_ RCGP Learning

The majority of people, including health care professionals (HCPs), have unconscious or implicit biases¹. These can affect the way we interact with colleagues, staff and patients, and even influence our decision making in regards to diagnosis and management of conditions².

Unconscious bias is the immediate judgement of something, or someone, based on our past experience, background and culture.  It is instinctive rather than a rational thought process and occurs almost instantaneously on encountering someone new. This bias can then influence our thoughts, beliefs and behaviour towards that person.

When we first meet someone, we subconsciously categorise them based on, for example, their gender, age, skin colour, accent, profession, sexual orientation³. We then use preconceived ideas of their intrinsic characteristics and form an immediate opinion about the person. Most people have unconscious biases, no matter how strongly they consciously oppose discrimination or prejudice. We tend to feel positively about someone who is similar to us, and negatively about those we perceive as ‘different’. These assumptions then effect the relationship we have with that person, including how close we will stand to them, and how often we make eye contact².

The term unconscious bias encompasses several types of bias such as gender bias, confirmation bias, age bias, and affinity bias, to name a few. These biases can affect everything from to which candidate we would offer a practice vacancy, to how we manage different patients with the same condition. It can be both positive and negative, as we may favour or disapprove of someone based on whether we feel they fit into ‘our group’ (namely, whether we feel they share similar characteristics to us).

Take a vacant salaried GP position as an example: You’re on the interview panel. The next applicant trained at the same medical school and enjoys the same hobbies as you. You immediately think ‘yes, this person is great’. The next applicant attended a rival medical school and has different hobbies; you’re not so sure about this applicant. This is an example of affinity bias. These opinions are formed without us even realising it and without taking into account the person’s qualifications or experience.  Once that initial judgement is formed, our brain then begins to gather evidence to support our assessment. However, this ‘evidence’ is also biased (confirmation bias) as we look for anything that will uphold our initial decision and disregard items that refute it.

Unconscious bias is well recognised in the interviewing process, and many private companies have procedures in place to reduce the risk of this happening⁴. But how does this translate into the world of healthcare?

Unconscious bias may have a significant impact on medical school admissions, with one American study reporting a notable race bias⁵ by those on the selection panel. International medical graduates (IMGs) are up to thirteen times more likely to be referred to the GMC than UK graduates⁶, which is thought to be due, at least in part, to unconscious bias. We commonly hear of female doctors being called nurse whilst male nurses or medical students are called doctor and are often talked to in preference to their senior female colleague.  

Not only does unconscious bias affect us and our colleagues, but it also has a crucial and concerning impact on our patients. In 2021 Mothers and Babies: Reducing Risks through Audits and Confidential Enquiries across the UK (MBRRACE-UK) released a report⁷ that showed black women were four times more likely to die in pregnancy than white women. Whilst socioeconomic factors and medical reasons were thought to contribute to the outcomes, this only accounted for a small proportion of women.  Black women report not being listened to or empathised with as much as their white counterparts⁸.

Graph from MMBRACE-UK 'Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19'. Used with permission from MMBRACE-UK. 

Several studies have shown that there is racial bias in regards to pain management, with black people frequently denied analgesia that their white counterparts are readily offered. Research by Hoffman et al (2016) reported that the false belief of biological differences between white and black people contributing to pain thresholds, are held by the general population, and more worryingly by medical students and qualified doctors⁹. This not only impacts women in labour, but all situations where adequate pain relief is important.

The Midlands Leadership Academy has developed an Unconscious Bias Toolkit¹⁰ which suggests several ways in which we can challenge our own unconscious biases.  The toolkit advises us to consider:

• What am I thinking?
• Why am I thinking it?
• Is there a past experience that is impacting my current decision?
• Is the past experience applicable now or is it based on a preference or bias?

Furthermore, the Royal Society⁴ advise that we should slow down when making decisions, reconsider reasons for decisions, question cultural stereotypes and monitor each other for unconscious bias. The Royal College of Surgeons have published a document on reducing unconscious bias¹¹ in which they suggest using Thiederman’s Seven Steps for defeating bias in the workplace.

1. Become mindful of your biases 2. Put your biases through triage 3. Identify the secondary gains of your biases 4. Dissect your biases 5. Identify common kinship groups 6. Shove your biases aside 7. Fake it till you make it (what we say can become what we believe)

Medical education - whether undergraduate or postgraduate - has a responsibility to promote curricula in a non-biased way.  There has recently been a push to decolonise medical education and incorporate cultural safety¹²: Decolonising medical education involves challenging beliefs and introducing ‘new normals’ such as representing signs and symptoms of illnesses in different skin tones; or promoting issues faced by discriminated groups, for example, including violence against women and racism in curricula¹³. Cultural safety is a concept developed by Māori Nurse Educator Irihapeti Merenia Ramsden, who recognised the health inequalities between indigenous and non-indigenous people in New Zealand. Cultural safety is to understand that health inequality is based on historical prejudice, and using lived experiences of those who have experienced discrimination ensures that differences in culture are respected throughout healthcare. If health care professionals and students understand how conditions may present in different ethnicities and genders, really listen to patients experiences and concerns regardless of their skin colour or own beliefs, and learn to challenge their unconscious bias, then hopefully we will develop a generation of healthcare professionals who can more fully appreciate and challenge health inequality in the UK.

The RCGP has recently launched an interactive eLearning module on Allyship, which includes information and suggested actions to promote anti-racism and bystander intervention. You can access the course here: https://elearning.rcgp.org.uk/allyship

