User blog: Rcgp Learning
1 May marks World Asthma Day, an annual event organised by the Global Initiative for Asthma (GINA). The event aims to raise awareness and improve asthma care around the world¹. It’s estimated that around 5.4 million people in the UK are currently receiving treatment for asthma, which amounts to around one in 12 adults².
According to Asthma UK, around three people die each day from asthma attacks and the UK has one of the highest death rates from asthma in Europe².
The National Review of Asthma Deaths (NRAD) was the first UK-wide investigation into asthma deaths, which looked into the 195 deaths that occurred between 2012 and 2013³. The review considered various areas of asthma care, such as use of NHS services and prescribing and medicines use. Another area that was investigated was ‘medical and professional care’ which found that out of the 195 people that died, only 44 (23%) had been provided with personal asthma action plans (PAAPs). For 84 people (43%), there was also no evidence that an asthma review had taken place in general practice within the last year before their death³.
The review also found that 61% of the deaths were of people that suffered from only mild or moderate asthma³. The NRAD concluded that their asthma was likely to have been poorly controlled and undertreated, which highlights the need for good control. While asthma is managed in both primary and secondary care, it is likely that patients will return to primary care to regularly monitor and review their asthma.
The 2016 guideline produced by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) states that asthma is best monitored in primary care by an annual clinical review. For adults, they recommend that the following factors should be monitored and recorded⁴:
- Symptomatic asthma control
- Lung function assessed by spirometry or by peak expiratory flow (PEF)
- Asthma attacks, oral corticosteroid use and time off work since last assessment
- Inhaler technique
- Bronchodilator reliance
- Possession of and use of a self-management plan/personal action plan.
To monitor symptomatic asthma control, both the BTS/SIGN and NICE guidelines recommend using a validated questionnaire that uses directive questions, such as the Asthma Control Test or the Royal College of Physicians’ ‘3 questions’⁴’⁵. To help with identifying and managing any red flags that arise as a result of the clinical review, the NICE Clinical Knowledge Summary for asthma can be accessed here.
NICE have recently issued some updated guidelines for the management of asthma and you can access a summary of the updates here.
The RCGP offers various eLearning materials on asthma and the following resources are FREE to all healthcare professionals:
Asthma – 1 CPD credit
Common atopic presentations in primary care – 5 minute screencast on asthma
Single Inhaler Therapy for Asthma – 5 minute screencast
RCGP members can also benefit from access to the following resources:
EKU18 – Wheeze & Asthma in Young Children
EKU 2017.2 – Management of asthma
EKU 2018.2 – Diagnosis, monitoring and chronic asthma management
EKU podcasts – Asthma: introduction to Asthma, Asthma: NRAD report and Asthma Management Guidelines, Asthma: Management of the Asthma Patient
- Tiotropium in asthma: what is the evidence and how does it fit in?
- Over diagnosis of Asthma in Children in Primary Care
- Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children
- Does inhaler choice matter?
- Systematic meta-review of supported self-management for asthma: a healthcare perspective
- Vitamin D supplementation to prevent asthma exacerbations
(1) The Global Initiative for Asthma (GINA). World Asthma day. Available from: http://ginasthma.org/wad/
(2) Asthma UK. Asthma facts and statistics. Available from: https://www.asthma.org.uk/about/media/facts-and-statistics/
(3) Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). [May 2014]. Available from: https://www.rcplondon.ac.uk/file/868/download?token=JQzyNWUs
(4) British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN). British guideline on the management of asthma. . Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
(5) NICE. Asthma: diagnosis, monitoring and chronic asthma management (NG80). [November 2017]. Available from: https://www.nice.org.uk/guidance/ng80
It is estimated that around 17% of the UK’s population have Irritable Bowel Syndrome (IBS)1, but there is no single cure that works for all patients. April marks IBS Awareness Month, aiming to spread important information about diagnosis and management of this often uncomfortable and painful condition.
A recent development in IBS treatment is the introduction of the low FODMAP diet – standing for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols.
