis are considered, record these and demonstrate why any were excluded. INVESTIGATIONS – Record any that have been requested. PATIENT INFORMATION Record what information has been given to the patient including patient information leaflets. Any medical treatment of patients has risks and benefits and they should be not only discussed with the patient but also recorded. 70 This is also relevant for the consent process which is covered elsewhere in the Study Guide. It may also be important to record when a patient has declined information, when questions are asked by a patient and the answers given. It is important to record details about the treatment advised including medication, dosage, duration and treatment and any advice or warning given about treatment. It’s also essential to record the follow-up information. This might include future appointments, follow-up investigations and any referrals made. When out in practice it is useful to review written medical notes recorded by a number of different doctors to see the different styles of keeping records. Problems commonly seen in medical records include the following: Poor handwriting and therefore illegible notes Incomplete records (eg TRxpenv it is assumed the patient has tonsillitis and a course of penv has been prescribed. This record would not be deemed acceptable by the professional body) Lost records – it is common in both hospital and general practice for written records to go missing if there are no back up copies records are permanently lost. RISKS ASSOCIATED WITH ELECTRONIC RECORDS Some risks are the same as written records eg. over-use of abbreviations or incomplete records but computerisation has introduced a number of new risks. There is some concern that computerised records may be less comprehensive and contain more abbreviations. Research to date has not proven this one way or the other. Secondly misuse of Read Codes - these are a clinical coding system used extensively in computerised health records to provide structure and allow complicated searches for specific codes. However it is important that a code for a diagnosis is only coded if it is definite eg. a patient querying angina may be included in a list of patients with definite angina when a search is made. This could have implications for research audit and also clinical management of that particular patient. BENEFITS FOR ELECTRONIC RECORDS They are safe if basic advice is followed, available when required, readily retrieved, readily analysed for audit research and quality assurance. They are also convenient, improve clinical outcomes, protect privacy, reinforce confidentiality and can have decision support such as use of templates, to manage patients, allow automatic reports and support email information and electronic data interchange. They also enable record transfer between healthcare professionals and provide a comprehensive audit trail. In Northern Ireland all practices are computerised to some extent and most practices although not yet paperless are certainly paperlight. However the natural progression from using written clinical records to using electronic means that some records are kept in a written and electronic format. When dual records are kept this is the time which carries the greatest risk. 71 It is important that the electronic system is developed as quickly as possible and that less and less dependence is put on the written record. When information is only kept on the written record and not the computer record and does not match then clinical errors may occur. EXPERIENCE DURING CLINICAL ATTACHMENT It would be useful to observe what information your GP inputs to the patient records after a consultation. You should also volunteer to do this. Please make sure you print your name. If a medical student in practice inputs either the electronic or written records it is important to get the general practitioner or health professional supervising you to check the entry you have made. With practice you will be able to quickly summarise the relevant parts of the consultation and record this adequately. This is a key skill in becoming a safe and competent practitioner and any skills you learn in general practice can be applied to any other clinical environment you find yourself in. REFERENCES Clinical Risks and Management of Primary Care: Authors – K. Haines, M. Thomas Radcliffe Publishing ISBN 1-85775-869-2. 72 Weeks 1 & 5 Friday, 11.15am – 12.30pm Dept. of General Practice Common Clinical Conditions Daktar Daktar!! You are a GP in a busy morning surgery in inner city Belfast. Your list of patients is as follows – what would you do??? 1. Miss Take , 26, (Lives in upper Malone) Good Morning Doctor. I’m awfully sorry to bother you but I seem to have had intercourse with my boyfriend - he drives a Porsche don’t you know – last night and appear to have forgotten any protection. I have a very high powered job in law (ie legal secretary) and could not possibly get pregnant. Good general health. LMP 2 weeks ago Present method of Contraception – nil (Porche driving boyfriend cannot afford condoms) No Known Drug Allergies Present Meds – nil. 2. Master Green 3, (Lives Falls Road) Brought by mum Darktar, Yer gonna have ta do summit about ‘is ear. ‘e’s been up all night an I aven’t had a wink. It’s bin going on fer 3 days – e’s roasting one minute then freezin’ the next and the ear pain started last night. Previously well. Temp 38.3 TM pink. No pus No cervical lyphademopathy 3. Mr Muscle 37 (Works in a gym) Well Hello Doctor, Do I know you from somewhere? I have a problem with my back, but I’m sure you’ll be able to fix it. I was taking my step class last night and I jumped off the step at the end while doing the splits – I’m, ever so fit – and when I landed my back was sore just above my gluteus maximus. What could I take to make it better? PMH – nil of note On examination – No neurological signs, no focal bony pain 73 4. Miss Red, 18 (Daughter of the Local ENT Consultant who taught you at QUB) Sorry to bother you doctor, my dad sent me – he wants a second opinion on my throat. It’s been sore for 3 days now and not getting any better. I’m doing my ‘A’ Levels next week and I really have to do well – I want to do Medicine. No PMH Throat Red, some exudate No cervical lympadenopathy Temp 38 5. Mr Orange, 16 (Lives Sandy Row) Right Doc! – How’s it going? Thing is, right, me spats are getting worse and me girl sent me down ta get summit. She wants me ta use this poncy face wash but I thought you might be able ta help. Mild acne, no scarring. 6. Miss Lead, 21 (Medical Student) Hello Doctor, I’ve just finished my Obs and Gynae attachment and I’ve been thinking about starting the pill. PMH – Nil Current Meds Smokes 10/day LMP 3/52 ago No Intercourse yet. 7. You’re about to call your next patient when the receptionist telephones you to say there’s an urgent call on the line and she says it can’t wait until the end of surgery – It turns out it is Miss Fit, 59, teacher, who feels she has the “flu”. She feels she has a fever – here temperature is 37.3 and has been coughing and sneezing all day whilst shopping in Tesco and playing golf. She feels she needs and antibiotic as she has to play Bridge tonight and doesn’t want to infect the other players. 8. Miss Chief, 3 brought by mum,18 Doctor, I left a sample of urine in, like you asked the last time (child unwell, vomiting, smelly urine) and it came back “positive” – What does that mean, is it serious? No allergies MSSU – Significant growth of Coliforms Sensitive to Trimethoprim Augmentin Nitrofurantonin Amoxycillin 74 9. Master Scratch 5, just started primary School, brought by mum (new age hippy) Hello Dr, It’s Jonny – He’s been sent home from school because its leaping – they all have nits! Will I have to cut all his lovely long hair off? PMH nil 10. Miss Guided, 23 (just back from Holidays in India), Urgent Appointment Good morning Doctor, thanks for fitting me in. I came back from Deli yesterday but the whole time I’ve been there I’ve had diarrhoea. I think I need something to stop it. 11. Adam Dyper, 6 week old baby. Daktar, he’s developed this really bad redness around the nappy area, is there anything I can use to help this clear up? On examination-red inflamed skin around nappy area with sparing of skin folds. 12. Amy Plaque, 30 year old secretary. My psoriasis has really flared up, I can’t cope with this. On examination- scaley plaques on limbs especially around extensor surfaces. Few plaques at hair line also. 13. Miss Itch, 5years old, scratching skin especially around flexures. Her big brother has hay fever. 14. Mr McFry, 56yr old publican Dakta, I tell you what, I was in with the nurse, she told me I got high blood pressure, and I needed to loose weight, what’s she on about?? BP 166/94 BMI 31 High weekly alcohol intake Smoker 40/day for 40 yrs. 15. Miss P Anic Just as your afternoon clinic is about to start, you get a call from a distressed lady. She is caring for her mother at home, who has terminal cancer. She feels her mother has difficulty going to the toilet and is straining. She also feels those new pain Killers are doing her no good. A Handout with Answers will be given out at the end of this session. 