I have just been working on The AIT newsletter for the National Primary care conference, which kicks off this Thursday in Harrogate (6th October 2010).

I must say I am very excited to have the privilege of helping out with the conference including chairing ‘the financial health check supplement’ with Colin Hunter.

I thought I would kick off this blog with my 'AIT conference newsletter', (see below). i will follow it up with my experiences as an AIT and the KSS AIT rep!

Conference report 2010

Welcome

Welcome to the RCGP National Conference at Harrogate. The theme this year is sustainable primary care; sustainable in having the central delivery of healthcare and growing healthy partnerships and sustainable in terms of playing our part in climate change.

Keynote speakers include Baroness Tanni Grey-Thompson, Iona Heath, David Pencheon, John Guillebaud, Jack Hayden and Clare Gerada. The BBC’s John Humphrys and Jonty Heversedge will also be chairing and hosting sessions throughout Conference

Last year saw over 200 AITs attend and this year promises to be even bigger and better so we hope you thoroughly enjoy both the educational and social activities that the conference has to offer! We had a lot of fun at the ‘AiT curry and karaoke night’ last year so make sure you book in advance to ensure your place! The AIT committee will be on hand to answer any queries and questions. The AIT committee has produced this newsletter to signpost you!

All the best with the rest of you GP training and hope you enjoy Harrogate and the conference

Jaz (Jaspreet Kaur Grewal)

RCGP KSS AIT rep

Streams of interest (including supplements)

Thursday 9^th October 2010

Welcome to our world (2.30pm): The conference will kick off with ‘Welcome to our world’. This will introduce the work of the RCGP AIT committee, first 5 and JIC (Junior international committee) and highlight how to get the most out of the primary care conference, a must for AiTs!.

AIT Supplements; Financial health check (6pm): This promises to be a fantastically interactive discussion lead by Dr Colin Hunter, RCGP Honorary treasurer. AITs will have the opportunity to discuss a wide range of issues from working as locum to joining practice.

Friday 8^th October 2010

Living the dream (11.50am): Professor David Haslam (Past president RCGP) and Dr Roger Neighbour (author of the inner consultation); two great names in general practice will be take us on a journey through their busy careers.

Broadening horizons: A world of opportunities in International general practice. (4.30pm): This will introduce the work of the JIC. The RCGP Annual Conference is truly an international event. This year we’re delighted to host 20 international GP Trainees from across the EU. They will be attending under the Vasco da Gama scheme, which exists to forge links between GP Training. There are loads of exciting things happening – look out for the VdG update in the Trainees’ stream events.

Saturday 9^th October

The well AIT clinic (10am): Experienced RCGP examiner Mei Ling Denney offers a master class on how to succeed in the CSA. Following this, it's your chance to meet with our College leaders – and get direct answers to your questions on training, assessment and prospects for future practice. Mei Ling will be joined by Professor Steve Field (Chairman RCGP), Dr Colin Hunter (RCGP treasurer) and Gregg Irving (Chair of AIT committee) .

Socials

Thursday: ‘AIT Curry, quiz and Karaoke’

There is a jam packed social programme this year which includes the AiT Social ‘Curry, Quiz and Karaoke’, which is back by popular demand. Once again we’ve taken over an entire Indian restaurant, the Jinah Indian Restaurant, located just 5 minutes from the Harrogate International Conference Centre. After the curry and quiz, it’s off to the Viper Rooms for karaoke time with the first5 group. We have secured an area in the club that will be exclusive to us all night! The cost of this fantastic event is a mere £15

Friday: There are two options for AITs the black toe gala dinner or comedy and quiz night.

Black tie Gala dinner at the Royal Hall: There will be black tie Gala dinner at the Royal Hall with a fantastic meal, murder mystery and entertainment. Tickets are £70 and places are limited.

Comedy and quiz night: Buffet supper and comedy evening at the HIC with host Paul Sinhar and other performers. The cost of this evening is £20.

Stands of interest

There will also be a variety of presentations, stands, displays, demonstrations to suit all tastes.... the list goes on! Also look out for the AiT stand in the RCGP Village and AiT areas situated around the Conference venue.

For full programme go to http://www.rcgpannualconference.org.uk/pdf/Delegate%20Information%20-%20May%202010.pdf

For AIT programme see http://www.rcgpannualconference.org.uk/2010/aits.aspx

Just a few reminders:

• Have you ever wanted to know more about what it is like being a GP in another country?

Through the European Commission’s Leonardo da Vinci Programme the RCGP Junior International Committee would like to support up to 30 UK AiTs or First 5 GPs to take part on a two week long Hippokrates Exchange Programme. The Exchange Programme gives AiTs and First 5 GPs the opportunity to undertake a two week exchange in another European country. Leonardo will cover the majority of costs and exchanges must take place between March 2011 and April 2012. The deadline for applications is the 22nd October 2010 .

For more information please go to: http://www.rcgp.org.uk/rcgp_international/junior_international_committee/leonardo_grants.aspx

The following thinking errors are relatively common habits of thinking that were originally described by Aaron Beck. CBT is used to 'un-learn' these habits.