The low FODMAP diet was developed in Australia by a team at Monash University in Melbourne2 after finding that foods high in certain short-chain carbohydrates can cause gastrointestinal discomfort. Short chain carbohydrates are poorly absorbed in the small intestine and are found in various foods, such as wheat, rye, pulses, lactose, fructose and some fruit and vegetables. These high FODMAP foods increase the amount of water in the small intestine which can contribute to loose stools. They start fermenting when they reach the colon, which may increase gas production and subsequently cause symptoms such as wind and bloating3. You can find examples of high and low FODMAP foods on the Monash University website here.
A 2017 review that assessed the results of published clinical studies on FODMAP, concluded that up to 86% of patients with IBS saw an improvement in overall gastrointestinal symptoms4.
As the symptoms of IBS can be similar to those of other diseases such as Inflammatory Bowel Disease (IBD) or bowel cancer, the NICE Pathway for IBS recommends looking for red flag indicators when a patient presents with IBS symptoms, to assess whether the patient should be referred to secondary care for further investigations5. More information about these red flags can be found here in the NICE Pathway.
While the efficacy of the low FODMAP diet seems impressive, patients should be referred to a dietitian before attempting it on their own, as recommended in the NICE guidance on IBS6. When a patient is referred to a dietitian, there will be three stages:
- Low FODMAP Diet - the patient will reduce their intake of high FODMAP foods for two-six weeks to establish whether the symptoms will respond to the change in diet.
- Re-challenge phase – if symptoms have improved, high FODMAP foods will be introduced for six-eight weeks so the patient can identify which FODMAPs trigger their symptoms.
- Adapted diet – the dietitian will personalise the diet to the patient, so they only avoid their ‘trigger foods’ and can resume a more normal diet2.
For further information about gastrointestinal conditions, the RCGP offers the following eLearning courses that are FREE to all healthcare professionals:
Inflammatory Bowel Disease - 0.5 CPD credits
Managing uncertainty in lower gastrointestinal tract presentations - 0.5 CPD credits
Diagnosis and Management of Coeliac Disease - 0.5 CPD credits
RCGP members can also benefit from access to the following content:
(1) Khanbhai. A and Singh Sura. D. Irritable Bowel Syndrome for Primary Care Physicians. [March 2013] Available from: http://www.bjmp.org/content/irritable-bowel-syndrome-primary-care-physicians
(2) Monash University. The Low FODMAP Diet. [Internet] Available from: https://www.monashfodmap.com/
(3) Magge. S and Lembo. A. Low-FODMAP Diet for Treatment of Irritable Bowel Syndrome. [Nov 2012] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966170/
(4) Nanayakkara. W.S. (et al). Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. [June 2016] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918736/
(5) NICE pathways. Irritable bowel syndrome in adults overview. Interactive flowchart. Available from: https://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults
(6) NICE. Irritable bowel syndrome in adults: diagnosis and management (CG61). [April 2017] Available from: https://www.nice.org.uk/guidance/cg61/chapter/1-Recommendations#dietary-and-lifestyle-advice
The Dermatology library is the latest addition to the RCGP’s Educational Libraries. It has been developed in partnership with the Primary Care Dermatology Society (PCDS) and the British Association of Dermatologists (BAD) and is free to access here.
The Dermatology library brings together national guidance, dermatology resources and RCGP accredited courses relevant to GPs and other primary healthcare professionals. It presents a variety of resources to suit your preferred method of learning, including screencasts and podcasts. The major areas in dermatology are presented in a clear and user-friendly format providing you with quick access to topics of interest, including:
• Dermatology overview
• Infection and infestation
• Genetic and systemic disorders
• Inflammatory conditions
• Specific lesions
• Urticaria and blistering.
These resources will support you as a GP to meet your clinical and CPD needs and improve your opportunities to specialise and diversify in your career, supporting the GPs with Extended Roles (GPwER) programme and accreditation process.
The Dermatology library will form part of a series of clinical, non-clinical and professional educational libraries the RCGP will publish with specialist organisations. In this series, you can also access the Women’s Health Library here.
March is just around the corner, which means that time is running out to complete your appraisal and boost those Continuing Professional Development (CPD) points. If you’re looking for a way to save some time and ease the stress of preparing for your appraisal, the RCGP’s GP SelfTest tool may be the answer.
With around 5000 users over the past year, GP SelfTest is already a popular tool on the RCGP’s eLearning website. You may have seen that it’s a useful tool for AKT preparation, but qualified GPs can also benefit from using GP SelfTest for their CPD and to meet the requirements for their appraisal and revalidation.