References

1. Schwarz, J., 1998. Roots of unconscious prejudice affect 90 to 95 percent of people, psychologists demonstrate at press conference, University of Washington, [online]. Available at: https://www.washington.edu/news/1998/09/29/roots-of-unconscious-prejudice-affect-90-to-95-percent-of-people-psychologists-demonstrate-at-press-conference/ [Accessed 06 April 2022]
2. FitzGerald, C. and Hurst, S., 2017. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18, 19. https://doi.org/10.1186/s12910-017-0179-8.
3. Rice, M., 2015. Unconscious bias and its effect on healthcare leadership. Healthcare Network, The Guardian. [online] Available at: https://www.theguardian.com/healthcare-network/2015/may/19/healthcare-leadership-best-practice-unconscious-bias. [Accessed 04 April 2022].
4. Frith, U., 2015. Understanding Unconscious Bias. The Royal Society. [online] Available at: https://royalsociety.org/topics-policy/publications/2015/unconscious-bias/?gclid=CjwKCAiA6seQBhAfEiwAvPqu18TssncdweUmNPHBiUb8o2UHBslILV8UOvM-fs7ePvbngXtmq6fdrRoC-PYQAvD_BwE. [Accessed 04 April 2022].
5. Capers, Q., 4th, Clinchot, D., McDougle, L., and Greenwald, A. G., 2017. Implicit Racial Bias in Medical School Admissions. Academic Medicine: Journal of the Association of American Medical Colleges, 92(3) pp.365–369. https://doi.org/10.1097/ACM.0000000000001388
6. Rimmer A, 2017. Unconscious bias must be tackled to reduce worry about overseas trained doctors, says BAPIO. British Medical Journal, 357 :j1881 doi:10.1136/bmj.j1881.
7. Knight, M., et al on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. [online] Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021. Available at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf [Accessed 04 April 2022]
8. Brathwaite, C., 2018. Black Mothers Are Disproportionately More Likely To Die In Childbirth - We Need To Address The Race Gap In Motherhood. Huffington Post [online] Available at:  https://www.huffingtonpost.co.uk/entry/race-motherhood-black-mothers-dying-childbirth_uk_5c078da3e4b0a6e4ebd9d5ec [Accessed 04 April 2022].
9. Hoffman, K.M., Trawalter, S., Axt, J.R., and Oliver, M.N., 2016. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), pp.4296–4301. https://doi.org/10.1073/pnas.1516047113.
10. Masuwa, P. and Sharma, M. Unconscious bias toolkit. NHS Midlands Leadership Academy. [online] Available at: https://midlands.leadershipacademy.nhs.uk/wp-content/uploads/sites/3/2020/12/Unconscious-bias-toolkit-final-version.pdf.
11. Royal College of Surgeons of England, 2016. Avoiding Unconscious Bias: A guide for surgeons. [online] London: The Royal College of Surgeons of England (Published 2016) Available at: https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/avoiding-unconscious-bias/ [Accessed 04 April 2022]
12. Wong, S.H.M., Gishen, F. and Lokugamage, A.U., 2021. ‘Decolonising the Medical Curriculum‘: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. London Review of Education, 19(1). DOI: 10.14324/LRE.19.1.16.
13. Lokugamage, A.U., Ahillan, T. and Pathberiya, S.D.C., 2020. Decolonising ideas of healing in medical education. Journal of Medical Ethics 46(4), pp.265-272. http://dx.doi.org/10.1136/medethics-2019-105866.

Children with life-limiting conditions face significant challenges when they transition from paediatric to adult care. The transition involves many changes:  the young person will transfer to adult specialities, to adult social care, and will experience changes in educational provision and legal changes involving parental responsibility for medical decision making.

The transition has been described as a ‘cliff-edge’ event, during which children and their families face significant stress, challenges, and unmet needs. When general practice is already aware of such a patient within their practice, a good service is already provided in many cases, but often young people with these conditions are not always visible, as the majority of their care is provided by paediatrics. Many of these young patients who thus far have had long term continuity of care from their paediatricians feel nervous or have little confidence in general practice and their ability to meet their complex needs. In some cases this can lead to ‘fire-fighting’, where general practice has to respond to crisis calls from young people (or their carers) with whom they may have had limited contact.

Recently, a small team at the RCGP – together with their colleagues from ‘Together for Short Lives’, produced an eLearning course on how the whole primary care team can contribute towards a good health transition from paediatric to adult care.  These modules are for all primary care clinicians who want to provide excellent care for a young person with a chronic and/or life-limiting condition who is transitioning from paediatric to adult care. The modules are based on the insights generated by a  pilot project which involved a steering group inclusive of general practice, palliative care, paediatricians, academics, and ‘Together for Short Lives’. Written by Dr Mike Miller, a paediatric palliative consultant with first hand experience of the pitfalls during transition and Dr Peter Lindsay, a GP with a special interest in paediatrics, the course combines the latest academic insights on health transition and the experiences of the authors and the steering group team.

During the pilot project, we recognised that there is overlap between young people with chronic and/or life-limiting conditions and young people with learning disabilities, and although the groups are distinct, there are similarities in their transition process. In many areas, local transition services for young people with complex needs are evolving rapidly: Leeds have developed an evolving transition network, and so far involves ongoing collaborations between education, the local children's hospice, social care, mental health services and learning disability leads.

As part of the pilot project, we performed initial searches within our practices for patients within these categories, and are now trying to develop processes to support transition. The pilot project highlighted the positive impact we can have in supporting the young person and family at a challenging and stressful time, and how we can improve health and social outcomes. As well as the routine care offered, general practice is uniquely placed to offer continuity of care through the transition period, early preparation for the transition to adult service, social prescribing and the help of the whole primary care team.  Primary care is also perfectly placed to address health needs that often go under-recognised in this group, such as sexual health and contraception. If we can develop mechanisms to reliably identify these patients, then young people with chronic and/or limiting conditions will benefit from all that primary care can offer.

The eLearning modules firstly outline the challenges facing young people and their families during the transition period, from the perspective of a paediatric palliative care consultant who has devoted much of his career to improving the experience of young people and their families at transition. Secondly, poorly understood areas are tackled, such as the legal framework underpinning mental capacity at transition, and the practical implications of this for the young person and family. The second module presents practical approaches and best practice to support this area in a GP setting, in the current challenging and busy context of general practice. Please see below for some tasters from the eLearning modules.

Please also see the Developing Positive Transitions for Primary Care resources section, which signposts to further key information.

If you would like to learn more please see our eLearning modules and further learning resources: 

'Better transitions: improving young people’s transfer from paediatric to adult services' eLearning course: https://elearning.rcgp.org.uk/bettertransitions

'Developing Positive Transitions for Primary Care' resources page: https://elearning.rcgp.org.uk/course/info.php?id=329

No-one expects their child to die before them – it isn’t the natural order of things.

From miscarriages to stillbirths and from perinatal deaths to deaths in childhood, the death of a child is a unique type of loss.

Pregnancy loss is the most common form of child loss. It is currently estimated that one in four pregnancies ends in miscarriage¹ so it is something many parents will experience. Even though they may have never been able to get to know their child, they will still feel a huge loss. They grieve the potential to get to know that child and the life they would have had. Many parents will also feel a sense of guilt following a miscarriage so it is important to look out for any hint of this and to reassure the parent that this was not their fault.

