a textbook of GENERAL PRACTICE This page intentionally left blank a textbook of GENERAL PRACTICE 2nd edition Edited by Anne Stephenson MB ChB, PhD (Medicine), ILTM Senior Lecturer and Head of Undergraduate Teaching, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College, London, UK First published in Great Britain in 1998 Second edition published in 2004 by Hodder Arnold, an imprint of Hodder Education a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.hoddereducation.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2004 Edward Arnold All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1T 4LP Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however, it is still possible that errors have been missed Furthermore, dosage schedules are constantly being revised and new side-effects recognized For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-10: 340 810521 ISBN-13: 978 340 81052 10 Commissioning Editor: Georgina Bentliff Development Editor: Heather Smith Project Editor: Wendy Rooke Production Controller: Lindsay Smith Cover Design: Amina Dudhia Typeset in 9.5/12 RotisSerif by Charon Tec Pvt Ltd, India Printed and bound in Spain Hodder Headline’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin What you think about this book? Or any other Hodder Arnold title? Please send your comments to www.hoddereducation.com THE GENERAL PRACTITIONER contents CONSULTATION Contributors vii Preface ix Acknowledgements x Introduction xi Chapter Learning in general practice: why and how? Mary Seabrook and Mary Lawson Chapter General practice and its place in primary care Anne Stephenson Chapter The general practice consultation Anne Stephenson 17 Chapter Common illnesses in general practice Joanna Collerton 31 Chapter Psychological issues in general practice Roger Higgs 41 Chapter General practice skills Helen Graham 59 Chapter Diagnosis and acute management in general practice Paul Booton and Joanna Collerton 118 Chapter Prescribing in general practice Paul Booton and Joanna Collerton 137 Chapter Chronic illness and its management in general practice Patrick White 161 Chapter 10 Treating people at home Patrick White 177 Chapter 11 Health promotion in general practice Ann Wylie 187 Chapter 12 Healthcare ethics and law Roger Higgs 211 Chapter 13 Clinical audit in general practice Steve Smith and Graham Hewett 226 v ❚ contents vi Chapter 14 The management of general practice Sue Fish 249 Chapter 15 Preparing to practise Richard Phillips and Cath Miskin 262 Chapter 16 Being a general practitioner Brian Fine 280 Glossary 303 Index 311 contributors Paul Booton BSc (Hons) MB BS MRCP MRCGP Senior Lecturer, Head of Final Year, General Practitioner, Guy’s, King’s and St Thomas’ School of Medicine, Clinical Skills Laboratory, London, UK Joanna Collerton BM BCh MRCP MRCGP Senior Research Fellow, The Institute for Ageing and Health, University of Newcastle, Newcastle upon Tyne, UK Brian Fine MA MB BChir DRCOG General Practitioner and Honorary Senior Lecturer, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK Sue Fish BA (Hons) Cantab Primary Care Service Manager, Primary Care Trust, London, UK Lambeth Helen J Graham DCH FRCGP ILTM Senior Lecturer, General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK Graham Hewett MSc BA (Hons) Clinical Governance Development Manager, South East London Shared Services Partnership, London, UK Roger Higgs MBE MA FRCP FRCGP General Practitioner and Professor of General Practice and Primary Care, Department of General Practice and Primary Care, King’s College London, London, UK Mary Lawson BSc (Hons) Senior Lecturer in Medical Education, Centre for Medical and Health Sciences Education, Monash University, Melbourne, Victoria 3800, Australia Cath Miskin MB BS MRCGP DRCOG DipMedEd Clinical Lecturer, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK; GP Principal, South London, UK Richard Phillips MA MRCP ILTM Senior Lecturer, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK Mary Seabrook BEd DMS PhD (Education) Freelance Education and Training Consultant, and Professional Life Coach, London, UK Steven Smith MB BS MRCGP DRCOG BSc (Hons) Clinical Adviser, South East London Shared Services Partnership, London, UK Anne Stephenson MB ChB, PhD (Medicine) ILTM Senior Lecturer and Head of Undergraduate Teaching, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK Patrick White MB ChB BAO MRCP FRCGP Senior Lecturer, Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK Ann Wylie MA (Health Education) ILTM Senior Tutor, Associate Lecturer (Open University) and Senior Health Promotion Specialist (Berkshire), Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, London, UK vii This page intentionally left blank preface This second edition has extended its range from being primarily intended for undergraduate medical students to include pre-registration house officers (PRHOs) New doctors, general practitioners (especially teachers) and other health professionals will find it useful As a medical student 30 years ago, I was very keen to meet patients and experience the full range of conditions that I would face as a medical practitioner I was also aware that my time as an undergraduate was limited It was therefore important for me to gather a kernel of knowledge, skills and appropriate attitudes that would take me through my final examinations into my house officer years with sufficient substance to allow me to be a good and safe-enough doctor However, at that time, either in the way that I perceived it or in the way that it was presented to me, general practice seemed to be such a vast and loosely determined discipline as to be too difficult to be used in this process On the other hand, it also appeared to have all the dimensions and potential that I needed to explore the realms of health, illness and healing to my heart’s content Now, as a teacher and practitioner of general practice, I have been able to revisit the discipline from a new perspective and in a much more productive way Over the past 30 years the discipline of general practice has been greatly developed and refined so that departments of general practice are now in the forefront of medical education The broad base of knowledge and wide range of skills that general practitioners hold and the opportunities that primary care affords in terms of an understanding of health and illness, together with