GP SelfTest provides an easy way to identify your educational needs and focus on the key areas that form part of your professional development plan (PDP). The Curriculum Wide Learning Needs Assessment test is particularly useful for this, as the results provide a breakdown of any topics that need some improvement. You’re then signposted to any ‘Curriculum Resources’ on the RCGP eLearning website that can help with this.
While you’re busy working on your PDP, you can also clock up some CPD credits to add to your log. You can capture and track your improved learning with the results and certificate that GP SelfTest provides. The certificates automatically update with your results and the dates you completed your tests, so you don’t have to remember this information yourself. By adding these certificates to your portfolio and recording any improvements in your results, you can easily demonstrate to your appraiser that you’re fit to practise. You can read more about CPD credits and appraisal here.
There is also a reflection notes section on GP SelfTest, where you can capture your thoughts on what you have learned and ask yourself questions such as:
How will this learning/improved knowledge from GP SelfTest impact upon your practice?
What have you done differently with your improved learning?
What impact will your improved learning have on your patients?
Has it helped you with a Quality Improvement Activity (QIA)?
Your notes can be printed with a certificate of your test results, and used as evidence of your CPD.
To start making your appraisal preparation quicker and easier, you can purchase your subscription to GP SelfTest here. If you need some more information first, you can find out more about the tool and how it can benefit you by visiting the GP SelfTest homepage here.
It’s estimated that over 1 million sexually transmitted infections (STIs) are acquired every day worldwide (1). Last year in England alone there were around 420,000 diagnoses of STIs, with chlamydia accounting for 49% of these (2). Despite the prevalence of STIs, many patients still choose not to go for regular sexual health checks. According to Public Health England’s 2017 report on STIs and chlamydia screening, there has been a decline in the number of STI tests carried out over the last 5 years (3).
National STI Day was launched a few years ago to encourage people to take responsibility for their sexual health and attend regular testing. It has been chosen to take place on the 14th January of each year, so that it falls two weeks after New Year’s Eve: a day when traditionally more alcohol than usual is consumed and people are more likely to engage in sexually risky behaviour. Various papers have demonstrated the link between alcohol, risky sexual behaviour and STI diagnoses, with women being more affected than men. (4) (5). This two week period after New Year’s Eve was deliberately chosen as the most common STIs can take two weeks to be detectable (6).
Despite that fact that STIs can lead to serious health problems, it seems that not everyone is as informed as they should be about the importance of safe sex. In 2016, the Family Planning Association (FPA) conducted a survey of more than 2,000 people aged 16 and over across the UK to find out what they knew and thought about safer sex and STI testing (7). Out of the findings of the survey, the following statistics are perhaps the most concerning:
- 68% said that they had never had an STI test
- 52% didn’t know that you can get an STI from oral sex
- 71% said they did not use any form of condom the last time they had sex
- Only 9% learnt at school about how to find and use sexual health services
While genitourinary medicine (GUM) clinics are commissioned to screen for and treat STIs, patients frequently present in general practice to seek advice about STIs and contraception. It's important that GPs are able to have open and honest conversations about sex and sexuality, and know where to signpost patients to sexual health services outside of general practice.
There are a range of sexual health services available in the UK, but as the RCGP highlighted in the 2016 ‘Time to Act’ report, there is evidence of restricted access to contraception and STI testing depending on patients’ location or age (8). The report also expressed concerns about the way sexual and reproductive health services are commissioned and the training available for GPs in sexual and reproductive health (SRH) available to GPs. You can read the full report here.