75 Week 5 Monday 3.15pm Dept. of General Practice COMPLAINTS HANDLING IN GENERAL PRACTICE AIM To introduce students to complaints in the General Practice Setting. OUTCOMES To define what is a complaint. To recognise good customer care and why it is important for any organisation. To list the key recommendations of the Wilson Report. To describe the basic complaint procedure in general practice. To recall common reasons for complaint. To list examples of good practice which may prevent complaints. Definition of a complaint Any expression of dissatisfaction which needs a response. Task Force Good Practice Guide 1995 Business takes Customer Service very seriously. Satisfied customers cause less stress and also take up less time. Finding a new customer costs 4-5 times more than keeping the existing one: good customer care keeps contracts and also helps to win new contracts. Only 10% of customers, who have had unsatisfactory service, will complain. Until fairly recently complaints were given little thought in the Health Service. To many health care professionals they were and still are regarded as an nuisance. There were many bureaucratic barriers to making a complaint. Patients had no idea how to go about it and when a complaint got into the system the process was rigid, slow and laborious. This caused much unnecessary stress on both sides. Several years ago a number of GPs who had complaints against them waiting in the system committed suicide and there were calls from all sides for a radical overhaul. The Wilson Report “Being Heard” 1992, recommended changes to handling 76 complaints in the NHS. A key recommendation was that Practices should establish a clear resolution process at local level. This should allow the majority of complaints to be dealt with quickly and to the satisfaction of both parties rather than a long drawn out process. Under their terms of service general practitioners are obliged to establish an inhouse complaints procedure for their practices. A Complaints Officer who may be a doctor or other member of the staff administers it. Details of the practice based procedures should be displayed in the waiting area and the practice leaflet. A complaint should be acknowledged within 2 working days and generally an explanation given within 10 working days. If the complainant is not happy they can ask for an independent review which if considered appropriate is looked at by an independent panel convened by the local Health Board. If still dissatisfied the complainant can appeal to the Ombudsman. The key features are that it should be easy to make a complaint and people should know how to go about it. The process should be responsive, confidential, simple and impartial. It should also be seen as being cost effective and above all, giving the opportunity to improve the quality of care provided by the practice. This certainly gives the patient important rights. However, rights have responsibilities. For example, a patient has the right to make an appointment to see a doctor but they have the responsibility to keep that appointment and see the doctor. An effective complaints system should put things right for individuals who have received a poor service. It allows practices to learn from complaints and also to make people aware that the practice cares how their service is perceived by their patients. Why do people complain? They may simply want to be acknowledged. It can provide an outlet for emotions and feelings. Often an apology or explanation is sufficient. Less commonly redress and or compensation is sought and occasionally punishment is demanded. Common reasons for complaints in General Practice Failure to visit Failure to diagnosis Error in prescription Failure to arrange emergency admission Delay in diagnosis Failure to examine 25% 20% 8% 6% 5% 5% 77 Delay in visiting Unsatisfactory attention Failure to refer Poor administration Other 5% 5% 5% 5% 1% Females are more likely to complain than males and complainants are usually less than 45 years old. 50% of complaints are from individuals complaining on behalf of someone else. Saying sorry can prevent complaints in the first place. Indeed, most instances of patient dissatisfaction never develop into a complaint because the doctor gives an instant explanation and a courteous “I’m sorry”. How to prevent a complaint with an apology Take all grumbles seriously no matter how unimportant or benign they seem. Acknowledge the grumble. For example, if a doctor arriving for the start of a surgery is late he should apologise - if there was good reason he should say so clearly. Own the grumble when it is directed at you; for example, if you, the doctor, have been perceived to be rude you (not the practice manager or the senior partner) should apologise. Learn from the grumble and take action to stop it happening again. Dealing with minor grumbles carefully at the outset will prevent the becoming major complaints. Saying sorry is about grasping nettles - very uncomfortable ones sometimes and swallowing your pride when necessary. Some kind of expression of regret is appropriate after any adverse outcome, and sometimes, an explicit apology as well. For example, if you accidentally give a child a vaccine containing the pertussis component when the parents have specifically forbidden it, apologise immediately, there and then. Patients have a right to know about such “hidden” accidents and letting them know is not covering your back. A full explanation is part of good clinical practice and should not be done just because patients will get the information by looking at the notes. Patients are entitled to a prompt, sympathetic account and an apology when appropriate - this is a recognition of their autonomy, their right to know about themselves. Words such as fault, blame and liability should be avoided. Additional Reading Pages 253 - 254, “Textbook of General Practice”, Stephenson. Pages 233 - 238, “Notes for the MRCGP”, 3rd Edition, Palmer. 78 Weeks 1 & 5 Fri 9.15am Dept. of General Practice EMERGENCIES This session introduces you to dealing with emergency situations away from the relative security of the hospital setting. Common emergencies will be covered 1. Management of the acute myocardial infarction 2. Status Asthmaticus 3. Acute Febrile convulsion 4. The unconscious patient and diabetic coma. 5. Meningococcal meningitis The second part of the session discusses paper work, equipment and drugs which should be included in the Doctor’s Bag. Recommended Reading Handbook of Emergencies in General Practice 2nd Edition 79 ETHICS COURSE There are two core sessions. These introduce and complement ethics teaching timetabled formally in other courses within the Curriculum. Week 5 Mon 9.15am Dept. of General Practice Introduction to Ethical Theories & Principles and Ethical Dilemmas in General Practice. Medical Research, Ethical issues. LEARNING OUTCOMES To: i) ii) iii) iv) v) vi) apply the moral issues arising in clinical practice and health services. analyse clinical situations in terms of ethical principles and recognise the ethical issues. describe the main ethical theories and principles. recognise the conflict between the various ethical principles and moral issues within various clinical situations. describe various moral arguments and understand the views of others. an awareness of one’s own moral values and an understanding of their basis. Ethics is part of every day medical practice. Ethical issues will be discussed by the Tutor as they present themselves in practice. INTRODUCTION Moral dilemmas are created by caring for people. The Medical Ethics course aims to raise your awareness of these problems and try and arrive at working solutions in a wide social context. Moral consciousness is not related to doctor status and cannot be taught or passively acquired by reading alone. Its development requires active participation in the debate. DEFINITIONS Ethics is fundamentally about “how best to conduct one’s life in the presence of other lives”. Medical ethics has been defined as the obligations of a moral nature which govern the practice of medicine. In one sense of medical ethics doctors have been receiving medical ethics education at least since the time of Hippocrates in the 5th Century BC. Thus the profession has accepted and continues to accept a code of ethics – a set of moral principles to govern its practice and it ensures that its members accept and implement this code. 80 From earliest times, various legal systems have incorporated some degree of regulation of doctors. The Hippocratic Oath (4th Century BC) indicated the early concern of the profession to regulate itself by laying down basic standards of conduct, not only between the doctor and patient, but also between teacher ad pupil. In the ensuing centuries the principles of Christian humanism dominated the practice of medicine. Traditions of etiquette in public and private life gradually evolved, coupled with those criteria of professional conduct which established the physician’s position in society. The changing attitudes of society and the major advances in medical science during the 20th century has led to recognition of the need for an updating of these simple ethical guidelines. This need was met initially by the Declaration of Geneva, formulated by the World Medical association in 1947, supplemented by Declarations on particular aspects of medical ethics, such as those concerning therapeutic abortion, research, and torture and other human or degrading treatment. For some ethics means little more then etiquette; the accepted conventions of a social role. Medical ethics in this sense means correct professional behaviour which is passed on from older to younger practitioners by precept and example. Sometimes when people talk about “medical ethics” they are talking about the legal rights and duties of doctors and patients (we might call this “legal medical ethics”). However, morality and the law are separate phenomena: actions which are legally permissible may still be morally wrong and in extreme cases it may be morally right to do something illegal. As stated above, the term ethics is used as an alternative to morals or morality. Thus we speak of an “ethical code” or a “moral code” and of “unethical” or “immoral” behaviour. Medical ethics is not must ethics for doctors – it is ethics for all those involved in giving and receiving health car. Here ethics refers not just to socially acceptable behaviour, but to what is claimed to be morally good or bad, morally right or wrong. This concept of medical ethics has been called “traditional medical ethics” and refers to ordinary professional morality. In this introductory handout, it is this concept of medical or health care ethics that is being considered. As doctors we aim to discover, analyse and relate to each other the fundamental concepts and principles of practical morality with a view to improving our practice of health care. Medical ethics is part of moral philosophy, the academic discipline concerned with the critical study of morality; seeking the fundamental principles, norms or values which lie behind particular moral judgements. SOME ETHICAL CODES (i) Hippocratic Oath The Hippocratic oath was probably written in the 5th Century BC. A doctor who takes the Oath swears above all to try to benefit his patient and not harm him or her. He also swears never to divulge what he sees or hears in the course of his profession. It is a patient-centred ethic hallowed by tradition. 