the great organizational advancements that have occurred in primary care, are now widely recognized to offer a rich learning resource for budding clinicians Undergraduate education, generally, also continues to be in a phase of rapid development In Britain this is being promoted by the General Medical Council, which has outlined recommendations most recently revised in 2003 in Tomorrow’s doctors It sees the development of appropriate attitudes, in relation to both the provision of care of individuals and populations and to the student’s personal development, as being as important as the acquisition of knowledge, understanding and skills It encourages learnercentred, problem-orientated learning systems and the promotion of small-group and self-directed learning Departments of general practice have been prime movers in these new directions This book reflects this development It is a distillation of what is necessary for a medical student and a PRHO to know and understand about general practice and being a general practitioner The second edition includes new chapters on healthcare ethics and law, prescribing and preparing to practise All the original chapters have been updated, some quite substantially The book is designed to encourage deep learning – a clearly presented and interesting text with a core of important information, and opportunities to reflect and experiment with the ideas in order to integrate and commit them to memory It is left to your general practice teachers and other specialists to provide the detail with which you can build on what is presented here The book ends with two chapters about your intended life as a doctor, included to emphasize the fact that all the clinical knowledge and skills in the world not, on their own, lead to a healthy and fulfilling life In the competitive and demanding world of medicine, this can be easily forgotten It is with this sentiment that I present this book, as well as with the wish that, as lifelong learners, we continue to experience the excitement and compassion that a life in medicine can provide Anne Stephenson ix Glossary ❚ characteristic of a particular disease that after seeing it you would entertain no other diagnosis An example might be the Koplik’s spots of measles that occur in no other situation, but not, paradoxically, the morbilliform (i.e ‘measles-like’) rash seen not only in measles but also in many other viral illnesses From the Greek pathognomonikos: patho- ϩ gnomonikos, able to judge Patient centredness Focusing on the patient’s story and taking into account the patient’s desire for information and for sharing decision making Personal Medical Services (PMS) A new type of UK National Health Service contract for GP practices introduced in 1998 Under a PMS arrangement, all GP principals of a general practice contract with their local primary care trust for the clinical services the practice will provide for its patients In return, the practice is guaranteed a budget to pay for this work and the staff This is a different contractual arrangement from the General Medical Services PMS GPs develop their own contract This contract is with the PCT, not with the Secretary of State for Health; it is local not national The contract can be tailored to suit the needs of the local population and local medical service provision, focused towards locally agreed priorities A PMS practice agrees to provide a range of primary care medical services to a defined population for an agreed sum of money Polypharmacy Where a patient is prescribed four or more drugs Prescribing of four or more drugs is not necessarily bad, and indeed may be necessary However, polypharmacy is a risk factor for potential harm from medication Portfolio A collection of evidence of work done, learning achieved, personal reflection, testimonials etc Positive predictive value This calculates the likelihood that an individual with a positive test actually has the disease It is a simple statistic: true positives/(true positives plus false positives) for any test, i.e it is the ratio of those who tested positive and who genuinely have the disease to all those who have tested positive Prescribing budget Budgets set by health authorities or primary care trusts (UK) for prescribing costs for individual general practices Primary care trust (PCT) In the UK, primary care trusts are freestanding, legally established statutory NHS bodies that are accountable to the local health authority They are organizations that integrate primary, secondary and community health services for a locality They have their own budget for delivering health care in their area; they are able to employ staff (district nurses/ health visitors etc.) and to develop new integrated services for patients They are key NHS partners for local authorities and local voluntary and community organizations They hold a significant majority of the entire NHS budget and are responsible for GP and community health services and other primary care services such as dental, pharmaceutical and optical In time, they may also extend to include social care and support services PCTs commission general and acute services, invest in primary and community care and work to improve the health of their local population GPs enter into a contract with the PCT (either GMS or PMS) to provide medical services for patients registered at the practice Primary health care That which provides health care in the first instance Primary healthcare team (PHCT) The primary healthcare team is made up of everyone who works at a general practice or primary healthcare centre: doctors, nurses, health visitors, midwives, physiotherapists, osteopaths, clinical psychologists, counsellors, dieticians, managers, secretarial staff, clerical staff, reception staff, cleaning and maintenance staff and others The team members may be employed by the practice or by the primary care trust Protocol A set way of dealing with a particular condition, often based on a detailed development of existing guidelines, for use by an individual organization, e.g general practice 307 ❚ glossary Psychosis The traditional clinical categorization of those (whom lay people might call ‘mad’) seriously distressed by strange beliefs and abnormal perceptions These beliefs and perceptions often appear to lead the patients to violence or (self-)destructive behaviour Evidence from well-designed