When a parent loses a child of any age, in that split second, their world is changed forever. They lose not only their child, but also many of the social networks linked to their child. They lose the potential to see that child grow up and if the child was their only child, their identity as a parent and the chance to become a grandparent. They lose not only the present but also the future. The loss of a child for this reason is very different to other types of grief.

Traditionally, grief has been described in a series of stages: Denial, anger, bargaining, depression and acceptance. Current thinking has now moved towards the ‘grieving process’ as a more accurate model. Whilst grieving, it is possible to move forwards and backwards between the phases over time. Some individuals skip phases and others may spend a long time at one particular stage. Certain anniversaries or triggers may cause the grieving person to move between phases fluidly.

 

In 2007, Harper et al showed that in the 15 years after losing a child or having a stillbirth, bereaved mothers were 2-4 times more likely to die than non-bereaved mothers and that the excess risk persists for 35 years after the bereavement, though the magnitude of the risk drops with time. The increased risk persists for three years for fathers, though clearly they have an increased risk of being widowed for much longer. The reasons for this phenomenon are not clear, but could involve immunosuppression due to severe stress, maladaptive coping strategies such as alcohol misuse, pre-existing poor health which may have contributed to the child bereavement, mental ill-health following bereavement, or bereaved parents presenting later with their own physical health problems. Further research into this area would be useful. The relevance to general practice is probably that we should be aware of this risk and make particular use of the GP ‘spidey sense’ when dealing with this group of patients. Never ignore your gut feeling as a GP – it has been shown to be reliable³.

I am writing this blog from personal experience, after losing my four-year-old daughter Grace to cancer in 2014. My personal experiences have helped me to support many other families in similar situations and in 2018 I wrote an eLearning course for the RCGP, designed to provide GPs with the tools to support patients who have experienced a loss during pregnancy, or the death of an infant or child. Each family needs something different, but the overwhelming message is that having someone simply able to be there for them as a point of contact, it can make a big difference.

When a family loses a child, it also has a significant impact on their siblings. Life for their surviving siblings never returns to normal so it is important to remember that their bereavement will affect many aspects of their life and behaviour.

“I feel like there is a piece of me missing. My friends get to play with their brothers and sisters. All I can do is look at a photo or visit his grave. It just isn’t fair. I feel on my own, and my friends don’t understand.”  A bereaved sibling, aged 8.

Often, a few simple measures taken by a practice can make a sizable difference to help families realise that they are not alone. When the practice has been informed of a child death, it is important to contact the family, by phone if possible. This need only be brief, but families do appreciate this and remember this contact down the line.

Families should be provided with a named GP, and alerts placed on the notes of both parents and all siblings so practice staff and professionals can be aware of the history without the family needing to repeat themselves each time.

If possible, enable bereaved parents and siblings to make appointments at minimal notice for a limited time. The death of a child can plunge a family into chaos meaning things are easily forgotten or they may need to be seen quickly to help with acute emotional situations.

Ensure that all professionals are notified. Check that electronic alerts inviting the deceased child for immunisations, reviews or other routine care have been turned off. It is also useful to familiarise yourself with the services and support that are available in your local area to signpost families to as required.

General Practice is extremely busy at the moment, but these simple measures are relatively time efficient and can make a real difference to these families.

 

References

1 Wilcox AJ, Weinberg CR, O'Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med, 1988; 319(4): 189-94. 

2 Harper M, O'Connor RC, O'Carroll RE. Increased mortality in parents bereaved in the first year of their child's life. BMJ Support Palliat Care, 2011; 1(3): 306-9.

3 Friedemann Smith C, Drew S, Ziebland S et al. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. British Journal of General Practice 2020; 70 (698): e612-e621.

'Stages of Grief' image used with permission from WPSU's Speaking Grief project. 

An NIHR GM PSTRC (NIHR Greater Manchester Patient Safety Translational Research Centre) funded free e-learning course which has been accessed by 7000 prescribers since 2014 has undergone an evaluation and been re-launched with the addition of new content. 

Dr Richard Knox from the University of Nottingham is one of the researchers who has worked on the e-learning course, Prescribing in General Practice. He talks about the impact of the course and the new updates here:

Prescribing in General Practice is an e-learning course, hosted on the Royal College of General Practitioners’ (RCGP’s) e-learning platform. It’s a case-based approach designed by prescribers so there’s a focus on real life examples. It was launched in 2014 and has recently undergone revisions from people who use it to ensure all the real-life examples that are used meet current guidelines.  The course was also evaluated by researchers at the GM PSTRC in a new paper, which has been published in the journal Education for Primary Care.

To help assess the course’s success, in the paper, researchers used the results of a questionnaire completed by those who finished the e-learning modules. According to this the course had a positive impact on knowledge, skills and attitudes. More than 98% of 750 survey responders said the course had been a useful part of their continuing professional development.

Those who responded also wrote additional feedback and some examples are below:

“This module comprehensively covered contemporary prescribing issues particularly with respect to safety. It was grounded in everyday practice and informed by real life examples of prescribing errors and how they may occur and how to mitigate against them at an individual and at a systems level.”

“Usefully it was from the RCGP so the majority of medicines and cases presented were similar to what I would encounter on a daily basis in work. I feel from completing this module my safety and efficiency in prescribing will improve.”

“This course is going to change/improve many aspects of my prescribing practice. I would definitely spend more time on writing clear instructions for patient.”

The course was initially developed to facilitate safer prescribing among GPs. However, funding from the GM PSTRC has enabled the course to be free-to-use for all prescribers, regardless of professional background. This has increased the impact of the course which improves the safety of prescribing more widely.

The original idea for the e-learning materials came as a direct result of findings from the General Medical Council’s PRACtICe study. This was a large study of prescribing errors in UK general practice, which revealed that about one in twenty prescriptions from primary care contains an error. The PRACtICe study included a root cause analysis that helped establish a set of recommended strategies that may improve prescribing. The need to invest further in education and training was identified by all GPs, whatever their stage or experience of prescribing. A series of focus groups made up of GP trainers, GPs in training, pharmacists and members of the public also confirmed support for further training to be made available. The value of e-learning was championed – with stakeholders requesting a strong case-based approach to help inform real-world practice.

The e-learning includes five distinct lessons, each taking about thirty minutes to complete:

• Lesson one – Appropriate drug selection
• Lesson two – Avoiding prescribing errors
• Lesson three – Choosing the right drug
• Lesson four – Right dose instructions
• Lesson five – Effective medication reviews

Due to the updates the course now includes specific sections on topics such as prescribing multiple medications for the same person at the same time (polypharmacy) and the use of the Seven Step medication review process.