81 (ii) The Declaration of Geneva. This is the modern restatement of the oath drawn up in 1947 by the World Medical Association and amended in 1973 and 1983. In it the doctor swears to maintain the utmost respect of life. Other codes of ethics followed: (iii) (iv) (v) (vi) Sydney in 1968 defined the criteria of brain death Oslo in 1970 discussed criteria for therapeutic abortion Tokyo in1975 adopted guidelines for doctors concerned with torture and punishment Lisbon in 1981 discussed patient rights and confidentiality. All these codes provide guidelines on specific issues, but they do not resolve adequately the conflict between the claims of the individual and the requirements of society. TWO MAJOR TYPES OF ETHICAL THEORY (i) Deontological theories based on “rights and duties” of persons (deon is the Greek word for duty). In this group the consequences of actions are not taken into account. The great religions expect obedience to moral rules that make no reference to consequences (e.g. the Ten Commandments). It is impossible in a few paragraphs to offer any sort of detailed explanation of the philosophical thought behind these theories. Suffice it to say in practice that the orthodox Christian view is that all human beings are morally equivalent and have natural rights, a right to life, a right not to be killed and a moral duty not to kill others. A common element in all deontological theories would seem to be that rightness and wrongness, goodness and badness are treated as intrinsic to actions of a particular kind (lying is bad in itself). Talk of rights, duties and (perhaps) justice is more commonly met in (and perhaps more suitable to) theories of this sort rather than those mentioned in the next section. (ii) Theories of consequentialism Consequentialist theories in contrast to those in the previous section judge rightness and wrongness, goodness and badness by a factor extraneous to the action itself, ie by reference to the consequences of such actions. Actions are not right or wrong in themselves, but only in relation to the consequences which follow from them. Such theories give no weight at all to the motives of intentions of an agent when judging the morality of his action. The best known of these theories is utilitarianism, the theory of utility. This theory is about maximising happiness and minimising misery as a consequence of action taken: that one’s actions are right insofar as 82 they tend to decrease happiness or increase misery ad morally neutral insofar as they tend to do neither. As Raanan Gillon says “this idea, encapsulated in the Benthamite slogan, “the greatest happiness of the greatest number”, is the basis of all utilitarian theories of ethics”. The most telling argument offered against utilitarianism is that sometimes the interests of the individual may be over-ridden by the interests of society as a whole as happens when the interests of the mother and society in therapeutic abortion overwhelm those of the foetus. THE MAJOR ETHICAL PRINCIPLES (i) (ii) (iii) (iv) (v) (vi) (vii) Beneficence – that one should do good to the patient. Primum non nocere – the principle of non-maleficence that one should do no harm. This principle is a cardinal principle already referred to in the Hippocratic Oath. Respecting the autonomy of the patient – this means that a patient should be free to determine his own actions and give consent to the treatment offered. Essentially autonomy is the capacity of the patient to think, decide and act on the basis of such thought and decision, freely and independently and without “let or hindrance”. Truth telling – the principle of being honest is an important moral principle if one is to preserve trust and confidence in the doctor-patient relationship. At times, however, it comes into conflict with the principle of beneficence, e.g deceiving a patient apparently for his own good. Confidentiality - the principle of confidentiality between doctor and patient is venerated in the Hippocratic tradition. It is not an absolute moral virtue, but essential to maintaining rapport, trust and confidence in the consultation and on-going doctor-patient relationship. Preserving Life – Phillips and Dawson argue that maintaining respect for life is not synonymous with preserving life at all costs. The principle of maintaining respect for the sanctity of life at all times gives rise to many modern moral dilemmas, e.g. the difference between killing and allowing a patient to die, the ethics of therapeutic abortion and research on embryos. Roman Catholic theology teaches that the human organism with a spiritual life principle has a right to life. This right to life, while not superior to mother or siblings, takes precedence over pain, distress, embarrassment or economic damage to the life of the family. Such a moral principle opposes the concept “pleasure is good; pain is bad” and conflicts with the principle of utility, of which we shall hear much later. Justice – principle of justice refers to the fair distribution of scarce resources within society and may conflict with one’s duty to individual patients. 83 OTHER MORAL DOCTRINES (i) Acts and omissions This is the difference between acting and refusing to act (e.g. between drowning someone by pushing them into deep water (action) and allowing someone to drown, although one has the power to save him (refusal to act). Some people maintain that the moral value of a piece of behaviour can vary according to whether it is an action or an omission. They might say for example that though it would be wrong to kill a patient by lethal injection (action), it might be morally permissible to withhold food and allow him to die (omission). Either way the consequences are the same; the man drowns, the patient dies. So we should note that for a consequentialist the difference between acts and omissions is morally irrelevant. Some deontologists would claim that it is relevant. (ii) Ordinary and extraordinary means This is a distinction between actions. In contrast to the previous one this doctrine which would normally be accepted by consequentialists and denied by (at least some) deontologists. Suppose for example that you have a patient who is irreversibly comatose though not brain dead. A consequentialist might argue that it was right (or at least permissible) to keep the patient alive by ordinary means (e.g feeding) because such a treatment does not cost very much and no one else is much harmed by it. He might say on the other hand that it would be wrong to sue extraordinary means (e.g a respirator) to keep the patient alive because such means are expensive and if they are used to treat a hopeless patient, other patients or potential patients who could benefit from them will be harmed by being deprived of resources. A deontologist, however, who believes in the sanctity of life might say that the means are irrelevant. We should try to preserve life whatever the means and whatever the costs. (iii) Double Effect “Double effect” refers to the situation where an action has two consequences, one good and one bad, both known to the agent. For example, giving painkillers to a patient will (a) relieve his pain (good), (b) hasten his death (bad). Believers in “double effect” say that whether it is right or wrong to give the painkillers depends on the intention of the doctor. If the drugs are given in order to relieve the pain the action is right (or at least permissible). If they are given with the purpose of hastening death the action is wrong even though the outcome is exactly the same. If you have understood the difference between consequentialist and deontological theories it will be clear that the “double effect” doctrine will be unacceptable to a consequentialist, since for him intentions are morally irreverent. Deontologists, however, who believe that intentions are important, will discern a moral difference. 84 Process Interactive talk based on ethical dilemmas in general practice. Small group work on ethical problems with feedback to plenary session. Assessment Some of the communication stations in the OSCE will address ethical issues. Additional Reading Talking to patients about cancer. BMJ 21st Sept 1996 p. 669-700. Consent BMJ 1985: 291; 1700-1. Good Medical Practice, GMC. Confidentiality: Protecting and Providing Information, GMC. Seeking Patients’ Consent: The Ethical Considerations, GMC. Maintaining Good Medical Practice, GMC. Serious Communicable Diseases, GMC. 85 Weeks 1 Tues, 9.15am, Dept. of General Practice Weeks 5 Tues, 9.15am, Dept. of General Practice EVIDENCE BASED PRACTICE AIMS To enable the student to (1) develop their understanding of scientific method in medical research and (2) evaluate written reports of research evidence relating to the practice of medicine. OUTCOMES The student should be able to: (1) identify the objectives of a reported research activity (2) list different types of study design in medical research (3) identify study designs appropriate for use in studying different clinical problems (4) list factors which may influence the interpretation of research findings (5) apply research evidence to everyday medical practice. CONTENT OF COURSE You will be given a short talk to introduce this part of the curriculum. Critical appraisal is one of the aspects of general competence which it is recommended that the undergraduate medical student should develop. One aim of the new