non-experimental studies from more than one centre or research group Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees Quality improvement A systematic process to manage change within organizations to bring about better patient care There are many tools and methods used for quality improvement, the most important being clinical audit Screening The process of discovering unknown or undisclosed disease risk or actual disease with a view to intervening to prevent the occurrence or the progress of the disease Randomized controlled trial (RCT) A study in which people are allocated at random to receive one of several clinical interventions Typically, RCTs seek to measure and compare different events that are present or absent after the participants receive the interventions These events are called outcomes As the outcomes are quantified (or measured), RCTs are regarded as quantitative studies Reflecting Thinking over what has happened and why, what this shows you, and what you need to differently, or what you need to preserve and strengthen Repeat prescribing When a GP makes a decision to continue a drug long term, the patient is allowed to request further supplies without needing to see the doctor each time Usually the system is computerized Research evidence The published results of clinical trials, experiments, evaluations, surveys and other projects Research aims to answer one or more specific questions and tells us ‘what we should be doing’ Research evidence is often thought of as being hierarchical and involving a five-point scale: Strong evidence from at least one systematic review of multiple, well-designed, randomized controlled trials Strong evidence from at least one properly designed randomized controlled trial of appropriate size Evidence from well-designed trials such as non-randomized trials, cohort studies, time series or matched case-controlled studies 308 Sensitivity A measure of how likely it is that a screening test will correctly identify individuals who really have the disease With a highly sensitive test, there will be few ‘false negatives’ Significant event analysis A formal type of reflection, important after unusually good or bad outcomes, that is sometimes particularly useful when the event involves several people or a team, as everyone can take part in the reflection Skill The ability to perform a task well, usually gained by training or experience Skills checklist A list of the components of a specified skill that can be used as a method of ensuring consistency in the performance of a skill Skills competence The possession of a satisfactory level in the performance of a skill Skills performance The demonstration of a skill in a real-life situation Skills proficiency The attainment of a skill to an advanced level (Practising a skill with adeptness.) Specificity A measure of how likely it is that a screening test will correctly identify individuals who not have the disease With a highly specific test, there will be few ‘false positives’ Structured care A planned approach to disease management based on a register of those affected who can be recalled at set intervals for formal review of the disease in order to maximize the potential to control the disease, treat symptoms and prevent complications Glossary ❚ Suicide The taking of one’s own life is still widely considered a tragedy under all circumstances and it remains the doctor’s duty to detect suicidal risk and prevent the act if at all possible In self-harm, there is a spectrum from threats or aggressive cutting/self-poisoning, which does not cause immediate loss of life (typically in the young), to the deliberate planning of a solitary death by the old and ill However, since the best predictor of completed suicide remains an episode of self-poisoning or self-injury, all such actions should be taken equally seriously Telephone consultations Consultations with patients that take place by telephone They may be initiated by the doctor or the patient, and have medico-legal implications and obligations that differ from those of face-to-face consultations Among these are the security of the communication line and the provision of confidential information when the identity of the other party cannot be assured Valuing diversity in health The appreciation of how variations in culture, background and health care may affect health and health care Summative assessment Assessment of the acquisition of and competence in knowledge, skills and attitudes at the completion of training 309 This page intentionally left blank THE GENERAL PRACTITIONER Index CONSULTATION Page numbers in bold type refer to figures; those in italics to tables An asterisk (*) before a page numbers denotes a glossary entry abdomen, acute abdomen 36 ACAS (Advisory, Conciliation and Arbitration Service) 256, 257 accountability, for general practice 13–14 acupuncture 140 acute abdomen 36 adjustment disorders 46 adult learning *303 adverse drug interaction *303 Advisory, Conciliation and Arbitration Service (ACAS) 256, 257 age groups, problems of 54–5 alcohol 141 and road traffic accidents 194 alcohol dependence *303 alcohol-related disorders, prevalences 168 alcoholism 44, *303 Alexander technique 140 Alma-Ata Declaration 15 alternative therapies 140–1 angina pectoris, GP’s perceptions of treatment for 230–1 anorexia nervosa *303 antibiotics, in children 147 anxiety of GP 291 of patients 44–5, 50, 51 appraisal annual, of doctors’ performance 60, 276 of staff 256 argument, in ethics *303 arm, upper, intramuscular injection sites 88 assessment formative *305 of patient 127 self-assessment 273 summative 114, 116–17, *309 asthma 36, 163 drugs for 169 prevalences 168 screening for 170, 171, 175 attachments preparation for 4–5 purposes audit see clinical audit auriscopes 79–80 autonomy 220, *303 of GPs 289–90 backache 35, 36 prevalences 168 benchmarking 241 beneficence 220 biographical disruption 166 Births and Deaths Registration Act 1953 103 Black Report 190 blood glucose measurement 116 blood pressure measurement 67–73, 115 background knowledge 67–8 indications 67 oscillatory methods/devices 68–73 blood sampling 95–100 contamination risk 95 equipment 96 needle and syringe system 99–100 practical points 99, 100 Vacutainer system 95, 96–9 blood testing, dipstick analysis 82–4 BMI (body mass index) 74–5 BNF (British National Formulary) 142, 150 body mass index (BMI) 