Please note, this course is now RCGP Members' benefit. Non-members have an option to purchase the course. You can access the Prescribing in General Practice course here.  

“Medicine is an art whose magic and creative ability have long been recognised as residing in the interpersonal aspects of the patient-physician relationship¹”.

Art is part of medical training from early on - lectures in medical school use images, cartoons, animations, and demonstration models. In our hospital jobs we all used drawings, lung fields with crosses, or a hexagon abdomen with a large liver on it were all used in the days of paper notes. However when asked to draw, medical students often recoil and claim that they are ‘not creative’ and cannot draw².

We are trained in communication skills to gather information in order to facilitate accurate diagnosis, counsel and give therapeutic instructions whilst establishing caring relationships with patients³. Patients gather information from many different visual sources in the GP surgery, so using drawings is a natural next step, yet one that is rarely discussed.

We already use visual imagery in the consultation - as GPs we might point to anatomical posters in our rooms, use drawings for minor surgery consent, or the “clock test” in dementia screening. Encouraging people to see drawing as a form of learning can help them to present information more efficiently within the consultation⁴.

We also all use metaphor and analogy frequently - as Anatole Broyard describes, metaphors may be as necessary to illness as they are to literature and are a relief from medical terminology⁵. Metaphors bridge the communication gap between healthcare professionals and patients, examples including the following:

“My tongue feels weird, like licking a battery.” (Oral thrush)

“Doctor, you know when you put your hand in a bag of rice – that nice sort of tingly feeling – I get that in my head in a sort of shock.” (SSRI discontinuation syndrome)

Clinicians can use visual metaphors; drawing a plug to describe the wrist retinaculum (Image 1) can increase understanding of the pathophysiology of carpal tunnel symptoms and be a simple start from which patients can improve their understanding.

While anecdotal evidence for the benefits of drawing in the consultation is plentiful, research is limited: A team at Edinburgh university were the first to document the use of drawing amongst 100 surgeons, 92% of whom valued drawing in surgical practice². Similarly, the vast majority of patients valued drawing in moderate or complex surgery consent explanations³. There is plenty of evidence for the neurological and cognitive benefits of using images in undergraduate and postgraduate pedagogy⁴, alongside the cognitive processing of learning⁵.

Before I studied medicine I attended the Glasgow School Of Art, reading Visual Communication.  I was taught to consider what it was I wanted to say, and then work out how best to communicate it visually. This meant considering which material to use and to capture the spirit of the subject I was drawing using appropriately descriptive markings.  This trained me to describe the essence of a concept or object and its function or position in the world. These principles can add value to a consultation as drawing supplements or contextualises the words we use. It can improve a patient’s understanding of physiology, pathology and pharmacology and reduce health anxiety; there is evidence that patient drawings can predict health outcomes and provide doctors with more insight into the patient experience⁶. Cartoons can be particularly helpful to explain pharmacology, particularly for those with limited literacy (Image 2). Colour is important – the red of an inflamed tympanic membrane, or a different colour to demonstrate a middle ear effusion. Just a few different pens can improve understanding.

My patients often ask to keep the drawings that I do (sometimes with the patient’s help) in a consultation as it represents their understanding of what was said. I see drawing as an adjunct in communication and possibly as a way to reduce complaints that can arise when patients feel that they have not been heard.

The use of images is not one-way as patients may add their own drawing, or bring pictures on their mobile device⁶.  The following drawings (with patient permission) show personal representation of the pain experience in cluster headache (Image 3) and in these descriptive sketches (Image 4) the pain of end stage osteoarthritis with spondylolisthesis. Reference to the feeling of dragging and vice-like pain can be seen. I am not alone – there are other professionals using imagery in medicine.

 

Professor Gabrielle Finn fosters a network of artists, scientists, educators and health professionals interested in alternative methods of displaying by painting anatomical structures directly onto the body.  She has kindly given permission for an image to be used here (Image 5).  Her work crosses specialties and encourages innovative alternative approaches to learning.

The team around Professor Paul Rea, Professor of Digital and Anatomical Education at the University of Glasgow, created an animation explaining hypertension using clay models which simply describe concepts which are difficult to describe verbally.

Professor Alice Roberts, Professor of the Public Engagement in Science at the University of Birmingham, uploads anatomical videos of embryological folding, and musculoskeletal anatomy, sometimes with the help of Jelly Babies.

 

In summary, at times there is a need in the doctor-patient consultation to change or extend the communication style. We can let our patients take over the pen to illustrate their concerns or symptoms. Good communication within the GP consultation and the use of alternative techniques to describe issues are valuable tools : sometime words fall short.

This blog was written by Dr Holly Quinton, GP and Illustrator. All images in this blog were provided by Holly with patients' consent. You can read more about Holly and visual consultations in the following BJGP article: How I use drawing and creative processes within the GP consultation. 

References:

¹Hall JA, Roter DL, Rand CSJ Health Soc Behav. 1981 Mar; 22(1):18-30

²Keenan I, Hutchinson J, Bell K, 2017, 'Twelve tips for implementing artistic learning approaches in anatomy education', MedEdPublish, 6, [2], 44, https://doi.org/10.15694/mep.2017.000106

³ Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, Lofton S, Wallace M, Goode L, Langdon L; Participants in the American Academy on Physician and Patient's Conference on Education and Evaluation of Competence in Communication and Interpersonal Skills. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Acad Med. 2004 Jun;79(6):495-507. doi: 10.1097/00001888-200406000-00002. PMID: 15165967.

⁴ Keenan I, Hutchinson J, Bell K, 2017, 'Twelve tips for implementing artistic learning approaches in anatomy education', MedEdPublish, 6, [2], 44, https://doi.org/10.15694/mep.2017.000106

⁵ C Kotei: Metaphors in Medicine Synapsis Journal Oct 2017

⁶ Daeboudt, Broadbent, Berger & Kaptein, Lupus, 20,290-289

Cardiovascular disease (CVD), which comprises myocardial infarction, angina and strokes, is ranked as the number one cause of mortality and is a major cause of morbidity world wide. The current NHS long term plan contains a goal to prevent 150,000 myocardial infarctions and cerebrovascular accidents in the United Kingdom over the next few years.