The RCGP offers various eLearning materials on sexual health and contraception and the following resources are FREE to all healthcare professionals:
Sexual Health in Primary Care – 2 CPD credits
Contraception – 1 CPD credit
HPV - the essentials – 0.5 CPD credits
Women’s Health Framework – Sexual and Reproductive Health Resources – some content is only free to RCGP members
RCGP Members can also benefit from access to the following resources:
EKU4 – Managing of genital chlamydia trachomatis infection
EKU9 – HIV in primary care and ‘HIV in primary care’ podcast
EKU2017.2 – Routine investigation and monitoring of adult HIV-1 positive individuals and increasing uptake of HIV testing
EKU hot topic (December 2014): HIV infection – Treatment and research
(1) World Health Organisation. 2016. ‘Sexually transmitted infections (STIs) factsheet’ [Online]. Available from: http://www.who.int/mediacentre/factsheets/fs110/en/
(2) Public Health England. 2017. ‘Infographic: Sexually transmitted infections and chlamydia screening in England, 2016’ [Online]. Available from: https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables
(3) Public Health England. 2017. ‘Sexually transmitted infections and chlamydia screening in England, 2016’ [Online]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/617025/Health_Protection_Report_STIs_NCSP_2017.pdf
(4) Hutton et al. 2008. ‘The Relationship between Recent Alcohol Use and Sexual Behaviours’. [Online]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588489/
(5) Connor et al. 2015. “Alcohol Involvement in Sexual Behaviour and Adverse Sexual Health Outcomes from 26 to 38 Years of Age”. Plos One. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135660
(6) National STI Day website. http://www.stiq.co.uk/about/
(7) Family Planning Association. 2016. ‘Sexual Health Week 2016’ [Online]. Available from: https://www.fpa.org.uk/sexual-health-week/sexual-health-week-2016
Royal College of General Practitioners. 2016. ‘Sexual and Reproductive Health Time to Act’ [Online]. Available from: http://www.rcgp.org.uk/-/media/Files/Policy/Media/8895-RCGP-Sexual-Health-online.ashx?la=en
Dr. Sam T. Claus was in the middle of a pleasant dream involving a mug of hot chocolate, several mince pies and a re-run of “It’s a Wonderful Life”. Inexplicably, the film was interrupted by a beeping noise and he woke to realise that his pager had gone off. Cursing the day when he decided to work in a practice that still does its own on call, he dialled the messaging service.
An hour later he was trudging through the snow to see Rudolph, a regular patient with a distinctive rhinophyma. Rudolph claimed this was due to rosacea, but Sam had his suspicions. Rudolph had told the messaging service that he was light-headed and thought it was his heart. Sam had other suspicions.
Sam found Rudolph on the sofa worse for wear snuggling with the remnants of a bacon sandwich. Concerned that getting close to Rudolph’s breath might get him into trouble with the local constabulary, Sam made a brief assessment and told Rudolph the unsurprising news that he had a hangover.
“But that’s not possible Doc”, exclaimed an indignant Rudolph “I’ve done my research”.
He pulled out a bag full of packets including some long-acting propranolol, a sachet of dried yeast and some fructose tablets.
“I’ve been online doc, any one of these will sort out a hangover and I took all three. There must be something wrong with me”.
“Aha” said Sam “you’ve consulted Dr. Google? I’m afraid he has led you astray. A meta-analysis of online hangover cures1 has clearly shown that none of them are any use – the only prevention is to drink moderately, or not at all. Have some paracetamol and lots of water– you’ll feel better soon”.
Sam left Rudolph to sleep it off, heading for the local nursing home where he was due for a ward round. He paused to pick up his beagle, Comet, this being an enlightened home which felt that the residents would benefit from contact with animals. As he made his rounds, Sam couldn’t resist the chocolates on most of the nursing stations and he reflected on how likely it would be that the boxes would still be there that evening. Probably not, a study having shown that the mean survival time of a chocolate on a hospital ward is 51 minutes2, with half the box generally being eaten in under two hours.
Sam’s mood worsened when he was asked to see Mrs. Blitzen, an elderly woman with severe diarrhoea following a course of co-amoxiclav. Cursing the overuse of broad-spectrum antibiotics, Sam approached her room and was amazed to see Comet race ahead of him, bark and lay down against her door. A sudden flash of recognition hit Sam as he remembered that Comet had taken part in a study whereby beagles were trained to detect Clostridium difficile and could do so with over 90% sensitivity and specificity3. Pulling on his gloves he prepared to dazzle the nurses with his quick-fire diagnostic skills.
Later that evening, a colleague now on-call, Sam was delighted to find that “It’s a wonderful life” was actually on the TV. Settling down with a hot chocolate and a plate of mince pies he reflected on his day and the curiosities that he might come across the next time he had the joy of holding the on-call pager.