74–5 bradycardia 66 brainstorming 243–4, 258 British National Formulary (BNF) 142, 150 building maintenance 260 buttocks, intramuscular injection sites 88 caloric test 91 capacity see competence cardiovascular diseases 34, 36 care for colleagues and team members 301 for doctors 300–1 for patients 300 care homes, drugs in 148 Care Programme Approach (CPA) 172–3 case conferences 223 case studies, learning through 224 cerebrovascular accident, acute 36 cerebrovascular disease after-effects 36 prevalences 168 change change analysis 239–40 change planning 243–4 coping with 282, 287, 288 chaperones 65, *303 311 ❚ Index chest infection, acute 36 children antibiotics 147 compliance 147–8 consulting with 106–9 dosage rates 147 drug metabolism 147 ear examination 80–1 history taking 108–9 immunizations for 286 milestone problems 54 prescribing for 146–8 upper respiratory tract infections (URTIs) 147 Children Act 1989 107 chiropractic 140 Chronic Care Model 161 chronic illness/conditions 34, 35, 36, 161–76, *303 categories of 163, 164 diseases of process 163 epidemiological data 167–8 further reading 176 impact of 163–5 management plan 172–3 models of illness 165–7 nature of 163 patient’s perspective 162–3 prevalences 168 screening 170–1 statistics 167–8 structured care 173–4 summary 175 surveillance 171–2 tripartite approach to 161–2 undetected/unseen 169–70 chronic obstructive airways disease 36 chronic obstructive pulmonary disease, prevalences 168 clinical audit 235–48, *303 audit cycle 237, 237 audit population 240 change analysis 239–40, 248 change planning 243–4 choosing a topic 239 computer databases 245 criteria and standards 237–9, 240–1 312 critical event analysis 241 current/future developments 245 data collection 241–2 definition 236 electronic 245 further reading 247 interface audit 245 methods of 241 multi-practice audits 241 outcome criteria 238 as part of contract 245 patient involvement in 245 patient questionnaires/ interviews 241 peer review 241 planning 239–44 prospective analysis 241 random case analysis 241 vs research 236 results, dealing with 242–3 retrospective case analysis 241 sampling techniques 242 standards 238–9 summary 246 telephone surveys 241 clinical effectiveness 235, *303 clinical governance 257–8 definition 227 clinical iceberg 32, *303–4 clinical reasoning 263–5, *304 Cochrane Collaboration 228 code of practice, examination of patients 63–5 colour blindness 84 Commission for Patient and Public Involvement in Health (CPPIH) 14–15 Committee on Safety of Medicines 142 communicable diseases 188–9 communication case study 14 cultural misunderstanding 26–7 within general practice team 258 GP–specialist 131 purpose of 266 relevance 266 skills see communication skills see also leaflets; posters communication skills 100–13, 266–7, *304 considering the reader 266 ethical/legal issues 266–7 format 267 group work 198–9 in health promotion 197–204 home visits 112–13 and the media 199 one-to-one consultations 197–8, 288–9 patients with limited English 110–12, 198 referral letters 100–1, 131 see also counselling community health services 11 community pharmacists 151, 157 community psychiatric nurses, as PHCT members 12 competence *304 complaints procedure 253–4 complementary therapies 140–1 compliance 145, *304 children 147–8 elderly people 149 see also concordance complications, prevention of 126 computers clinical audit and 245 in general practice 259–60 patient records 260 prescribing by 151, 154, *304 use of 64, 65 concordance *304 over treatment 145–6 see also compliance confidentiality 62–3, 212–13, 218 home visiting 184 in written communication 266 consent to disclose 267 see also informed consent Index ❚ constipation 35 consultation(s) 17–30, 282, *304 behaviours helping/hindering 26–8 with children 106–9 clinician’s personality affecting 265–6 content 19 cultural misunderstanding 26–7 doctor-centred 20, 21–2 doctor’s tasks in 23–4 with elderly people 106–9 factors affecting rates of 33–4 frameworks/models 24–6 further reading 29, 29–30 moral issues 216–17 narrative approach to 28 one-to-one 197–8, 288–9 patient-centred 20–2 patient’s tasks in 22–3 preventative and health promotion issues 37 process 19 qualities of 18–19 reflecting on 27 roles within 19–20 skills for 26 social issues 37 stages of 24–6 summary 29 telephone consultations 182–3, *309 triggers to timing of 33 consulting rooms, seating arrangement 64 continual professional development 234–5, 291–2 contracts see GP contracts controlled drugs, prescribing 154, 155 counselling 140 person-centred non-directive approach 198 problem-solving approach 198 psychoanalytical approach 198 Cremation Certificate 102 crisis management 257 crisis points 46 criterion-referencing 114–15 critical event analysis 241 criticism constructive 273 feedback 273 video/audio recording 273 cultural aspects home visits 112 language problems 110, 198 leaflet translations 200–1 misunderstanding in communication 26–7 culture *304 death, communicating with relatives 106 death certificate 101–6 background knowledge 101–2 procedure 103–6 decision making 285–6 dependency 51 depression 36, 44, 50, 51–3 Descartes, René 42 diabetes [or diabetes mellitus] 36, 169 glucose dipstick analysis 81, 82 patient management of 126, 129 prevalences 168, 169 screening 170, 171 telephone consulting 183 diagnosis 118–25 clinical 120 differential 120 drugs and 138–9 further reading 135 in general practice 120–3 history as basis for 121–2, 123 levels of 120 listening to patients 121–2 pathological 120 problem list 120 safe management vs formal diagnosis 119 skills used in 65–87 summary 134 uncertain, recording 266 differential diagnosis 120 dipstick analysis 81–4 indications 81 practical points 82–4 testing blood 82–4 disclosure, consent to 267 disease cure 126 vs illness 43 poverty as determinant of 190 prevention 126 disease groups, presenting to general practice 34 disease pattern, changing 297–8 disease protocol *304 disease register *304 dispensing community pharmacists 151, 157 dispensing practices 156, *304 by doctors 155–6 dispensing practices 156, *304 distractions 269 distress, serious 45, 47, 48, 57 district nurses, as PHCT members 12 diverticular disease 36 dizziness 35 doctor-centred consultation 20, 21–2 doctor’s bag, contents 155–6 dosette boxes 149 dress for consultations 64 for home visits 113 Drug and Therapeutics Bulletin 151 drug formulary *304 