undergraduate curriculum is to create a critical and enquiring doctor, willing and able to continue learning throughout his/her professional career. By appraising their own work and that of others, as reported in medical literature, doctors should seek to continually improve the quality of their medical care. In small groups you will discuss with a tutor the definitions and meanings of words commonly used in medical research. Guidelines will be given for an appropriate method of assessing written information with regard to evaluating its relevance to clinical practice. There will then be an opportunity to put these guidelines into practice by assessing a written report both individually and as a member of your small group. Within the group you should discuss your individual assessments and agree a conclusion about the value of the evidence presented. Tutors will facilitate your discussion and help you to interpret the research findings. There will be one further formal opportunity to practise your skill in critical appraisal later in the course but you should remember also to relate your learning in this part of the course to what is presented to you in the part of your course concerning audit. ASSESSMENT Assessment takes place as part of the Final MB examination. You will be given published research articles and asked to critically appraise them. Scoring of your answers will be based on the objectives of the course. Currently this assessment consists of a two-hour written paper. Additional Reading Pocket Guide to Critical Appraisal, Crombie BMJ Publishing Group. 86 Weeks 5 Tues, 2.00pm Dept. of General Practice HEALTH PROMOTION This session will examine an effective interviewing technique (incorporating a model of behaviour change) on how to facilitate behaviour change and to discuss the possibility of incorporating the technique into daily practice. Effective approaches to helping people change an unhealthy behaviour will be discussed and in particular the technique of Motivational Interviewing used in conjunction with Prochaska and DiClemente’s Model of Behaviour change. There will also be an opportunity for you to practise the technique in small groups using various case scenarios. On completion of the session perhaps your beliefs and attitudes to Health Promotion will have acquired a new perspective. Doctors have an important role in delivering health care. This session may help you become more effective when you take on the role. A resource pack will be given to you at the beginning of the session. AIMS The aim of this session is to enable students to explore and to practise the technique of Motivational Interviewing in conjunction with Prochaska & DiClemente’s Cycle of Change, as a tool to facilitate behaviour change. OUTCOMES At the end of the session students will have 1. to describe Prochaska & DiClemente’s model of behaviour change; 2. memorize the principles and strategies of Motivational Interviewing; 3. demonstrate the technique of Motivational Interviewing to help people change an unhealthy behaviour; 4. judge how this technique of Motivational Interviewing could be integrated into practice. 87 THE WORLD HEALTH ORGANISATION The World Health Organisation (WHO) established in 1948, is a specialist agency of the United Nations with primary responsibility for international health matters and public policy. A total of 165 member states provide a budget for the work of WHO. WHO has no legislative authority but it uses its considerable status to influence health policy worldwide. HEALTH PROMOTION IN CONTEXT Health Promotion first appeared as a term and concept in 1974 when the Canadian Minister of National Health and Welfare, Marc Lalonde, published “A New Perspective on the Health of Canadians” (Lalonde 1974). It introduced into public policy the idea that all causes of death and disease could be attributed to four discrete and distinct elements: inadequacies in current health care provision; lifestyle or behavioural factors; environmental factors; bio-physical characteristics. It was felt that improvements within the environment and in behaviour could lead to a significant reduction in morbidity and premature death. As a result of this report, emphasis in public policy shifted from treatment to the prevention of illness and the promotion of health. The Ottawa Charter (See handout) The first international conference on health promotion was held in Ottawa, Canada, in November 1986. Dialogue between lay people, health and other professional workers, representatives of governments, statutory and non-statutory organisations; politicians and administrators resulted in agreement on the Ottawa Charter for Health Promotion. Five major challenges for health promotion were identified: to build healthy and integrated public policies; to create supportive environments; to strengthen community participation and action; to develop personal skills; to reorient health services. 88 These five action areas provide a framework for the delivery of health promotion programmes. The Ottawa Charter also included three process methodologies through which people could begin to take control over and improve health. These were: advocacy enablement mediation OTTAWA CHARTER 1. Build healthy public policy To make the healthier choice the easier choice for individuals as well as policy makers. 2. Create supportive environments To enable us to take care of each other, our communities and our natural environment. 3. Strengthen community action To enable communities to set priorities and make decisions for better health. 4. Develop personal skills To enable people to exercise more control over their own health and environments and make choices conducive to health. 5. Reorient health services To lead to a change of attitude and organisation of health services in order to respond to the needs of the population. BEHAVIOUR CHANGE THE STAGES OF CHANGE MODEL Prochaska almost 20 years ago began researching how – and why – people change, he was confronted by a bewildering array of therapeutic systems, each claiming to provide answers, but no one significantly more effective than the other. Over the years Prochaska and his team have studied thousands of self-changers and developed the Stage of Change model which has now been accepted as a good model to conceptualise the way that people alter their behaviour. The stage of change model has been used mainly as a basis for primary care training for health education. The model allows for relapsing behaviour and redirection of programmes. It has potential but does require training in assessment 89 of clients’ stage of behaviour change. It is basically a one - one intervention, building on counselling interventions to facilitate individual change. The influences of the wider environment on the individual must be integrated into each stage of the model to ensure that interventions are relevant to the client’s life experience. Stages of Change Prochaska and DiClemente have analysed motivation to change across a wide range of problem areas and have identified five major stages of change. (Prochaska and DiClemente 1984) The system has five stages, each one of which has to be gone through for change to be long lasting. The first is called Precontemplation. In this stage, a person has no real desire to alter their behaviour. In fact, they resist change. They don’t want to think, talk, or read about their problem because they feel the situation is hopeless. Prochaska states that they are often demoralised and in denial. For example, a young drinker may consume five pints every night but does not believe that they have a drink. In the second stage, Contemplation, people acknowledge they have a problem and think about how to solve it. The same drinker might perceive a link between marital problems or other pressures and alcohol consumption. When perception of the costs and benefits of behaviours begins to alter, a person may move into the Preparation stage. This involves setting a definite date for change and planning how to do it. Only then are they ready for the Action stage. Last, but not least, comes Maintenance, when people work at sticking to their goals and attention is turned towards prevention of relapse to less healthy behaviours. The key to the programme is first deciding what stage the person is at, and then using whatever process of change best applies to that stage. The majority of people who are likely to be targets of health promotion initiatives are in either the Precontemplation or the Contemplation stages. Health promotion interventions should be designed to be appropriate to each individual’s stage of change. For example, in Precontemplation, consciousness raising is vital to the person becoming aware that they have a problem. However, in Action, interventions such as developing coping skills, countering techniques – substituting healthy responses for problem behaviours – and rewards that reinforce good behaviour are relevant and useful. Most people intuitively know what works best for them. 90 This model of change has been shown to work. The cycle allows for change to occur but with recognition of the very real possibility of relapse to the former behaviour. For example, most people attempting to stop smoking will relapse. They may become demoralised and may not want to consider a further attempt. Fortunately, the vast majority do eventually progress again to the action stage. ROLE PLAY FOR SMALL GROUP WORK Three persons in a group and swap roles every 8-10 minutes. 1. Patient 2. Doctor 3. Observer 1. Patient Contemplator Smoker / excessive alcohol consumption / weight reduction / Drugs Choose situation that you personally can associate with to make it easier to role play. Suggestions Excessive alcohol: Business person, busy working and social life, Caught speeding, alcohol level just under the limit. Smoker: Attends for inhaler for wheezy chest. Brother's inhaler worked well for him/her. Father died of Lung Cancer 10 years previously. Overweight: BMI >32 Routine BP check, elevated at 175/110. Strong Family History of Ischaemic Heart Disease. 