For those of us  working in primary care, HMG-CoA reductase inhibitors (statins) have for some time been an important part of primary prevention of cardiovascular disease. We know that they reduce the risk of a first event for healthy individuals at high risk of CVD and reduce the chance of a further event in secondary prevention. According to NICE, statins should be offered to anyone who has a 10% or greater risk of developing CVD in the next 10 years¹ which makes them one of the most commonly prescribed drugs in the UK. 

As the numbers needed to treat (NNT) are well within the range considered worthwhile in primary prevention (such as hypertension) but higher than in other interventions², patients may have mixed feelings about taking continuous medication if it is not certain that they will directly benefit.  

With the help of a QRISK2 calculator you can break down the numbers into a theoretical group of 100 patients all with a QRISK score of 10% and demonstrate the numeric benefit.

On a population level, the benefits of taking statins are a lot more evident. According to NHS England, if only 45% of the people in the ‘at high risk’ category for CVD were identified and treated, 6000 strokes and heart attacks could be avoided over the next 10 years³. NICE estimate that when treating 500 people over a period of 3.9 years, 1 death from CVD could be avoided. They also estimate that treating 46 people for 3.7 years would prevent one non-fatal myocardial infarction⁴. From a public health point of view, this would prevent a significant amount of events and deaths overall considering there are 7-8 million people taking statins in the UK alone⁵.

Patients may be reluctant to start or continue taking statins if they hear negative media reports about their side effects. A study from the British Heart Foundation (BNF) found that 11% of people were more likely to stop taking statins for primary prevention of CVD, after a period of particularly negative media coverage during 2013-2014⁵. 

NHS England are currently reviewing if high-dose statins can be made available directly from pharmacists, to enable easier patient access and ultimately lower the levels of heart disease and stroke. They estimate that these conditions cost the NHS more than £7 billion a year³, whereas dispensing statins costs around £98 million a year as of 2018⁵. 

 

The following resources can help with explaining the benefits and risks of statins to patients:

• British Heart Foundation – Statins information sheet
• NICE – Are statins the best choice for me?
• NICE – Patient decision aid
• PHE - Health Matters: What you need to know about statinsh

You can also access the recently launched ‘Reducing cardiovascular risk in primary care’ eLearning course for FREE on the RCGP eLearning site. RCGP Members can also benefit from access to the ‘Risk estimation and the prevention of cardiovascular disease’ module in EKU 2018.1.

 

References

¹ NICE. 2016. Are statins the best choice for me?. [Online]. Available from: http://indepth.nice.org.uk/are-statins-the-best-choice-for-me/index.html

²  Taylor, F et al. Statins for the primary prevention of cardiovascular disease (2013) Cochrane Systematic Review – Intervention https://doi.org/10.1002/14651858.CD004816.pub5

³ NHS England. 2019. NHS to review making statins available direct from pharmacists as part of Long Term Plan to cut heart disease. [Online]. Available from: https://www.england.nhs.uk/2019/09/nhs-to-review-making-statins-available-direct-from-pharmacists-as-part-of-long-term-plan-to-cut-heart-disease/

⁴ NICE. 2016. Multimorbidity: clinical assessment and management (NG56). [Online]. Available from: https://www.nice.org.uk/guidance/ng56/resources  

⁵ British Heart Foundation. 2020. Statins: 10 facts you might not know. [Online]. Available from: https://www.bhf.org.uk/for-professionals/healthcare-professionals/blog/statins-10-facts-you-might-not-know

The Learning hubs are the newest addition to the RCGP’s Online Learning Environment (OLE) and serve as a ‘one-stop shop’ for any resources that GPs may need to find on a specific topic. Within each hub, there are various modes of learning, including standard eLearning courses and bite-sized learning such as; screencasts, podcasts, apps and patient journeys.

The link to the main hub page is conveniently located on OLE homepage, in a blue block named ‘Learning hubs’. This main page lists all of the topics available and provides easy access to each individual hub. When a user selects a hub, the hub page will show you a range of different sub-topics and the modes of learning available.

The learning hubs were introduced to provide an easy way for GPs to find the content they need for their CPD and to ultimately create a better user experience. Having a centralised topic area means that GPs don’t need to waste time searching for the content they want to access. Instead, they can find all of the resources they need in one place. GPs can dip in and out of each mode of eLearning and can therefore fit their learning around appointments and their day-to-day roles. It is also easy to track the learning they have completed on a particular topic and add this to their appraisal toolkit. Find out more about uploading RCGP eLearning completions to the Clarity appraisal toolkit.

 Here are the top five benefits of using a topic-specific hub:

1. As mentioned previously, GPs can spend more time learning, rather than searching for relevant CPD
2. Each Learning hub features examples of the different types of eLearning you can find on the RCGP’s OLE
3. Users can benefit from trying different types of learning to see which mode works best for them
4. All of the learning completed in the hubs counts towards CPD
5. The resources in each hub build on each other, providing GPs with a broad knowledge on that one topic

 

Currently, there are four hubs live on the OLE. These are as follows:

Allergy

The Allergy Hub encompasses all of the types of learning available on the RCGP’s OLE. It consists of eLearning modules, an app, a podcast, a patient journey and a screencast. These resources aim to educate GPs on the various presentations of allergy, including food allergy and respiratory problems such as asthma. They also cover symptoms, management in primary care and when to refer to secondary care. 

The Allergy Hub includes the following resources:

• Allergy eLearning course
• Asthma eLearning course
• Allergy education app
• Food allergy podcast
• Common Atopic Presentations in Primary Care - screencast
• Patient cases: Practical Aspects of Allergy Diagnosis – patient journey

 

Autoimmunity

The Autoimmunity Hub primarily focusses on coeliac disease, including an eLearning course, podcast and app that all feature this sub-topic. There is also a patient journey module which looks at four different autoimmune diseases, from initial presentation to diagnosis. These resources aim to help GPs through autoimmune disease diagnosis, management and referrals in primary care.

The Autoimmunity hub includes the following resources:

• Coeliac eLearning course
• Coeliac disease podcast
• Autoimmunity education app
• Patient cases: Managing Uncertainty in Autoimmunity – patient journey

 

 

LGBT

This collection of eLearning modules, podcasts and screencasts aims to inform and update all members of the general practice team on particularly important aspects of primary care for LGBT people, to improve both experience and outcomes for our patients. It was produced with the help of a grant by the Government Equalities Office and with the guidance of the RCGP’s LGBT+ steering group.