drugs abuse 155 adverse interaction *303 adverse reactions see side effects 313 ❚ Index drugs (cont.) in care homes 148 carried by doctors 155–6 classification *303 controlled 154, 155 diagnosis and 138–9 effectiveness of 141 GP/hospital communication on 144–5 hospital discharge notification 158 interactions 143–5 metabolism 144, 147, 148 practice formularies 138, 150–1 see also medication; prescribing; prescriptions duties 217–18 and consequences 218–19 dyspepsia 35 ear external, problems 35 temperature taking 76, 77 wax in 35 ear examination 77–81, 116 background knowledge 78–9 children 80–1 indications 78 practical points 80–1 procedure 79–81 ear syringing 91–5 background knowledge 91 electrical syringe 92–3 equipment 91–2 manual syringe 91–2, 93–4 practical points 94–5 procedure 92–4 eczema 35 education core curriculum 37 health promotion 191 of patients 126 personal professional development 286–7 see also learning elderly people compliance 149 314 consulting with 106–7, 109–10 drug metabolism 148 medication review 149, 150 milestone problems 54 polypharmacy 148 prescribing for 148–50 progress review 149–50 electronic audit 245 emotional aspects of illness/treatment 56–7 emotional overload of GPs 292 endocrine disorders 34, 36 Enlightenment 220 epilepsy 36, 170 drugs for 169 prevalences 168, 169 ethics 13, 211–25 argument *303 conflict and compromise 211–13 ethical circuit 219 further reading 225 good practice 215–16 governance issues 267 in health promotion 206 issues in written communication 266–7 medical 213–14 patients as moral strangers 215–16, 223 of stages of change model 197 summary 224 unanticipated revelations 216 ethnic group *304 ethnicity, consultation rates 33 etiquette, professional, in examination of patients 65 evaluation research 228, 231–2 evidence-based medicine 131–3, *304 effectiveness of drugs 141 further reading 135–6 information sources 132 steps in practice of 132 examination of patients code of practice 63–5 in general practice 123–5 objective structured clinical examination (OSCE) *306 professional etiquette 65 skills used in 65–87 exercise 140, 141 Healthy Walks 199 leaflets promoting 202 expectations of patients/public 271 changes in 299–300 experimental research 228, 228–9 fairness 221 family practice see general practice finance management 259 FOG (Frequency of Gobbledegook) formula 200 forced expiratory volume (FEV) 84 formative assessment *305 gastrointestinal diseases 34, 36 gatekeepers, primary care practitioners as 15, 285 General Household Survey 167–8 General Medical Council (GMC), guidelines 214, 215 General Medical Services (GMS) contract 251–2, 259, 281, *305 general practice *305 accountability for 13–14 as a business 249–50 contribution to primary health care 12–14 core values 13 developing role of 288 further reading 16 future in UK 15 future internationally 15 income 252, 259 lessons for medical profession 300–1 power structures in 13–14 Index ❚ preparation for see preparation for practice recent developments 297–300 role in NHS 251–2 structure and organization changes 298–9 summary 16 see also care; ethics; primary health care; primary healthcare teams general practitioners (GPs) 280–302 career path 283 contracts see GP contracts coping with change 282, 287, 288 core values 13 decision making 285–6 definition 281 gatekeeper roles 15, 285 as independent contractors 281–2 personal professional development 286–7 problem-solving approach 290 providing/managing a service 284 providing personal care 283–4, 300–1 role conflict 213, 217 skills appraisal 60, 276 summary 301 as team members 285, 289, 301 as trainers 288 vocational training 282–3 work aspects see work aspects of GPs genitourinary diseases 34 goal setting 271 GP assistants 281 GP associates 281 GP co-operatives *305 GP contracts General Medical Services (GMS) 251–2, 259, 281, *305 Personal Medical Services (PMS) 251–2, 281, *307 GP principals 281, *305 GP registrars 281, 282–3, *305 GPs see general practitioners grounding 274, *305 group work, in health promotion 198–9 groups patient-participation groups 14–15 peer-support groups 273 see also teams ‘guess and test’ see hypotheticodeductive reasoning guidelines 133, *305 drugs 150 further reading 136 General Medical Council 214, 215 prescribing 138–45 haemorrhoids see piles hay fever 35 headache 35 health definitions 189–90 determinants of 189, 190–1 health and safety 260 Health Belief Model 32–3, *305 Health Development Agency (HDA) 205 health promotion 187–210, *305 aims and objectives 203–4 background 187–9 communication skills 197–204 definitions 187, 188, 190, 197, 207 education 191 ethical issues 206 evidence base 204–6 extension beyond medical base 206–7 further reading 209–10 global issues 207 Healthy Walks 199 journals/bulletins 191, 205 leaflets see leaflets models of see health promotion models Ottawa Charter 191 planning for 202–3, 204 posters 202, 203–4 public health and 188 skills for 197–204 summary 207 health promotion evidence 204–6, *305 health promotion models 191–7 Beattie’s model 193–5 behaviour change approach 195 educational approach 195 empowerment approach 195 Ewles and Simnett approaches 195–7, 202, 203 health promotion theory *305 medical approach 195 Nordenfelt’s health enhancement model 192 social change approach 195, 196 stages of change model 196–7 Tannahill model 193 Tones model 192 health promotion specialists 191, *305 health promotion theory *305 see also health promotion models health visitors, as PHCT members 12 Healthy Cities Project 190 Healthy Walks 199 height measurement 73–5 help, asking for 271–3 hepatitis B immunization 89, 95 Hippocratic Oath 214 history taking 56 children 108–9 in diagnosis 121–2, 123 home visiting 112–13, 177–86 confidentiality 184 criteria for 178–81, 181 further reading 186 315 ❚ Index home visiting (cont.) identification 112 out of hours 182–3 problems with 183–4 reasons for 181, 183 statistics 181–2 students’ questions about 112–13 summary 186 see also housebound patients homeopathy 140 honesty vs truthfulness 267 hospices 125, 126 hospital-at-home 177, 184–5, *306 hospital careers, relevance of general practice hospital discharge notification, drugs 158 housebound patients health and social services for 185 services for 184–5 teamwork 185 see also home visiting human immunodeficiency virus (HIV), consultations and 20 hyperlipidaemia, screening 171 hypertension 36, 163 