2. Doctor Use yellow sheet as prompt No more than 2 sentences at a time Once you get comfortable with technique, try advice giving 3. Observer Interrupt process each time you feel statements are inappropriate or the doctor is ‘advice giving'. Feedback to doctor/patient as interview proceeds 91 PRACTICAL STRATEGIES IN MOTIVATONAL INTERVIEWING A. The Good Things and The Not-So-Good Things Aim To explore people’s feelings about the behaviour in question, without imposing on them any assumptions about it being ‘a problem’. They, rather than you, identify problem areas or reasons for concern and change. Function Often useful soon after first raising the subject, this strategy can serve the following functions: 1. to explore the behaviour in a non-threatening manner 2. to build rapport, and understand the context of the behaviour 3. to minimise resistance because you talk about the positive thing first, then discuss “less good things” rather than ‘problems’ or ‘concerns’, which allows the person to identify problem areas without feeling labelled How to do it 1. Ask open-ended question about the positives: “What are some of the good things about your use of …….. ?” “What do you like about ……..?” These usually emerge rather quickly. Use reflective listening and summarise as necessary. 2. Ask open-ended question about the negatives: “What are some of the less good things about your use of ……..?” “What about the other side?” “What do you not like about ……..?” Elicit these one by one, finding out why the person thinks these are ‘less good things’. Open-ended follow-up questions are useful here such as: “In what way does this affect you?” “What is it that you don’t like about this?” “Can you give me some examples?” 3. Offer a summary reflection as succinctly as possible, drawing together the good things and the less good things. Use ‘you’ language, and give the person time to respond. For example: “So, using alcohol helps you relax ….. you enjoy drinking with friends, and it seems to help when you’re feeling fed up. On the other hand, you sometimes feel controlled by the stuff, you wonder if you’re harming your health, and on Monday mornings you find it hard to do anything at work.” 92 Reminders Avoid using words like ‘problem’ or ‘concern’ unless the person does. Don’t assume that a ‘less good thing’ is a concern for the person. Keep the task at hand, and avoid raising new topics or ideas of your own. When the person offers concerns, consider using the ‘Exploring Concerns Strategy’. PRACTICAL STRATEGIES IN MOTIVATONAL INTERVIEWING B. A Typical Day Aim A good general strategy to explore the context in which the behaviour occurs, by asking the person to describe a typical day or session in detail. Function This can be useful soon after raising the subject, particularly with people who seem less concerned. The interviewer raises no problems, concerns, or hypotheses. This strategy can build rapport, and aids in assessment including evaluation of readiness to change. How to do it 1. Explain the purpose and define a time-frame “Can we spend the next 10 minutes talking about your …… so that I can understand better how this fits into your everyday life?” 2. Locate the day / session to be described “Think of a fairly typical recent day (time) which would give a good picture of how you use …… Can you think of one?” 3. Ask for a detailed description “I’d like you to take me through this day, a step at a time, and tell me how …… fits into -your day. You woke up at …” 4. Follow the person’s description using reflective listening and simple open questions “What happened then?” “How did that make you feel” 93 Reminders Avoid raising ‘concerns / issues’ of interest to you but not to the person. Watch the pace. Push gently forward if going too slow, but don’t rush, and slow the person down if going too fast. If the person raises a problem, acknowledge it but continue on if reasonable, agreeing to come back to it later. PRACTICAL STRATEGIES IN MOTIVATONAL INTERVIEWING C. Exploring Concerns Aim To help people express for themselves what concerns they have. Function This is an important strategy, often the foundation for building motivation for change. It highlights elements of ambivalence, and can lead to the generation of discrepancy… a sense of discomfort … which can often precede a decision to make change. This strategy can only be used with people already expressing some concern, or who have opened up an area of concern (for example, in response to the “Good things and Not-so-Good things”) How to do it 1. Explore concerns on at a time. To open up discussion, ask an open question like: “What concerns do you have about ……..? “In what ways has …….. been a problem for you?” It can also be useful to ask about how / why others have been concerned. Explore the concern in detail. Use follow-up questions, ask for examples, and use reflective listening. Summarise the concern in ‘you’ language. 2. Move on to the next concern with an open question: “What other concerns do you have about ……..?” “How else has …….. worried you?” “In what other ways has …….. been a problem for you?” “What concerns you most about this?” Again, explore in detail and summarise, as above. It can be useful in such summaries to incorporate ‘the good things’ as well, particularly if resistance is encountered. “So on the one hand you like …….. because …….., and you also are concerned that ….. 94 3. When all concerns seem to have been elicited, summarise them in ‘you’ language that captures both sides – the good things and the concerns. Reminders Don’t rush. Use simple open questions and reflective listening. The person may feel ‘inefficient’, but in fact it is the best way to make rapid headway. Don’t wander too far from exploring concerns. The discrepancy that is often highlighted is this strategy can lead to discomfort. Tears are not uncommon. Be supportive, and don’t rush the person into a decision. Let the person raise the topic of change. 95 Weeks 1 & 5 Thurs, 9.15am – 10.45am. Dept of General Practice CHILD HEALTH IN GENERAL PRACTICE AIM (a) To provide students with background into the scope of child health care provision in family practice before taking part in the attachment. (b) To compare and contrast the roles of the general practitioner and the paediatrician in the provision of child health care. OUTCOMES 1. To describe in what way preventative medicine can be applied to child care. 2. List the primary vaccination schedule. 3. Describe the components of a comprehensive developmental surveillance programme for the under 5s. 4. List the common diseases of childhood. 5. To show the ways childhood diseases present in general practice. 6. Compare how the approach to paediatric history taking and examination differs from adult practice. PROCESS Presentations Small group work 96 Child Health Issues Child Health in General Practice Preventative Medicine Surveillance Family Health Common diseases of Childhood Common problems in children Developmental Dr. Kieran McGlade Department of General Practice Queen’s University, Belfast Department of General Practice Preventative Medicine in Child Care Ante-natal care Childhood Immunisations Primary ante-natal screening folate supplements and nutrition Neonatal immunisations given at 2, 3 and 4 months Primary immunisations care environment feeding Mumps and Rubella vaccine in second year of life Department of General Practice Queen’s University, Belfast Department of General Practice Things not to miss Hypothyroidism dislocation of the hip Retinoblastoma Syndrome Department of General Practice Developmental Surveillance Queen’s University, Belfast assessment of a child’s developmental progress with the aim of detecting pre-symptomatic disability Screening procedures should be brief, simple, cheap and reliable May be combined with immunisation visits - if so, screening should be done first Department of General Practice What do we look for in developmental screening? Normal growth pattern Height, weight, head circumference Achievement of developmental milestones (indicating neurological development) Gross motor function Fine motor function and vision Hearing and speech Social behaviour and play Department of General Practice Queen’s University, Belfast Periodic Phenylketonuria Down’s Diphtheria, Tetanus, Pertussis and HIB Polio drops Measles Immunisations Congenital Queen’s University, Belfast Queen’s University, Belfast Queen’s University, Belfast How do we carry out developmental screening Often in a clinic and Health visitor Direct observation Listening to parents / carers GP History is important - we want to find out what the child can and cannot do Specific tests Department of General Practice Queen’s University, Belfast 97 Developmental Screening Tests 6 weeks Head Control usually achieved by 6 weeks Moro response present at 6 weeks, gone by 6 months Gaze fixes in mother’s face, follows a brightly coloured object past the midline Rattle or bell, 15cm at ear level - quietens or turns to sound. Department of General Practice Queen’s University, Belfast Family Health Family Life Cycle Stages The new couple of first child School age family Adolescent family Launching family Empty nest Ageing family Birth Department of General Practice Queen’s University, Belfast Common diseases in Childhood Group Tasks Nappy List the commonest diseases in childhood. List the commonest presenting symptoms in childhood. Department of General Practice Queen’s University, Belfast rash Respiratory Tract Infection Infectious Diseases Urinary tract infection Asthma Eczema and other rashes Trauma Upper Department of General Practice Infectious diseases and common infections Common Problems Measles URTI Sore Mumps Otitis Headaches Rubella Pertussis Chickenpox Department of General Practice media Tonsillitis UTI Gastro-enteritis Herpes stomatitis Meningitis Queen’s University, Belfast Queen’s University, Belfast tummy Rashes and fevers wetting - enuresis Behavioural problems / school refusal Cough Diarrhoea and vomiting Bed Department of General Practice Queen’s University, Belfast 98 Group tasks (2) how you might manage the following scenarios: On observing a consultation with a child - questions to ask yourself Discuss A six month old baby presenting with a fever A five year old presenting with a cough A nine year old with an itchy rash on her trunk. A ten year old child with recurrent headaches Department of General Practice Queen’s University, Belfast Summary Child health is an integral part of GP. embraces prevention, diagnosis and treatment. A knowledge of the family is an important key to the understanding of child health problems. Flexibility of approach, attention to detail, observation and listening to children and parents are of crucial importance. It Department of General Practice Queen’s University, Belfast Reference: A Textbook of General Practice, 2nd Edition. Pages: 80 – 81 108 – 109 146 – 148 286 Who is the patient? is the reason for the consultation? What opportunities does this consultation present? Is the consultation structured any differently from an adult consultation? What Department of General Practice Queen’s University, Belfast 99 EASTERN HEALTH AND SOCIAL SERVICES BOARD CHILD HEALTH SYSTEM SURVEILLANCE PROGRAMME 6-week Developmental Surveillance Doctor/GP/CMO - Cephalo-caudal examination: Weight - Length - Head Circumference Fontanelle: anterior posterior Eyes: appearance red reflex fixing following smiling Ears: hints for parents startle pinnae screening for children with “at risk” factors Palate CVS: auscultation femorals Respiratory System Abdomen: liver, spleen Hernia Labia/testes Hips: (?) CDH Hands Feet Spine Skin Developments: tone posture head control graso moro behaviour 100 EASTERN HEALTH AND SOCIAL SERVICES BOARD CHILD HEALTH SYSTEM SURVEILLANCE PROGRAMME 7-month Developmental Surveillance HEALTH VISITOR: Height Weight Physical: general observation Hips: (?) CDH Testes Hearing: distraction test Vision: observation and enquiry (?) strabismus Locomotor: sits with support rolls prone to supine weight bearing Manipulation: reaches out for objects transfers cube from one hand to another Speech/Language: babbling Social behaviour: smiles and laughs Health promotion: nutrition and weaning dental play and social stimulation safety etc. 101 EASTERN HEALTH AND SOCIAL SERVICES BOARD CHILD HEALTH SYSTEM SURVEILLANCE PROGRAMME 18-month Developmental Surveillance HEALTH VISITOR: Vision } observation and parental enquiry Hearing } Physical examination: general observation Developmental screening undertaken by parental enquiry and observation and not by formal testing. Locomotor: gait walking unaided Manipulation: pincer grasp Speech/Language: understands simple commands Social Behaviour Health promotion: N.B. discipline safety social stimulation and play dental etc. Height and weight only if indicated 102 EASTERN HEALTH AND SOCIAL SERVICES BOARD CHILD HEALTH SYSTEM SURVEILLANCE PROGRAMME 27-month Developmental Surveillance HEALTH VISITOR Speech and language screening using proposed amended Cherryville test. Health promotion. Hearing screening of children “at risk”. 4-year Pre-School Developmental Surveillance GP AND HEALTH VISITOR Height Weight General physical development Testes Hips Co-ordination Gross motor and Fine Motor: observation Language: observation Social: toilet training Screening for vision and hearing if parental/professional concern. Health promotion: Preparation for School Health 103 MULTICULTURAL ISSUES IN PRIMARY CARE Week 5 Mon 4.00pm Dept. of General Practice INTRODUCTION Northern Ireland is becoming increasingly multicultural with the arrival of migrant workers, asylum seekers and refugees. General practitioners are facing the challenge of developing new ways of providing care to communities with different health needs and different understandings of health. While asylum seekers and refugees face some health problems that are specific to them, they are often similar to other deprived or excluded groups. The challenges of providing healthcare to a culturally diverse patient population include having sufficient knowledge about Northern Ireland’s main cultural groups while avoiding stereotypes as lack of such knowledge can lead not only to personal distress and offence but may have serious consequences for treatment. Good communication is also essential for an effective consultation. The use of interpreters in General Practice in Northern Ireland varies. This may reflect a lack of experience of use, an under-estimation of the need for interpreters, concerns over the cost or about the extra time needed when using an interpreter (ICGP 2005). Providing cultural competent health and social care is an imperative as patients expect practitioners to provide care that is sensitive to their cultural beliefs and values, appropriate to their needs and free from discrimination. AIMS This session aims to increase students’ sensitivity to the health and social needs of patients from different cultures. LEARNING OUTCOMES At the end of this session students should be able to….. Describe the effects of different cultural and social practices for doctor-patient interactions with particular reference to different naming systems, health beliefs, religious beliefs and collectivist societies. Discuss barriers to communicating with patients from different cultures and the role of the interpreter. Describe the health needs of asylum seekers and refugees. Handouts will be given out in class during this session. Reading Crowley P. (2003) General Practice Care in a Multicultural Society. www.icgp.ie Cheal AC and Fine BP. (2005) Resource Pack to help General Practitioners and other Primary Health Care Professionals in their work with Refugees and Asylum Seekers. Lambeth Primary Care Trust website. Irish College of General Practitioners. (2005) A Guide to Interpretation Services and Cultural Competency. www.icgp.ie Lloyd M and Bor R. (1996) Ch: 7 ‘Communicating with patients from different cultural backgrounds’ in Lloyd M. and Bor R. Communication Skills for Medicine. London: Churchill Livingstone. 104 Some Modified Essay Questions are listed. We suggest you do the questions just in the time scale indicated and then check your answers with the Marking Schedule listed. 105 You are a GP in an urban health centre with access to laboratory and Xray facilities at the district general hospital one mile away. You have an active primary care team working with you. 30 mins PART 1 120 Mr Albert Torrens is a 45 year old man whose wife telephones you, his general practitioner, one morning at 2.00 am. She tells you that he has severe pain in his stomach and is vomiting. Q.1 How do you respond? You arrive at the home and find Mr Torrens looking shocked, pale and sweating. He is sitting upright, leaning forwards. Q.2 What further questions would you ask? Q.3 What are your initial major differential diagnoses for a patient with severe non-colicky epigastric pain? List 3. 106 Q.4 Describe your examination of Mr Torrens. You admit Mr Torrens to the local hospital as a surgical emergency. Q.5 What investigations do you think should be done when he arrives there? After investigations Mr Torrens is diagnosed as having acute pancreatitis. Q.6 What are the common causes for this condition? List 4. Mr Torrens settles with conservative management and is discharged home a week later. His wife and 15 year old daughter, Alison, bring his discharge note to the surgery. Mrs Torrens mentions that Alison has developed a cough and seems to be short of breath with exertion. Q.7 What salient features would you wish to consider in taking a history and examining Alison? 107 You diagnose that she has a chest infection and decide to give her an antibiotic. Q.8 What specific question will you ask before writing the prescription? Q.9 Write a prescription for an antibiotic for Alison. Mr Torrens brings Alison back for review two weeks later. She is well again but he complains of vague right sided pain and tells you that his urine has become very dark. Q.10 What do you specifically look for on clinical examination? You check his liver function tests which confirm that he has acute hepatitis. He admits to a recent heavy consumption of alcohol. Q.11 What further questions would you ask him? 108 He returns to see you 4 weeks later with obvious weight loss and deep jaundice. You arrange his admission to the local hospital's medical ward. Q.12 What investigations would you expect to be done and what abnormalities would support the diagnosis of alcoholic hepatitis? Q.13 How would you expect him to be treated? A week later he is discharged and you visit him at home. Q.14 What topics would you cover during the consultation? Over the next 6 months you see Mr Torrens several times, he claims to feel well and to continue to abstain from alcohol. Then, during morning surgery, you receive a phone call from Mrs Torrens. She has found her husband lying on the floor and cannot rouse him. Q.15 What questions do you ask her on the phone? 109 You go and see him. He is obviously jaundiced and smells of alcohol. He is responsive to painful stimuli. Q.16 How do you manage the situation? In hospital his level of consciousness rises but despite treatment he develops fulminant liver failure. Q.17 What complications do you expect to develop? Ten days later Mr Torrens dies. You are informed of his death by hospital staff who tell you Mrs Torrens is very distressed. You go and visit her in her home. Q.18 How would you plan to manage the consultation? 110 PART 2 68 Mr Brown (aged 35) and his son, John (aged 4/12) arrive for their appointment. The health visitor has diagnosed that John has atopic eczema affecting mostly his face and flexors. 30 mins Q.1 What advice would you give Mr Brown on (a) Prognosis (b) Non pharmacological advice. List 6 areas. (c) Steroids. List 6 areas. 