The LGBT Health Hub includes the following resources:

eLearning courses:

• Inequality in healthcare provision: the current state of LGBT health
• Creating an inclusive primary care environment
• Mental health and suicide prevention
• Screening issues in the LGBT population
• The older LGBT Patient
• Sexual and reproductive needs of the LGBT community

Screencasts:

• Addressing LGBT Health inequalities
• Understanding the non-binary patient
• Using language that is inclusive of the LGBT population

Podcasts:

• Improving your practice to be more inclusive
• Sharing vs disclosure
• Parents of LGBT kids

 

Diabetes

The latest addition to the ‘Learning Hubs’ section is the Diabetes hub, which contains five eLearning courses, three screencasts and two webinars. Whilst the primary topic is diabetes, GPs can access a range of different topics under this umbrella; ranging from medication, lifestyle modification, the NHS Diabetes Programme and most recently, diabetes and COVID-19. These resources aim to help GPs with general diabetes management and advises on how to work with patients to control their condition.

The Diabetes hub includes the following resources:

eLearning courses:

• Polypharmacy
• Diabetes Medication Review & Optimisation
• Targeted use of Anti-Diabetics
• Type 2 diabetes and the low GI diet
• NHS Diabetes Prevention Programme

Screencasts:

• Lifestyle Modification
• Newer Insulins
• The Management of Diabetic Kidney Disease

Webinars:

• Type 2 Diabetes: Dialogue with Experts
• COVID-19 & Diabetes

 

Access the main hub page.

Intermittent fasting (IF) is a pattern of eating whereby the person undertakes a regular (usually daily) fast of at least 16 hours. In light of National Obesity Awareness Week in January or in keeping with New Year’s resolutions, patients may seek advice on weight loss from their GP and opinions on the efficacy of certain diets. This blog will discuss some of the evidence around fasting for weight loss and management of type 2 diabetes (T2D) and other cardiovascular risk factors.  

Ingested food is stored in the body as liver glycogen and as fat, the process of lipogenesis being mediated by insulin. Energy is provided by glycogenolysis, however after around 12 hours of fasting, hepatic glycogen becomes depleted and adipose tissue lipolysis begins to occur. A recent NEJM review article suggested that ‘intermittent  fasting  elicits  evolutionarily  conserved,  adaptive  cellular  responses  that  are  integrated  between  and  within  organs  in  a  manner  that  improves  glucose  regulation,  increases  stress  resistance,  and  sup-presses inflammation”¹

For patients, we can explain that across our evolution we not always had access to three meals a day, and that after about 8 to 12 hours the body enters a ‘fat burning’ phase.

There are many ways to fast, with the most basic being a fast of at least 16 continuous hours in every 24. To get results in terms of weight loss or increased health benefits, the fasts should ideally be done on a daily basis. Two popular IF methods are as follows:

• 16:8 – Fast for 16 hours and eat all meals within an 8 hour window. This typically means skipping breakfast and eating two meals a day.

• 20:4 – Fast for 20 hours and eat all meals within a 4 hour window. This would involve eating one meal or having two smaller meals a day.

 A relatively short fast of 16 hours can be incorporated as part of daily life. The ‘intermittent’ nature of IF is that the fasting is flexible and at the convenience of the individual – the number of fasts per day and the exact hours of fasting can be altered if needed e.g. to allow the patient to eat normally at a social event.

Alternative methods include the 5:2 diet, which includes eating a balanced diet for 5 days out of the week and only consuming 500 calories for the remaining 2 days. Whilst this has been shown as an effective method for weight loss, it differs from intermittent fasting as it involves reducing calorie intake instead of not eating at all. 

There is evidence to suggest that IF may reduce the need for prescribed insulin in patients with diabetes².

IF is a relatively new concept, with some studies being small and of short duration; longer and larger studies are needed. Some examples of the evidence around IF are given below:

• A 2014 crossover study of 54 patients with T2D found that the group which ate only two meals per day, had better outcomes than those who ate the same calories spread out over six smaller meals. The group eating only two meals per day had a greater reduction in BMI, waist circumference and fasting plasma glucose³.

• A 2015 literature review of 15 studies found that various types of fasting reduced weight and improved lipid profiles and called for further research, with greater information about food intake so as to differentiate between the benefits of fasting and the benefits of calorie restriction⁴

• A 2019 study randomised 88 obese women into four groups (control, calorie restriction and IF with or without calorie restriction). All food was measured and provided by the study. Those who fasted for 24 hours three times a week lost more weight than those who simply restricted their calories, even though the calorie intake of the two groups was identical. The fasting group also had lower lipids and fat mass than the calorie restriction group⁵.

• A 2019 study of 15 men who limited their food intake to nine hours in each 24 hour period, whilst wearing a continuous glucose monitor, were found to have improved glucose tolerance and fasting triglycerides during the fasting period compared to the control period⁶.
• Another 2019 study followed 19 participants with metabolic syndrome who limited their dietary intake to a 10 hour period for 12 weeks. There were significant reductions in BMI, waist circumference, LDL cholesterol and blood pressure⁷.

It seems that IF therefore has the potential to be beneficial for patients with T2D and metabolic syndrome; it may be the case that educating patients on the benefits of IF can help in the management of T2D and reduce the need for pharmacological interventions⁸.

IF is a relatively new concept in relation to T2D so there are no official guidelines for healthcare professionals on how to manage a diabetic patient who wishes to do try it. As with any kind of fast, it is not recommended for pregnant/breastfeeding women or for children.

RCGP members can find out more about using diet to manage Type 2 diabetes by accessing our eLearning course on ‘Type 2 diabetes and the low GI diet’. Non-members can pay £25 to access this course.