detection rate 169–70 over-diagnosis 169–70 prevalences 168, 169 ‘rule of halves’ 171 screening 170, 171 telephone consulting 183 ‘white coat hypertension’ 170 hypochondriasis *306 hypothetico-deductive reasoning 264, 265, *306 identification for home visits 112 identity badges 64 ignorance, vs uncertainty 270 illness(es) chronic 34, 35, 36, 161–76, *303 common 31–40 316 core curriculum for students 37 vs disease 43 further information about 37–9 further reading 40 major 34, 35, 36, *306 meaning of 189 minor 34–5, 35, *306 models of see models of illness structuring and remembering information about 38–9 summary 39 see also illness behaviour; and specific illnesses illness behaviour 32–3, *306 ethnicity and 33 immunizations for children 286 medical staff 95 income, general practice 252, 259 incompetence, vs uncertainty 270 inductive reasoning 264, 265, *306 infections 34 see also specific infections inflammatory bowel disease 36, 163 information, for patients 254 information technology see computers informed consent 63, *306 inhaler, use of 115 injections 87–91 background knowledge 87 intramuscular see injections, intramuscular subcutaneous/intradermal see injections, subcutaneous/intradermal injections, intramuscular 87 equipment 88–9 procedure 89–90 sites 87–8, 89–90 injections, subcutaneous/ intradermal 87, 89 equipment 88–9 practical points 90–1 procedure 90 injuries 34 insurance companies, communications to 267 insurance cover 215 interface audit 245 Internet, as source of advice for patients 140 interpreters 110–12 investigations see tests irritable bowel syndrome 36 ischaemic heart disease 36 audit 237–9, 240, 241–2, 244, 248 prevalences 168 screening 170 isolation of GPs 290–1 Jakarta Declaration 190 Johari Window 274 journals 191, 205, 286 junior doctors 270 justice 221 distributive 221 retributive 221 ketone testing 82 Kolb’s learning cycle 276 Korotkoff sounds 68, 71–2 Lalonde Report 189–90 Language Line interpreting service 110–11, 198 law 211–25 further reading 225 in other countries 214 in practice 214–15 recording reasons for decisions 215 summary 224 lay referral system 31 leaflets in health promotion 199–202, 203, 204 readability 200 translations 200–1 use of 201–2 Index ❚ learning 1–8 through case studies 224 continual professional development 234–5, 291–2 frequently asked questions 2–4 help in passing exams key areas in general practice 2–4 Kolb’s cycle 276 lifelong 275–7, 287, 291–2 limitations of clinical environment structuring and remembering information about illnesses 38–9 student concerns student preconceptions student problems and dilemmas 6–7 summary tips for 5–6 see also education; training legal issues, in written communication 266–7 life events 46 life transitions 46, 53 lifelong learning 275–7, 287, 291–2 lifestyle, sedentary 141 lifestyle change 141 limitations, self-awareness of 271–3 available help 271–2 problem areas 272–3 listening, in consultations 26 lung cancer, smoking and 189 major illness 34, 35, 36, *306 management definition 250 management cycle 250 of uncertainty 269–71 see also patient management; practice management management team 252–3 media, communicating with 199 medical audit 235–6 see also clinical audit Medical Certificate of Cause of Death see death certificate medical defence unions 64 medical encounters, three functions model 23 medical skills, changes in 298 medical staff, immunizations 95 medication anxiolytic, withdrawal symptoms 51 communication about, primary–secondary care 158 help for patient in taking 146 hospital discharge notification 158 over-the-counter (OTC) 138, 157–8, *306 review 146, 149–50, *306 scale of use 138 see also drugs; prescribing; prescriptions Medicines Control Agency 157 Medicines Resource Centre, reviews 151 mental health 46–7 classification and assessment 47–9 dangerousness 49 symptoms and circumstances 49–53 see also psychological issues mental illness 285 metabolic disorders 34 metabolism, drugs and 144, 147, 148 milestones, problems related to age groups 54–5 MIMS (Monthly Index of Medical Specialties) 151 mind/body split 42 mini-peak flow meters 84–7 background knowledge 84 practical points 86–7 procedures 86–7 minor illness 34–5, 35, *306 models of illness 165–7 biopsychosocial model 166–7 functional model 166 medical model 165–6 social model 166 sociological model 166 Monthly Index of Medical Specialties (MIMS) 151 multi-practice audits 241 multi-tasking 269 multiple sclerosis 36 prevalences 168 musculoskeletal disorders 34, 36 myocardial infarction, acute 36 narrative approach 223, *306 to consultations 28 in psychological issues 56 National Association of GP Co-operatives (NAGPC), home visits 180 National Institute for Clinical Excellence (NICE) 228, 234, 235 National Morbidity Survey in General Practice (NMSGP) 167, 168 National Service Frameworks (NSFs) 234, 235 needs vs demands 232 in healthcare, definition 232 individual vs community 286 needs assessment research 228, 232–3 negative predictive value *306 negotiation, with patient 271 nervous system diseases 34 neurological conditions 36 NHS general practice role in 251–2 walk-in centres 11 NHS Direct 11, 182 NICE (National Institute for Clinical Excellence) 228, 234, 235 non-compliance 145 non-judgementalism 266–7 317 ❚ Index non-malevolence 220 non-steroidal anti-inflammatory drugs (NSAIDs) 142, 149 NSFs (National Service Frameworks) 234, 235 nurse prescribing 156 obesity 74–5, 141 objective structured clinical examination (OSCE) *306 operational management 257 organizational skills 268–9 osteoarthritis 36 prevalences 168 osteopathy 140 otitis externa 35, 93 otitis media 35 structuring and remembering information about 38–9 otoscopes see auriscopes Ottawa Charter for Health Promotion 191 out-of-hours care *306 co-operatives 182–3 home visiting 182–3 primary care centres 182 Out of Hours Review (DoH plan) 182 over-the-counter (OTC) medication 138, 157–8, *306 overseas future of general practice and primary health care 15 law 214 overwork, GPs 291 PACT (prescribing analysis and cost) data 158–9, *306 Parkinson’s disease 36 paternalism *306 pathognomonic *306–7 patient-centred consultation 20–2 patient centredness *307 patient confidentiality 62–3 patient management 127–30 further reading 135 negotiating with patient 128–9 318 objectives 125–7 planning care 125–7 summary 134 see also treatment patient-participation groups 14–15 patients