111 Mr Brown asks for his blood pressure to be taken. Your nurse had taken it that morning obtaining a reading of 180/100. You obtain a pressure of 150/95. Q.2 Give reasons as to why the two readings differ. List 5. Q.3 Describe specifically your examination of Mr Brown. Q.4 What simple tests would you carry out? Q.5 Discuss non-pharmacological management and advice with Mr Brown. 112 Q.6 If Mr Brown's pressure did not settle suggest a pharmacological plan of therapy. Your nurse says that she would like an HIV test. Q.7 What areas would you cover in your pre-test counselling. List 10. 113 PART 3 80 Marion Green, who is twenty, comes to see you almost in tears as she has frequency and dysuria yet again. Since she became sexually active 18 months previously the problem has become worse. She has had about eight episodes in the last year. When the problem started MSU's were regularly done and coliform infections identified on nearly all occasions. The symptoms do respond to antibiotics but have recurred so frequently she now dreads intercourse and this is producing difficulties with her present boy-friend. Q.1 What areas would you wish to discuss with your patient? Q.2 Apart from E.coli what other organisms are implicated in Urinary Tract Infection? List 4. Q.3 Which findings on dipstick analysis are a good indicator of Urinary Tract Infection. Q.4 How would you propose to manage the condition on this occasion? Give the dosage of drugs you might use. 114 Q.5 What other prophylactic medicine might you also prescribe at this time? Marion returns in 10 days and tells you her symptoms have cleared up as is usual, however, she is worried about recurrence. Q.6 How would you plan to manage the patient at this stage? Several years pass before you see your patient again. She had left your practice but has now returned as a young wife and mother. Her husband is a local business man who travels on business a lot. She asks you for a prescription for "thrush" and tells you she has had several episodes in the last year and it usually responds to Canesten. Q.7 Is investigation essential at this stage? Give your reasons for investigating or not investigating. If you do decide to investigate what would you do? Q.8 What organisms infecting the female genital tract can and cannot be isolated with certainty in the setting of General Practice? 115 As expected Candida is found in this case. Q.9 What treatment would you prescribe for this episode and what strategies might be adopted to ease her recurrent attacks? 116 PART 4 66 Mrs Bailey, a 45 year old school teacher brings her son John to see you. He is eight years old. The presenting complaint is one of a persistent dry cough which is annoying the whole family. 30 mins Q.1 What areas would you wish to cover in the preliminary history? Q.2 What examination would you carry out? You decide that John probably has asthma and give him a salbutamol inhaler to try. Q.3 What advice do you give to John and Mrs Bailey and what general aims should you have in mind when treating children with asthma? 117 You ask John to come back for a review in one week's time, however, he does not attend for another month or so. The salbutamol inhaler worked very well initially, however, over the past week he has been getting more and more wheezy and out of breath. Two days ago it was so bad he ended up in the A&E department of the local hospital and was given nebulised salbutamol which rapidly alleviated his symptoms. Q.4 What might you include in your management now? John does well on his regular inhaled steroid. However, several months later you are called out in the middle of the night to his house. He had just returned from a school camping trip that evening when his asthma became much worse. Mrs Bailey is very anxious and says he is having his worst ever attack. You decide to call round immediately. Q.5 What are the features of a severe asthmatic attack in a child? Q.6 What treatment would you consider for a severe asthmatic episode? 118 ANSWER & MARKING SCHEDULE You are a GP in an urban health centre with access to laboratory and Xray facilities at the district general hospital one mile away. You have an active primary care team working with you. 30 mins PART 1 120 Mr Albert Torrens is a 45 year old man whose wife telephones you, his general practitioner, one morning at 2.00 am. She tells you that he has severe pain in his stomach and is vomiting. Q.1 How do you respond? Ask details of pain - how long, character. ? known precipitating factor eg food, alcohol ? content of vomitus - eg blood ? similar past medical history ? current status re severity of pain Agree to visit. 6 You arrive at the home and find Mr Torrens looking shocked, pale and sweating. He is sitting upright, leaning forwards. Q.2 What further questions would you ask? Further details of pain - exact site, radiation, character, duration, precipitating and relieving factors Vomitus - content, volume Earlier food & drink consumption Any relevant contact Similar episode in past Recent bowel movement 6 Q.3 What are your initial major differential diagnoses for a patient with severe non-colicky epigastric pain? List 3. Acute duodenal ulcer - perforation Myocardial infarction Acute pancreatitis 3 119 Q.4 Describe your examination of Mr Torrens. Observe - colour, respiration, general condition CVS - BP: Pulse: HS RS - auscultate lung fields Abs - observe: palpate: percuss: auscultate - consider PR max 10 You admit Mr Torrens to the local hospital as a surgical emergency. Q.5 What investigations do you think should be done when he arrives there? A. Bloods - (i) (ii) (iii) (iv) (v) FBP, including WCC PCV U&E LFT, including calcium, glucose Serum amylase If shocked - blood gases B. C. D. Urinalysis ECG XR - Straight XR Abd; ?CXR max 8 After investigations Mr Torrens is diagnosed as having acute pancreatitis. Q.6 What are the common causes for this condition? List 4. 1. 2. 3. 4. Gallstones/biliary tract disease Alcohol Post trauma esp. abdominal surgery Viral 4 Mr Torrens settles with conservative management and is discharged home a week later. His wife and 15 year old daughter, Alison, bring his discharge note to the surgery. Mrs Torrens mentions that Alison, who has Down's Syndrome, has developed a cough and seems to be short of breath with exertion. Q.7 What salient features would you wish to consider in taking a history and examining Alison? Physical - details of general health, other symptoms, Cough ?productive duration relation to exercise ?wheeze associated Psychological - effect of father's illness possible adolescent problems 120 Social - ?schooling/prospect of changing to work situation 10 You diagnose that she has a chest infection and decide to give her an antibiotic. Q.8 What specific question will you ask before writing the prescription? Has she any allergies? Q.9 1 Write a prescription for an antibiotic for Alison. eg Amoxycillin specify caps / tabs / syrup Correct name Specific direction to take Quantity specified. 8 Mr Torrens brings Alison back for review two weeks later. She is well again but he complains of vague right sided pain and tells you that his urine has become very dark. Q.10 What do you specifically look for on clinical examination? Icterus Hepar - tender +/- splenomegaly (possible sign of chronic liver disease eg spider naevi, etc) 4 You check his liver function tests which confirm that he has acute hepatitis. He admits to a recent heavy consumption of alcohol. Q.11 What further questions would you ask him? Amount how much, how often When, where, why - circumstances of drinking Ever felt he should cut down? Ever been annoyed by people criticising his drinking? Ever felt guilty? Ever had to drink first thing in morning Memory blanks Physical effects, including trauma 121 Legal offences Problems at work Problems with finances Problems with family Ever secret drinking? 10 He returns to see you 4 weeks later with obvious weight loss and deep jaundice. You arrange his admission to the local hospital's medical ward. Q.12 What investigations would you expect to be done and what abnormalities would support the diagnosis of alcoholic hepatitis? FBP increased MCU LFT increased GT, AST, ALT Ultrasound abdomen other diagnosis indicated Coagulation screen, including PTI : hope to find named? Liver biopsy, fatty necrosis 10 Q.13 How would you expect him to be treated? Alcohol withdrawn Vitamin supplements Sedation eg chlordiazepoxide if develop DT's After support/referred for alcohol addiction 4 A week later he is discharged and you visit him at home. Q.14 What topics would you cover during the consultation? His awareness of problem Motivation - attitude to problem, to alcohol, to prospect of change General health - appetite, weight Attitude to and of family Financial and work situation Goals - plans for future - involvement of help eg AA, alcohol addiction teams, etc. 6 122 Over the next 6 months you see Mr Torrens several times, he claims to feel well and to continue to abstain from alcohol. Then, during morning surgery, you receive a phone call from Mrs Torrens. She has found her husband lying on the floor and cannot rouse him. Q.15 What questions do you ask her on the phone? Any response from him at all? Is he breathing OK? Evidence of injury? What does she think has happened? 4 You go and see him. He is obviously jaundiced and smells of alcohol. He is responsive to painful stimuli. Q.16 How do you manage the situation? Ask Mrs Torrens about his recent health & behaviour Examine him physically Arrange hospital admission Suggest Mrs Torrens should accompany him Enquire about Alison's care if she does go to the hospital Allow Mrs Torrens to express her fears, questions, feelings Explain possible causes eg fall, introxication, other reasons need to be excluded ?head injury. 