The following resources are free to both members and non-members:

• ‘Five Minutes to Change your Practice’ screencast on Updated management of type 2 diabetes in adults
• EKU Journal watch item on Effects of intermittent fasting on health, aging, and disease

RCGP members can also benefit from free access to the following resources on Type 2 diabetes:

• EKU17: Diabetes in Adults, Children & Young People (Type 1 & 2)
• EKU18: Type 2 Diabetes in Adults: Management
• EKU Screencast: Type 2 diabetes in adults: management

References

1 De Cabo, R., & Mattson, M. P. (2019). Effects of Intermittent Fasting on Health, Aging, and Disease. New England Journal of Medicine, 381(26), 2541–2551. doi:10.1056/nejmra1905136

² Diabetes UK,  2019. About Type 2 diabetes. [Online] Available at: https://www.diabetes.org.uk/Type-2-diabetes

³ Kahleova H, Belinova L, Malinska H, et al. Eating two larger meals a day (breakfast and lunch) is more effective than six smaller meals in a reduced-energy regimen for patients with type 2 diabetes: a randomised crossover study [published correction appears in Diabetologia. 2015 Jan;58(1):205]. Diabetologia. 2014;57(8):1552–1560. doi:10.1007/s00125-014-3253-5

⁴ Grant M. Tinsley, Paul M. La Bounty, Effects of intermittent fasting on body composition and clinical health markers in humans, Nutrition Reviews, Volume 73, Issue 10, October 2015, Pages 661–674,

⁵Hutchison A.T. et. al., 2019. Effects of Intermittent Versus Continuous Energy Intakes on Insulin Sensitivity and Metabolic Risk in Women with Overweight. Obesity (Silver Spring). 2019 Jan;27(1):50-58

⁶Hutchison A.T., et. al., 2019. Time-Restricted Feeding Improves Glucose Tolerance in Men at Risk for Type 2 Diabetes: A Randomized Crossover Trial. Obesity (Silver Spring). 2019 May;27(5):724-732. Available at https://www.ncbi.nlm.nih.gov/pubmed/31002478

⁷Wilkinson M.J. et. al., 2019. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2019 Dec 2. pii: S1550-4131(19)30611-4. Available at https://www.sciencedirect.com/science/article/pii/S1550413119306114

⁸ Firmly S., et al., 2018. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/

Many thanks to Dr Rachel Hudson and Dr Claudia Camden-Smith for their help with producing this blog. 

Stress is a problem

Being a GP can be an extremely varied and rewarding career, but the pressure of dealing with an ever-increasing number of patients every day can take its toll.  It’s estimated that GPs in England alone provide first contact care to more than 1.2 million patients per day¹. Many practices struggle with staffing levels, meaning that some GPs are taking on even larger list sizes than before.

According to the Ninth National GP Worklife Survey² of 2195 GPs, the average reported working week was 41.8 hours, which has stayed consistent since 2008. Nine out of ten GPs reported experiencing considerable or high pressure from increasing workloads, amongst other stressors such as paperwork and having insufficient time in the working day to do their jobs. The 2015 Commonwealth Fund International Survey of Primary Care Physicians found that GPs in the UK had the highest levels of stress out of the 10 nations surveyed³

A GP’s personal life can also be affected. The GMC’s 2018 report on ‘The state of medical education and practice in the UK’ found that 72% of younger GPs feel that their work-life balance has deteriorated as a result of their stress at work. The report also found that one out of four doctors had considered leaving the medical profession at least every month. One of the most alarming findings was that two out of every 100 doctors said that they had to take a leave of absence due to stress for at least one month in the last year⁴.

With many GPs regularly fearing that they can’t cope in their current roles, it’s not surprising that burnout is increasing. The BMA’s 2019 report on ‘Caring for the mental health of the medical workforce’ found that a total of 88% of GP partners and 85% of sessional GPs face a 'high' or 'very high' risk of burnout⁵.  Regional reports from the RCGP found that a proportion of GPs feel so stressed that they are unable to cope. The figures for this were 31% in Wales⁶, 37% in Scotland⁷ and 32% in Northern Ireland⁸.

Recognising the signs of stress and burnout

Even though GPs are expected to recognise the signs in their patients, they may not always realise that they are stressed themselves. It’s easy to plough on with day-to-day tasks and to become consumed with work, so the tell-tale signs such as irritability, poor sleep and increased alcohol use may be missed. The NHS website page on stress includes lists of the physical, mental and behavioural symptoms that may be overlooked.

The NHS Practitioner Health Programme (PHP) was launched in 2008, with the addition of the NHS General Practitioner Health Service (GPH) in 2017. These services aim to provide support to practitioners who are struggling with mental health or addiction problems, so that they can find help before these issues escalate further. According to the PHP’s report on their first 10 years of service, around half of all PHP patients are GPs. Between 2008 and 2018, over 5000 doctors presented to PHP and 83.5% of these were due to mental health problems. For GPs specifically, this figure rises to 88%, with 10% presenting with addiction problems. The remaining 2% is classified as ‘other’¹. In general, NHS staff have higher sickness rates than the rest of the economy. The latest sickness absence reports, from NHS digital, show that the sickness rate is now at 4.23% in England. From the sicknesses reported, 27.1% of Full Time Equivalent (FTE) days were lost due to anxiety, stress, depression or other psychiatric illnesses⁹.

Dealing with stress

Resilience is mentioned a lot in relation to managing stress. It can be defined as “the ability to adapt and succeed in the face of adversity and stress”. A resilient person can maintain their wellbeing and continue moving forward when they are tested by life’s difficulties. Being resilient doesn’t come naturally to everyone and can be something to develop over time. The Chartered Institute of Personnel and Development have produced ‘Developing resilience: a guide for practitioners’  which contains evidence-based guidance. NHS England also looks at resilience from a clinician’s point of view and summarises the 'Eight principles for being a resilient doctor' which are set out by the Australian Medical Association. These principles focus on the changes that can be made in everyday life to help with developing resilience.

Taking time to improve wellbeing can be a good stress-reliever. The New Economics Foundation (NEF) outlines ‘Five ways to wellbeing’, These consist of:

• Connect – Make time for family and friends. Build relationships with colleagues and neighbours. Become part of your local community.
• Take notice – Think about what matters to you most and take time to appreciate it. Be aware of your feelings and emotions. Try meditation and mindfulness.
• Keep learning – Try something new and embrace new experiences. Learning a new skill can boost your confidence and create an escape from stressors.
• Be active – Think about which physical activity you enjoy and that suits you. Regular exercise is associated with lower rates of depression and anxiety and helps to slow down age-related cognitive decline.
• Give – Do something nice for a friend or stranger or volunteer your time to the community. Feeling part of a wider community can be rewarding and build connections with those around you.

In order to ensure the wellbeing of doctors in their workplace, the GMC outline an ‘ABC of doctors’ core needs’. When these needs are met, it’s suggested that people are more motivated and have better overall health and wellbeing. Even if one of the needs is not met, it can have a negative impact on a doctor’s wellbeing and motivation. The following needs are taken from the GMC’s ‘Caring for doctors Caring for patients’ report¹⁰

• Autonomy or control – the need to have control over our work lives, and to act consistently with our work and life values.
• Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to feel valued, respected and supported.
• Competence – the need to experience effectiveness and deliver valued outcomes, such as high-quality care.