courtesy/consideration for 61, 62, 109 education of 126 as experts 14–15 information for 254 informed consent 63, *306 involvement in clinical audit 245 numbers attending surgery 169 questionnaires/interviews 241 reactions to symptoms 31–4 reasons for seeing doctor 119 role of 42 patient’s agenda 286 pattern recognition 264 peak expiratory flow rate (PEFR) measurement 84–5, 115 peer reviews, in clinical audit 241 peer-support groups 273 peptic ulcers 36 Personal Medical Services (PMS) contract 251–2, 281, *307 personal professional development 286–7 perspectives, concept of 219, 223 pharmaceutical companies, and GP education 235 pharmacists 151, 157 PHCTs see primary healthcare teams phlebotomy see blood sampling physical therapy 139–40 physiotherapy 139–40 piles 35 poisoning 34 polypharmacy *307 elderly people 148 portfolios 274, 276–7, *307 positive predictive value *307 posters, in health promotion 202, 203–4 poverty 190–1 practice formularies 138, 150–1 practice image 254 practice management 249–61 building maintenance 260 and clinical governance 257–8 complaints procedure 253–4 finance management 259 further reading 261 health and safety 260 information leaflets 254 information technology 259–60 management cycle 250 management team 252–3 need for 249–50 operational management 258 patient care 253–4 practice image 254 staff management 254–7 strategic planning 258–9 summary 260 systems working efficiently 253 team management 258–9 practice managers as PHCT members 12 role of 251, 252–60 see also practice management practice nurses, as PHCT members 12 preparation for practice 262–79 further reading 279 log diaries 263 summary 278 prescribing 137–60 advisors 151 budgets *307 for children 146–8 computer-based 151, 154, *304 controlled drugs 154, 155 costs 145, 158–9 for the elderly 148–50 further reading 160 generic 145, 150 Index ❚ guidelines 138–45 monitoring 158–9 by nurses 156 practice formularies 138, 150–1 prescribing analysis and cost (PACT) data 158–9, *306 repeat prescribing 148, 154–5, *308 support for 150–1 prescriptions contents 151–4 legal responsibility for 151 repeat prescriptions 148, 154–5, *308 writing 151–4 primary care practitioners, as gatekeepers 15, 285 Primary Care Trusts (PCTs) 13, 251, 281, 299, *307 primary health care 9–16, *307 aims 10 definition 10 future in UK 15 future internationally 15 general practice contribution to 12–14 importance of 9–10 research evidence and practice changes 226–7 summary 16 websites 16 see also general practice primary healthcare teams (PHCTs) *307 boundaries 12 management by 129–30 members of 11–12 working relationships with 268 priority setting 268–9 problem-solving approach 290 professional conduct 275 prospective analysis 241 protocols 133, 257, *307 chronic disease management plan 174 drugs 150 further reading 136 psychiatric diseases 34 psychiatric illness, Care Programme Approach (CPA) 172–3 psychiatric services, referrals to 285 psycho-emotional conditions 35 psychological issues 41–58 a ‘contested’ field 46–7 further reading 58 importance of 41–2, 44–6 narrative approach 56 provision of help 53 summary 57 systemic thinking 41, 55 therapy 140 see also mental health; mental illness psychosis 45, *308 psychosomatic illnesses/diseases 46 psychotherapy 140 public health, health promotion and 188 pulse measurement 115 background knowledge 66 practical points 66–7 radial 65–7 quality improvement *308 random case analysis 241 randomized controlled trials (RCTs) 228, 228–9, *308 ‘real’ medicine reasoning clinical 263–5 hypothetico-deductive 264, 265, *306 inductive 264, 265, *306 receptionists, as PHCT members 12 ‘red book’ funding mechanism 252 referrals 130–3, 271, 271–2 electronic 100 lay referral system 31 to psychiatric services 285 reasons for 130–1 referral letters 100–1, 131 reviewing patients after 131 reflecting *308 reflection 273–4 reflexology 140 regulation legal see law in practice 214–15 professional, GMC guidelines 214, 215 relationships see working relationships relaxation techniques 140–1 renal failure, chronic, screening 171 repeat prescribing 148, 154–5, *308 research 227–33 and changes to clinical practice 233–5 vs clinical audit 236 evaluation research 228, 231–2 experimental 228, 228–9 needs assessment research 228, 232–3 randomized controlled trials 228, 228–9, *308 survey research 228, 229–31 research evidence 226–7, 227–33, *308 research networks 228 respiratory diseases 34, 36 results of tests, interpreting 123–4 retrospective case analysis 241 rheumatoid arthritis 163 RIME model of self-assessment 273 road traffic accidents, and alcohol 194 role conflict 213, 217 Scandinavian Simvastatin Survival Study 228–9 schizophrenia 163 prevalences 168 screening 124, 170–1, *308 opportunistic screening 171 population screening 171 319 ❚ Index self-assessment 273 self-care 31 self-help, by patients 140 self-limiting conditions 139 sensitivity of tests 123–4, *308 sexual activity 141 sharps bins 89, 96, 98 sharps disposal 98–9 SHEPS (Society of Health Education and Promotion Specialists) 191, 196 side effects classification 141–3 continuous 141 delayed 141 drug interactions 143–5 end-of-use (withdrawal) reactions 141, 142 idiosyncratic 141, 142 predictable 141, 142 reporting to Committee on Safety of Medicines 142 wrongly-identified 142–3 significant event analysis *308 simvastatin, Scandinavian Simvastatin Survival Study 228–9 sinus arrhythmia 66 skills 59–117, *308 acquiring new 60 assessment of 114–17 basic 62–5 in clinical examination 65–87 in clinical management 87–100 in communication see communication skills in diagnosis 65–87 further reading 114 groupings 60–2 organizational 268–9 postgraduate level 116–17 students’ questions 61–2 summary 113 in treatment of patients 62, 87–100 undergraduate level 114–15 see also specific procedures 320 skills checklist *308 skills competence *308 skills performance *308 skills proficiency *308 skin diseases 34 sleeplessness 51 smoking 141 and health promotion 196–7, 205–6 lung cancer and 189 social capital 190–1, 207 society, changes in 298 Society of Health Education and Promotion Specialists (SHEPS) 191, 196 sore throats 126 specificity of tests 123–4, *308 sphygmomanometers 68–72 staff management 254–7 discipline 256 GPs’ responsibilities 60 grievances 256–7 induction 255–6 recruitment 255 staff appraisal 256 training 256 stages of change model of health promotion 196–7 standards, maintaining 