- Pittler Max H, Verster Joris C, Ernst Edzard. Interventions for preventing or treating alcohol hangover: systematic review of randomised controlled trials BMJ 2005; 331 :1515
- Gajendragadkar Parag R, Moualed Daniel J, Nicolson Phillip L R, Adjei Felicia D, Cakebread Holly E, Duehmke Rudolf M et al. The survival time of chocolates on hospital wards: covert observational study BMJ 2013; 347 :f7198
- Bomers Marije K, van Agtmael Michiel A, LuikHotsche, van Veen Merk C, Vandenbroucke-Grauls Christina M J E, Smulders Yvo M et al. Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study BMJ 2012; 345 :e7396
As the campaign to overcome the stigma attached to mental health continues, self-harm is one of many symptoms of mental health issues that may present in primary care, particularly in children and young people. According to the Royal College of Psychiatrists, around 1 in 10 young people at any age will self-harm at some point (1). Incidence may be even higher than this, as many patients don’t seek help.
When they do seek help, GPs are likely to handle the initial conversation with the young person, taking a history, finding out their methods and how often they self-harm, whilst trying to establish possible triggers and underlying causes. This may seem like an impossible feat during a 10-minute appointment, but up to date numbers on self-harm show the importance of effectively dealing with self-harm at the first presentation.
According to a recent study published in the BMJ, there was a 68% increase between 2011-2014 in the number of girls aged 13-16 who reported self-harm to their GP (2) with a three times higher incidence rate than in boys. As shown before, those who self-harmed were at greater risk of suicide than those who didn’t. Out of the 16,912 records of self-harm that were examined in the study, the main methods were drug overdoses (84.1%) and self-cutting episodes (12.3%) (2). With these statistics in the media, they may raise awareness and subsequently encourage patients and/or their parents to visit their GPs. Self-harm has recently featured in popular TV programmes aimed at a younger audience: the teen soap opera Hollyoaks recently focussed on a group of female friends who turn to self-harm to cope with their personal struggles and looked at the impact this had on their lives. The subject was also touched upon in the controversial 2017 Netflix series 13 Reasons Why, which was criticised earlier this year for potentially glamorising suicide. Whilst the series primarily follows a suicidal teenager, it also makes reference to self-harm.
With a new spotlight on self-harm, it’s important for GPs to be aware of how to best manage these patients safely in primary care. The NICE clinical guideline on ‘Self-harm in over 8s: short term management and prevention of recurrence’ provides recommendations for all healthcare professionals and gives an overview of the next steps after a patient is referred.
For more information about how mental health issues in children and young people can be managed in general practice, we created the ‘Child and adolescent mental health’ course. The course is FREE to access for all healthcare professionals and will give you 1 hour towards your CPD. If you’re an RCGP member, you can also access the following resource:
(1) Royal College of Psychiatrists, 2016. ‘Self harm’ [Online] Available from: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx [Accessed 25 October 2017]
BMJ. 2017. ‘Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study in primary care’ [online] Available at: http://www.bmj.com/content/359/bmj.j4351 [Accessed 25 October 2017]
The Applied Knowledge Test (AKT) exam is coming up this month, which may mean that you have booked your place and are now ready to get started on some revision. Preparing for an exam can be nerve wracking and many people have their preferred ‘revision routine’ to ensure that the information sticks in their mind.
To make revising easier, the RCGP provides a tool called GP SelfTest, which is specifically geared towards preparing you for your AKT exam. The content is aligned with the RCGP curriculum, so you can be confident that you’re starting in the right place with your exam prep. GP SelfTest’s value goes beyond AKT too as its structure around the RCGP curriculum can help you create ePortfolio entries on what you have learnt and those areas that are more difficult.
Whether you already have your ‘go to’ revision method or you’re open to some tips, here are just some of the ways that GP SelfTest can adapt to your learning styles:
I prefer to revise…on the go
If you have some time to kill on your commute or you simply prefer to get out of the house when revising, you can take GP SelfTest with you. It can be used on tablets and mobile devices so you have an excuse to take a break from your computer.
I prefer to revise…in small chunks
Using an online tool to revise gives you the flexibility to dip in and out of the content. If you start a test on GP SelfTest, you can stop at any time and pick up where you left off when you’re ready to go back to it.
I prefer to revise…with a time limit
Some people find that learning under pressure works better for them. With the AKT mock exams on GP SelfTest, you have the option to select a timed test that replicates the amount of time you will have on the day.