The RCGP recognises that being a GP is one of the most difficult jobs in medicine. As the first point of contact for most patients, a GP sees an average of 41 patients per day¹¹. The RCGP’s ‘Fit for the Future’ campaign is the College’s vision for the future of general practice. It covers the changing role of the GP, the tools and skills needed to fulfil this role and the vision of an expanding general practice workforce. This campaign outlines the ways that primary care can adapt to ever-changing health needs and ultimately help to relieve the dangerous levels of stress that GPs currently face.

Further information about the ‘Fit for the Future’ campaign can be found on the RCGP website.

Getting help

For any GPs who are struggling with the pressures of their role or showing signs of stress or burnout, the following resources may help:

• NHS GP Health service – Confidential service for GPs and GP trainees in England. It can help with issues relating to mental health, including stress or depression, or addiction problems. It’s provided by health professionals with expertise in addressing the issues concerning doctors. The BMA also have a support service that is open to the whole of the UK.
• Online cognitive behavioural therapy (CBT) – This can be accessed via your local ‘Improving Access to Psychological Therapies’ scheme in England. In Scotland, there are online self-help resources available on ‘Moodjuice’.  The ‘Living Life to the Full’ website also contains many online CBT resources that are available throughout the UK.
• The Balint Society – The society aims to help all health and social care professionals in the UK better understand the emotional content of their patient relationships. As a member of the Balint Society you can join a ‘Balint group’, which is a gathering for members to discuss particularly difficult patient cases confidentially in a safe space.
• Mentoring – Becoming a mentor or mentee provides an opportunity to develop professionally and discuss any work-based issues. In either role, mentoring can be a great way to get further insights in to your own working situation, whilst having an impartial sounding board for any difficulties experienced in your role.  You can find out more about The Faculty of Medical Leadership and Management (FMLM) mentoring scheme. You can also contact your local RCGP Faculty to see if any local mentorship schemes are available. Further mentoring resources can be found on the BMA website.
• Mental health apps – A range of different apps that can help with anxiety, self-harm and exploring mindfulness are listed on the NHS website.
• Big White Wall – This website offers a support network, resources for self-management and live therapy via text, audio or secure video. It is accessible, for free, to UK serving personnel, veterans and their families, and some UK Universities and colleges. It is also available in some locations via the NHS. Eligibility can be checked via their website.
• The RCGP provides support and advice on GP wellbeing and mental health.
• A list of further support services that are specifically aimed at GPs in England can be found on the NHS website. If you are registered with GP Online, you can also access a list of support organisations on their website.

References

¹  NHS Practitioner Health Service. 2018. The Wounded Healer: Report on the First 10 Years of Practitioner Health Service. [Online]. Available from: http://php.nhs.uk/wp-content/uploads/sites/26/2018/10/PHP-report-web.pdf

²  Policy Research Unit in Commissioning and the Healthcare System. 2017. Ninth National GP Worklife Survey. [Online]. Available from: http://blogs.lshtm.ac.uk/prucomm/files/2018/05/Ninth-National-GP-Worklife-Survey.pdf

³  The Commonwealth Fund. 2015. 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. [Online]. Available from: https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians

⁴  General Medical Council. 2018. The state of medical education and practice in the UK. [Online]. Available from: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk

⁵  British Medical Association. 2019. Caring for the mental health of the medical workforce. [Online].

⁶  Royal College of General Practitioners Wales. 2018. Transforming general practice: Building a profession fit for the future. [Online].

⁷  Royal College of General Practitioners Scotland. 2019. From the Frontline. The Changing landscape of Scottish general practice. [Online]. Available from: https://www.rcgp.org.uk/-/media/Files/RCGP-Faculties-and-Devolved-Nations/Scotland/RCGP-Scotland/2019/RCGP-scotland-frontline-june-2019

⁸  Royal College of General Practitioners Northern Ireland. 2019. Royal College of General Practitioners Northern Ireland GPs Survey. [Online]. Available from: https://www.comresglobal.com/wp-content/uploads/2019/11/RCGP_ComRes_Northern-Ireland-GPs-Survey_Wave-4_Tables.pdf

⁹  NHS Digital. 2019. NHS Sickness Absence Rates, July 2019, Provisional Statistics. [Online]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-sickness-absence-rates/july-2019-provisional-statistics

¹⁰  General Medical Council. 2019. Caring for doctors Caring for patients. [Online]. Available from:  https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf     

¹¹  Pulse. 2018. GPs have almost twice the safe number of patient contacts a day. [Online]. Available from: http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/gps-have-almost-twice-the-safe-number-of-patient-contacts-a-day/20035863.article

Keeping track of your eLearning completions has just got easier. Our latest feature on the RCGP Online Learning Environment (OLE) is the eLearning portfolio – a direct link between your eLearning activity and the Clarity appraisal toolkit.

When preparing for your appraisal, it can be difficult to remember all of the learning you have completed in the past year, let alone how many CPD credits you have earned in the process. With this in mind, we have added a new portfolio section to keep everything in one place and to make it easier to upload to your Clarity account.

Your eLearning portfolio is conveniently located in the ‘Navigation’ block, which is visible at the side of the screen on various pages on the OLE. This means that you’re just one click away from your personal portfolio on pages such as the OLE homepage and the clinical content section. When accessing your portfolio for the first time, you will be asked to log in to your Clarity account to link with your eLearning account. After this initial log in to Clarity, your accounts will remain linked for the next 30 days.

For any user with a Clarity account, the eLearning portfolio will hold a record of your learning for the last 12 months with the option to export any items in this record to your Clarity appraisal toolkit. The portfolio will allow you to review all of the learning activities completed in this period, update the CPD credits you have earned for each one and also add in any reflective notes. From the portfolio you will also be able to view and download any certificates associated with the learning activities, saving you from having to go back in to each activity individually to find these. As with the certificates, if you have completed any sections on GP SelfTest your results will be available to view and download in the portfolio.

 

Any eLearning activity you complete on the OLE counts towards your CPD credits. The following activities will automatically appear in to your portfolio:

• eLearning courses
• Essential Knowledge Updates/Challenges
• GP SelfTest

Activities such as the ‘Five Minutes to Change your Practice’ screencasts and the eLearning podcast can be added manually to your portfolio to track how long you have spent on them. This also applies to any learning activities that don’t include certificates upon completion.

This new feature will be available to any users with a Clarity account from October 2019. For a demonstration on how to get started, you can view our FAQ video.

 Find out more information on appraisal and revalidation for GPs.