Rediscovering enjoyment of general practice – SAPC Day 2

Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK

 

Was I wrong!

Pioneering Professional Practice doesn’t sound like the most stimulating title of a Plenary Address but Helen Stokes-Lampard, Chair of the UK's Royal College of General Practitioners (RCGP) Council, gave an uplifting, encouraging and inspiring address on the topic on day 2 of the SAPC ASM 2017. Helen encouraged us all to rediscover the joy and sparkle of general practice despite poor morale, a constant feeling of being under siege, and increasing resource limitations in the profession. I liked her analogy that primary care, secondary care and social care were interdependent and need to be together- a three legged stool that depended on all three components to remain stable. And she emphasised the importance of looking after ourselves: “We need to put our own oxygen masks on first!” She shared a new idea, the “Number needed to undo harm.” General practice faces many criticisms and we need to share the positive messages. In her visits to many practices around the country she felt there was a particular unifying factor. “It’s not the coffee, it’s the conversation and interaction with colleagues” What good practices have in common is the ethos of being a team.

International relationships are very important to SAPC. John Furler from Australia gave the distinguished paper. Australian general practice systems are different in that the model incentivises doctor consultation and throughput, and does not incentivise delegation. So his study was particularly significant as it looked at the effect of encouraging nurses to undertake diabetic care. With this integrative model, significantly more patients commenced insulin and there was an improvement in HBA1c.

Gayle Halas from Manitoba gave us fascinating insights into the dissonance underlying patients’ cognitive engagement with educational health interventions. Despite the information available, only 20% of patients participate, and Canada has one of the highest attrition rates internationally. So, why don’t patient interact or are less engaged than we might expect? There were a number of possibilities. She described them in academic terms but I liked how she used patients' own descriptions:

Diagnosis involved treatment …and I am not ready for the full deal.

I am not like them.

I am not going to change my lifestyle jut to please someone else.

Nathan Davies gave a presentation as winner of the Yvonne Carter Award for Outstanding new researcher 2017. He described the difficulties in managing the challenges and uncertainty in end of life care for people with dementia through his qualitative work exploring what was good end of life care—mostly about fostering respect and dignity, compassion and kindness.

There was considerable emphasis on early diagnosis of cancer. Constantin Koshiaris discussed the diagnosis of Myeloma.  There was nothing fundamentally new in the presenting and diagnostic features, which include back pain, infections, abnormal blood count, and raised markers (ESR and PV). It’s a difficult condition to identify early and I look forward to their identification of diagnostic models.

Becki Law presented the “Wicked” study- (Wales Interventions and Cancer Knowledge and Early Diagnosis) She presented the qualitative component asking doctors about their personal beliefs and behaviours in referral. Family doctors were keen to maintain their professional reputation with “appropriate” referrals. But, they felt they were not trusted by secondary care where their referrals were sometimes downgraded. They were also aware that they may practice defensive medicine. While I thought the acronym was chosen to resonate with the musical show, I found one of the questions from the audience particularly interesting- could the title be adversely interpreted as reflection of the GPs' referral misbehaviour in the literal interpretation of the word?

Nadia Llanwarne’s study of delay in diagnosis of melanoma also struck a chord. Could it be that skin lesions are often seen as an afterthought in the consultation? Or is it patients’ interpretation of what we say in the consultation? In giving advice, it’s a very difficult balance between reassurance and active surveillance.

What is frailty? It’s not a disease. It’s associated with ageing but not the same. It’s a loss of physiologic reserves so that we cannot cope with minor insults. Stephen Pye described his work in trying to construct an electronic frailty index using an accumulative deficit approach. Epidemiology can help but it is difficult to get a model that works in practice. Frailty, vulnerability, complex elderly. We know and understand what it is but struggle to find an all-inclusive model. Louse Robinson gave us some insights from her remarkable study on ageing, where the next reporting milestone will be when her cohort reaches the age of 95. It was her musical metaphor that most caught the imagination. The Beatles may have written “When I’m 64”, but being older now starts at 84.

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