I prefer to revise…by setting goals
After completing one of the AKT mock exams, GP SelfTest gives you the option of tracking and analysing your test results. This will give you an idea of what you need to work towards. The tool will also show you a benchmark comparison between your results and those of your peers.
I prefer to revise…by targeting improvement areas
If you’re not sure which areas require the most attention, you can take the Curriculum Wide Learning Needs Assessment exam, which contains a sample of questions from each topic. Based on your results, you can then complete a Topic-Specific test to further your knowledge.
To explore GP SelfTest for yourself and to see how it can fit in to your revision methods, you can access the tool here. Over 100 new questions have recently been added, with more coming soon.
For a first-hand account of how GP SelfTest helped Dr Rasitha Perera to prepare for his AKT exam, you can read his blog post here.
Over the last few months the population of the United Kingdom has witnessed an unusually high number of national tragedies in quick succession: the terror attacks in Manchester, Westminster, London Bridge, Finsbury Park and the devastating fire at Grenfell Tower.
There is clear evidence that traumatic events such as these can lead to the development of a range of psychological and mental health issues, such as adjustment and anxiety disorders, depression, and post-traumatic stress disorder (PTSD). While the spectrum of responses to these traumatic events is broad, they will nevertheless impact on the patient’s ability to function, on their relationships and their ability to work and socialise.
Some of those exposed will experience only a short-term period of distress of up to four weeks, but those who do not recover may develop more serious mental health problems. Even people who are not in close physical proximity to these events may experience heightened anxiety, and there will be some who will be particularly concerned due to real or perceived discrimination because of their religion and/or their ethnicity.
Primary care is facing significant and ongoing demands due to these events, as initial treatment is likely to be sought in general practice settings. While the vast majority of GPs will be familiar with the signs and symptoms of the aforementioned mental health problems, the diagnosis of post-traumatic stress disorder may be missed or attributed to depression or anxiety disorders.
To find out what we in general practice could do, I spoke to Dr Jonathan Leach, a GP in Bromsgrove with a special interest in post-traumatic stress disorder and was able to ask him a few questions. Jonathan served 25 years in the military and has personal experience of responding to and supporting colleagues and patients who have been involved in major incidents. I also had a look at the literature on PTSD in primary care and especially the ‘normal response’ to traumatic events and how we can support victims (including ourselves) in general practice.
As expected, the choice of literature is vast, so I started with the 2005 NICE guideline on PTSD (Jonathan Leach is one of the members of the NICE committee working on the update), which as usual was good value. I also liked the Royal College of Psychiatrists guidance on ‘coping after a traumatic event’ which listed the range of emotions and responses to expect after being exposed after a traumatic event. Under the ‘What happens next’ heading, the team of authors listed a range of emotions that victims might be experiencing:
In our conversation Jonathan emphasised that it is important for us to acknowledge to the patient that it’s normal and acceptable to feel like this. He also felt that we should allow our patients to express these feelings and give them time and empathy. Only if the patient does not improve after some time and the feelings and memories are becoming more intrusive, is it time to think about our diagnoses. The so-called ‘normal’ response can vary considerably: some patients will develop a marked reaction that resolves over a few weeks, while others have no or very little symptoms.
PTSD in primary care is common, but underdiagnosed: prevalence of PTSD is around 6-10% in the civilian population, so we should see a considerable amount of patients with these symptoms, though maybe sometimes without recognising the underlying diagnosis. There seems to be moderate evidence that the primary care PTSD screening test (PC-PTSD) has good accuracy as a screening tool in both military and civilian settings in high risk populations and it is easy to administer in just a minute or two. Jonathan reminded me that those high-risk populations are not only veterans and patients who have suffered a recent mass traumatisation event such as the Grenfell Tower fire, but also women suffering sexual violence. The National Women’s study reported that almost one in three female victims of sexual violence develop PTSD at some stage during their lives. These are often events that can go back a long time, so it is important that the symptoms are recognised and specialised PTSD treatment can be initiated. Brief psychological trauma focused interventions (five sessions) may be effective if treatment starts within the first month after the traumatic event for symptomatic patients, but beyond the first month, treatment should be trauma-focused CBT or EMDR. This of course depends on the availability of PTSD-focussed care on your patch.