6 In hospital his level of consciousness rises but despite treatment he develops fulminant liver failure. Q.17 What complications do you expect to develop? Mental confusion - deepening coma Increasing jaundice Flapping tremor Bleeding - purpura, haematemesis 4 Ten days later Mr Torrens dies. You are informed of his death by hospital staff who tell you Mrs Torrens is very distressed. You go and visit her in her home. Q.18 How would you plan to manage the consultation? Allow her to ventilate Be aware of bereavement reaction, especially discuss possible feelings of guilt, blame, anger and resentment Fears for future - especially with regard to Alison Discuss how to tell Alison about father's death Ensure available practical help for present Assure of continued support and availability 12 123 PART 2 68 Mr Brown (aged 35) and his son, John (aged 4/12) arrive for their appointment. The health visitor has diagnosed that John has atopic eczema affecting mostly his face and flexors. 30 mins Q.1 What advice would you give Mr Brown on (a) Prognosis No cure. 90% grow out of it. (b) 2) ) ) Non pharmacological advice. List 6 areas. ) ) ) ) Avoid soap/perfumed products Don't overheat Synthetic material filled pillows/duvets Cotton clothing Pre/post swimming with vaseline Avoid biological washing powders Avoid pets ) ) ) ) ) max 14 Minimise house dust National Eczema Society (c) ) 6 ) ) Steroids. List 6 areas. ) ) Only when necessary Use sparingly Only on eczematous skin Not on face (other than 1% HC) Follow doctor's instructions Report back for regular review How much to apply What to do if condition worsens ) ) ) ) ) ) 6 ) ) 124 Mr Brown asks for his blood pressure to be taken. Your nurse had taken it that morning obtaining a reading of 180/100. You obtain a pressure of 150/95. Q.2 Give reasons as to why the two readings differ. List 5. - Patient more relaxed Size of cuff Different syphgmomanometer Position of arm Patient lying / standing Kortacoffs sounds 4th / 5th 5 Q.3 Describe specifically your examination of Mr Brown. Heart size HT Lungs for creps Heart for murmurs, eg coarctation Abdomen for kidneys Fundi to grade degree of Femorals 6 Q.4 What simple tests would you carry out? - Q.5 3 Discuss non-pharmacological management and advice with Mr Brown. - Q.6 Urine for protein and sugar U & E for renal function ECG to determine if LVH Non smoking Minimise alcohol consumption Regular exercise No salt to diet Diet to achieve optimal BMI 10 If Mr Brown's pressure did not settle suggest a pharmacological plan of therapy. - Diuretic therapy eg Bendrofluo\ide 2.5mg daily Beta-blocking drugs eg Atenolol 50mg daily Calcium-channel blockers eg Nifedipine 30mg daily Ace inhibitors eg Captopril 12.5mg bd 16 125 Your nurse says that she would like an HIV test. Q.7 What areas would you cover in your pre-test counselling. List 10. What exactly the test is including seroconversion? The difference between HIV and AIDS Medical benefit of knowing HIV status How HIV infection is transmitted Support servides in event of a possible infection Medical confidentiality Is more time needed to think it over? Does the patient need to see a counsellor? How she will get the result Employment issues PART 3 10 80 Marion Green, who is twenty, comes to see you almost in tears as she has frequency and dysuria yet again. Since she became sexually active 18 months previously the problem has become worse. She has had about eight episodes in the last year. When the problem started MSU's were regularly done and coliform infections identified on nearly all occasions. The symptoms do respond to antibiotics but have recurred so frequently she now dreads intercourse and this is producing difficulties with her present boy-friend. Q.1 What areas would you wish to discuss with your patient? 1. 2. 3. 4. 5. 6. Q.2 Highly unlikely to be serious condition. Reassurance. Need for laboratory test - MSU Sexual history - difficulties. Explanation of how sexual activity increases the risk of UTI occurrence and simple advice to counteract this. Contraception Treatment Referral for investigation 6 Apart from E.coli what other organisms are implicated in Urinary Tract Infection? List 4. Staphylococcus Klebsiella Proteus Pseudomonas 4 126 Q.3 Q.4 Q.5 Which findings on dipstick analysis are a good indicator of Urinary Tract Infection. Protein Blood Nitrite Leucocyte esterase 4 How would you propose to manage the condition on this occasion? Give the dosage of drugs you might use. Increased fluid intake Alkalinizing agent (pot cit / sod bic) Single dose antibiotic 3 day course Trimethoprim 200 mg bd x 3 days Amoxicillin 250 mg tid x 3 days Cephaloxin 250 mg 8 What other prophylactic medicine might you also prescribe at this time? Canesten pessary to prevent vaginal thrush. 2 Marion returns in 10 days and tells you her symptoms have cleared up as is usual, however, she is worried about recurrence. Q.6 How would you plan to manage the patient at this stage? Repeat advice on prevention Prophylactic antibiotic treatment using either Trimethoprim or nitrofurantoin Referral for investigation in case she has a congenital abnormality or a simple correctable condition eg urethral stricture 6 Several years pass before you see your patient again. She had left your practice but has now returned as a young wife and mother. Her husband is a local business man who travels on business a lot. She asks you for a prescription for "thrush" and tells you she has had several episodes in the last year and it usually responds to Canesten. 127 Q.7 Is investigation essential at this stage? Give your reasons for investigating or not investigating. If you do decide to investigate what would you do? Not really necessary. Classical symptoms. No possibility of STDs. Should test urine for sugar As she is "new" patient might carry out speculum examination and take a swab. Also because it would provide opportunity to ensure cervical smear status up to date. Q.8 12 What organisms infecting the female genital tract can and cannot be isolated with certainty in the setting of General Practice? High vaginal swab will pick up Trichomonas, Candida and Gardnerella and Group B Streptococci. 1 each = 4 Chlamydia and neisseria gonorrhoea difficult to culture in GP. 1 each = 2 An endocervical swab and urethral swab in special transport medium with good access to a local laboratory are essential. 1 each = 4 ) ) ) ) ) 10 ) ) ) ) As expected Candida is found in this case. Q.9 What treatment would you prescribe for this episode and what strategies might be adopted to ease her recurrent attacks? Clotrimazole either as single dose vaginal tablet or a 3 night course of 200 mg. Cream may also be used. 4 Oral antifungals eg fluconazole 150 mg may be used as an alternative. 2 12 - Ensure diagnosis is correct - HVS Ensure compliance with treatment Check for predisposing factors - diabetes, Fe anaemia, pregnancy, antibiotics, steroid therapy, thyroid disorders Investigate partner Prophylactic treatment 6 128 PART 4 66 Mrs Bailey, a 45 year old school teacher brings her son John to see you. He is eight years old. The presenting complaint is one of a persistent dry cough which is annoying the whole family. 30 mins Q.1 What areas would you wish to cover in the preliminary history? More about the cough: how long, character, any partic. time of day 4 How is he otherwise - any fever or constitutional upset 2 10 2 Any restriction in activities eg sports Any family history of asthma Q.2 2 What examination would you carry out? General appearance eg pallor, obesity, chest shape, fever, cyanosis, any obvious breathing difficulties at rest Ausculate chest looking for equal air entry and any evidence of expiratory wheeze Take a peak flow reading in the surgery Give child peak flow meter home to do daily peak flows and review after a week 4 2 2 10 2 You decide that John probably has asthma and give him a salbutamol inhaler to try. Q.3 What advice do you give to John and Mrs Bailey and what general aims should you have in mind when treating children with asthma? Explanation of the diagnosis and how treatment will help Need for a regular review particularly in the early stages to guage appropriate level of therapy Involve the child (and the family) in the management Emphasise the importance of adequate treatment (partic. parents should not be afraid of medications) Aim to abolish symptoms Importance of allowing normal growth in children Aim for child to be able to participate in normal activities (eg sport, PE) and to minimise absence from school Avoidance of identified causes where possible 2 2 2 2 2 1 1 1 14 129 Aim to use the lowest effective doses of convenient medications minimising short and long term side effects 1 You ask John to come back for a review in one week's time, however, he does not attend for another month or so. The salbutamol inhaler worked very well initially, however, over the past week he has been getting more and more wheezy and out of breath. Two days ago it was so bad he ended up in the A&E department of the local hospital and was given nebulised salbutamol which rapidly alleviated his symptoms. Q.4 What might you include in your management now? Reiterate importance of regular review Prescribe regular inhaled anti-inflammatory agents such as cromoglycate and be prepared to step up to inhaled steroids (beclomethasone or budesonide) sooner rather than later. Short acting beta-antagonists should ony be used as required for symptom relief. Address any concerns or fears in John or his parents Arrange review 2 12 4 2 2 2 John does well on his regular inhaled steroid. However, several months later you are called out in the middle of the night to his house. He had just returned from a school camping trip that evening when his asthma became much worse. Mrs Bailey is very anxious and says he is having his worst ever attack. You decide to call round immediately. Q.5 Q.6 What are the features of a severe asthmatic attack in a child? Too breathless to talk Too breathless to feed Respiratory rate > 50 per min Heart rate > 140 per min PEF < 50% of best previous result Cyanosis Silent chest or feeble respiratory effort Fatigue or exhaustion Agitation or reduced level of consciousness 1 1 2 2 2 16 2 2 2 2 What treatment would you consider for a severe asthmatic episode? Oxygen via face mask Salbutamol or terbutaline via a nebuliser Prednisolone tabs 1 - 2 mg/kg body weight up to 40 mg IV hydrocortisone IV aminophylline 4