291–2 strengths and weaknesses 276, 277 stress, GPs’ 287 structured care *308 Structured trainer’s report 116 students see education; learning suicide *309 summative assessment *309 survey research 228, 229–31 bias 230 symptoms alleviation of 126 non-specific 34 patients’ reactions to 31–4 psychological aspects 49–53 treatment of 139 tachycardia 66 teams caring for housebound patients 185 GPs as team members 285, 289, 301 management team 252 team management 258–9 see also groups; primary healthcare teams (PHCTs) technology changes in 298 see also computers telephone consultations 182–3, *309 telephone surveys 241 temperature ranges 75 temperature taking 75–7 tensions, of GP 291 tests appropriateness of 125 decision to request 124–5 diagnosis vs management purposes 123 interpreting results 123–4 range of 125 screening 124 sensitivity/specificity of 123–4 thermometers, types 75–7 thigh, intramuscular injection sites 87–8 throat infections 35 thyroid disorders 36 time organizing 269 time keeping 268–9 use of 270–1 training vocational training 282–3 see also education; learning transcendental meditation 140–1 treatment monitoring progress 129–30 non-drug therapies 139–41 patient compliance 145 planning 127 risks and benefits of 127–8 symptomatic 139 see also patient management truthfulness vs honesty 267 Index ❚ ulcers, peptic 36 uncertainty, vs ignorance/incompetence 270 uncertainty management 269–71 upper respiratory tract infections (URTIs) in children 147 self-treatment 139 urine analysis 81, 82, 115 Vacutainer system 95, 96–9 values 212, 219, 222–3 valuing diversity in health *309 varicose veins 35 venepuncture see blood sampling victim blaming 195, 196 virtues 219, 222–3 vocational trainees see GP registrars vocational training 282–3 see also education; learning; training walk-in centres 11 walking Healthy Walks 199 see also exercise wax in ears 35 see also ear syringing websites, primary health care 16 weight measurement 73–5 ‘whole-person medicine’ 18 withdrawal syndrome 51 work aspects of GPs basic 283–7 negative 290–2, 300–1 non-basic 287–8 positive 288–90 typical working day 293–7 typical working week 293, 294–5 see also general practitioners work aspects of patients, affecting health 141 working relationships 268 yoga 140–1 321 [...]... spite of this, a large range of primary care activities and organizations has been developed and introduced to meet the challenges and to support general practice These have included a move towards integrating health and social services in primary care; primary care-led purchasing; a greater accountability of general practice to the NHS; general practice fund-holding; the development of paperless general. .. cornerstone of primary health care Historically, this has developed from ‘the doctor working alone’ to ‘the practice as an organization’ As this model of health care has been widened to include consideration of such things as population-based health promotion (as well as diagnosis and treatment) and care of populations (as well as individuals), the role of general practice has changed and that of the GP has... selection of the members of the UK general practice team Name Employed by Role includes Training Receptionist General practice Reception and telephone duties, filing Various Practice manager General practice Planning, organizing, managing a general practice Various Practice nurse General practice Assessment, diagnosis, treatments, health promotion, special extended roles Registered General Nurse (RGN),... general practice relevant for those going into hospital careers? About 50 per cent of UK medical graduates enter general practice Some decide early that they 2 want to take this option; others plan a career in hospital medicine but find, for various reasons, that they switch to general practice at a later stage Before deciding on a career path, it is important to explore all the options, and general. .. in general practice For example, most heart attacks and acute psychiatric crises occur outside the hospital Traditionally, medical education was based almost exclusively in hospitals This is changing to reflect current patterns of care, and to provide a better balance of experience What will I do in general practice? General practice attachments at different stages of the medical course may be designed... development of the NHS has been led by primary care The central place of general practice in the provision of primary healthcare services has not been challenged However, there has been an increasing reliance on general practice to continue to develop and provide free and equal access to health care in the face of greater restraints on resources This has placed an enormous strain on general practice providers... health care What is primary health care and what is it aiming to achieve? Who are the principal members of the primary healthcare team? How do general practice and the general practitioner contribute to primary health care? ■ ■ ■ ■ 9 11 ■ ■ 12 ■ How do we ensure that the patient receives most benefit from general practice and the primary healthcare service? 14 What is the future for general practice and... variety of cases and a wide range of patient groups In general then, we suggest that general practice is the best place to learn about: ■ the range of primary care services and how to access them, ■ the effects of patient beliefs and lifestyle factors on health, 3 ❚ learning in general practice: why and how? ■ ■ ■ environmental, social and psychological factors affecting health, the management of common conditions,... injuries and illnesses and are open and available for anyone General practice (family practice) provides first contact, patient-centred, comprehensive and continuing care to a patient population The general practice tasks are to promote health and well-being and to treat illness in the context of the patient’s life, belief systems and community and work with other healthcare professionals to co-ordinate care... teamwork, organizational skills, uncertainty and personal limitation, constructive criticism, professional conduct and lifelong learning explore areas of professional development that are essential for the safety of a new doctor Finally, whether or not you are an aspiring GP, Chapter 16 talks about the life of a GP to remind us that a personal and a professional life are inextricably intertwined and