For those of us who have been involved in traumatic events at work or outside the workplace, it is important to realise that just because we are doctors we are not immune to developing these symptoms. There are some papers examining the PTSD rates among emergency medicine and other hospital doctors, suggesting the numbers to be around 12-13%, higher than in the general population. I couldn’t find any numbers on PTSD in general practitioners but wouldn’t be surprised if the numbers are similar. Having psychological symptoms resulting from the things we have been exposed to at work is therefore not unusual, and if concerned, seek help from your own GP (or the NHS GP Health Service) and get advice, treatment and if necessary, take some time off.
While not everybody might share my taste in TV-Drama, I always thought the award winning West Wing episode “Noël” dealt with PTSD in a rather mature and touching way, and – while for most health professionals a bit too overdramatised and simplistic – demonstrates the intrusiveness of flashbacks and the emotional changes that victims can go through when exposed to traumatic events. Maybe one to watch on the weekend.
Bisson et al (2007): Early Psychosocial Intervention Following
Traumatic Events. Am J Psychiatry 164:1016 - 1019
Royal College of Psychiatrists (2013): Post-Traumatic Stress Disorder; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.aspx retrieved 04/08/2017
Royal College of Psychiatrists (2014): Coping after a traumatic event; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/copingafteratraumaticevent.aspx retrieved 04/08/2017
National Institute for Health and Care Excellence (2005): NG26 Post-traumatic stress disorder;
Bisson JI et al: Early Psychosocial Intervention Following Traumatic Events. Am J Psychiatry July 2007, 164:1016-1019
Sonis, J: PTSD in Primary Care—An Update on Evidence-based Management. Current Psychiatry Reports, Jul 2013, 15:373
Sorkin, A: Noël. The West Wing. Warner Bros; Dec 2000
Spoont et al (2015): Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review. JAMA Aug 04; 314(5), 501-10
Tjaden, P., & Thoennes, N. (1998). Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. National Institute of Justice Research in Brief. Retrieved from https://www.ncjrs.gov/pdffiles/172837.pdf
Wilberforce et al (2010): Post-traumatic stress disorder in physicians from an underserviced area. Family Practice, 27(3), 333-343
What are the questions going to be like? What are the areas I need to focus on? Do I need to focus on breadth of knowledge or detail or both? These are just a few of the questions I usually contemplate when preparing for an exam… and ones I felt I was able to answer prior to sitting my Applied Knowledge Test (AKT), thanks to RCGP’s latest learning resource – GP SelfTest.
Training to be a GP – an expert generalist – is challenging. The curriculum is broad and the need to cover this is reflected in the wide clinician experiences that we come across in our speciality training years. The need for Continuing Professional Development (CPD) and self-assessment therefore is ever more important.
With this in mind, the RCGP have developed GP SelfTest – a tool for AiTs and qualified GPs’ post Certificate of Completion of Training (CCT) to help identify and assess areas of learning. Having used the tool initially to help prepare for the AKT exam, I have come to appreciate its use not just as a revision aid but also to ensure that I can continually pinpoint and focus my learning long term.
The questions are usefully presented in a number of different ways. I started with the Curriculum-wide Learning Needs Assessment. This was particularly useful in taking that all important but scary first step into starting revision! This was a random selection of 100 questions that after answering, gives a breakdown of results by curriculum area and compares to results from peers. It usefully links to associated eLearning courses, EKUs and podcasts for each category in the RCGP curriculum.
There are also the options to filter a set of questions to a particular topic, have a “lucky dip” of a set number of questions or to sit a timed or untimed AKT Mock exam. Being able to focus on a topic/curriculum helps consolidate knowledge after a particular clinical rotation or learning experience such as paediatric rotation or dermatology clinic. Not only does it help ensure that knowledge learnt from a clinical setting is relevant to the GP curriculum but it can also help those wanting to develop areas of expertise.
There is a choice between a six months or 12 months subscription and you can get further information on GP SelfTest here: www.rcgp.org.uk/GPSelfTest. GP SelfTest is continuously being developed and the question bank being added to, so now is a great time to sign up and ensure you are prepared in being that expert generalist!
Rasitha Perera is a GPST2 doctor based in the Chesterfield training programme. He is the current Vice Chair of the RCGP AiT Committee and Committee Lead for the Learn work-stream.