• All or none thinking
• Things are seen in black and white. If you don't finish something perfectly, then you're a complete failure. Things in life are either wonderful or terrible.
• Over generalisation
• One may conclude that since a single negative event occurred in the past that it will occur over and over again.
• Jumping to conclusions
• Something is interpreted negatively (incorrectly) even though there are no facts or evidence to support the conclusion. One way to reconcile this would be to check out the situation and gather information instead of assuming.
• Mental filter
• The focus is so intently on one negative detail that the whole outlook on the situation is negative.
• Rejecting the positive
• The positive experiences are rejected and held firmly that they "don't count" for one reason or another. Enjoying positive feelings isn't allowed as a bad or negative feeling is sure.
• Magnification or minimising
• One's own human errors and other' successes are magnified (blow out of proportion). Alternatively, successes and good qualities are minimised (discounted) while minimising other's mistakes.
• Should statements
• This leads to anger, guilt, frustration and resentment. Attempting to motivate oneself by saying should or shouldn't is like saying one has/needs to be punished in order to do something. "I should have done more to help," does one no good in the long run.
• Emotional reasoning
• If one feels a certain way then that means it is true. "I feel bad, so it must be true and I am a bad person."
• Labelling and mislabelling
• An even more extreme form of over generalising. Saying "I'm a loser" after making one mistake is attaching an inaccurate label to oneself. Mislabelling could be calling another person "lazy" when describing their behaviour.
• Blame and personalisation
• This is when one takes personal responsibility for something that is not in their control. An example could be blaming oneself for a spouse's medical illness by saying, "I am to blame, if only I had made him/her exercise more."
  

Having jusy done a fantastic expedition medicine course (http://www.expeditionmedicine.co.uk) in Keswick I am desperate to go away again!

http://www.medicstravel.org has some good ideas and it would be well worth doing a summer mountain leader course (http://www.mlte.org/).

I have stumbled accross some great medically-related blogs recently:

http://blogborygmi.blogspot.com/
http://doctormama.blogspot.com/
http://insidesurgery.com/
http://www.islandmedstudent.com/home/
http://www.medschoolhell.com/
http://med-source.blogspot.com/
http://megspeaks.blogspot.com/
http://prep4md.blogspot.com/
http://pharmamotion.com.ar/
http://drdeborahserani.blogspot.com/
http://improbableoptimisms.blogspot.com/
http://surgeonsblog.blogspot.com/
http://www.thefurrymonkey.co.uk/
http://oldmdgirl.blogspot.com/
http://blog.usmleturk.com/
http://www.usmlemd.wordpress.com/

Over a recent 4 month stint in general practice I have been presented with several patients trying to get fit and loose weight, often unsuccessfully, for many years. Not an unusual scenario. However, a handful of these patients had opted for e-fitness. Yes, they had a purchased a Wii Fit with the belief it would help. Perhaps it will, I'm sure it won't. Merely loosing a few pounds from their pocket is my sceptical interpretation. 

All things considered, however, if a patient has motivation, who are we to stand in their way? Purely for reasons of professional development I decided to purchase a Wii Fit to se what it was all about so I can further empathise with my clients. You will be pleased that an in-depth thesis of my findings is beyond the scope of this blog but I was pleased to see that there are several motivational aspects to the product. These range from serial BMI measurements to promoting some yoga moves and mild muscle workouts by unlocking more games after doing them. But how do we know how much they are doing? I think we're experiencing the evolution of a new subject we need to enquire about in addition to simply asking how much they use it! Questions might include the following: How many hula-hoops can you do? What's your score in the yoga tree pose and step aerobics? Which games have you unlocked?

Johari Window

New Year's Eve in Accident & Emergency!

Sadly, I saw my New Year in in Accident and Emergecy - as a doctor of course! The temptation of a well paid locum was too much!

It's quite enjoyable and satisfying to see some acute cases which can often be sorted quite easily. It was quite unusual that there was only one intoxicated patient and the rest were normal run-of-the mill A&E cases. The following are some of the cases I saw that I feel have some learning points.

Pulled Elbow

My first case was a 3 year-old child who wasn't using her right arm after she was caughtby her outstretched hand while sliding down a slide. She was holding her arm by her side, not bending it and not using it to play with. On examination there was no deformity, swelling or bruising and it seemed to be tender over her radial head. Putting firm pressure on the radial head with my thumb while pronating the forearm and flexing the elbow produced a satisfying little click (along with a bit of crying)!

After leaving her to play for 15 minutes it was quite obvious she was now using the arm much more normally.

A pulled elbow occurs when sharp traction is applied to a child's forearm/hand, for example when they trip whilst walking holding a parent's hand. The radial head slips slightly out of the annular ligament whcih usually holds it close to the proximal ulna. X-ray would appear normal so is not indicated unless there is suspicion that there may be a fracture (based on history). The above procedure will relocate the radial head and no more treatment is required except for warning the parents to try to avoid pulling on their arm!

Dog Bites

I saw 2 people with dog bites. The first was a child who presented over 12 hours after the attack which rang alarm bells in my head that a delayed presentation is inappropriate and may signify NAI or neglect. Social services were contacted.

The second patient was an adult with a partial amputation of his ear in addition to some severe neck lacerations. Fortunately there was no significant neurovascular damage. It is important to clean animal bites well with copious irrigation, leave them open to heal by secondary intention and prescribe broat spectrum antibiotics that cover anaerobes (eg, co-amoxiclav) . However, in this case I couldn't just leave his ear handing off! So he was warned about the risks of infection but cleaning, antibiotics and a primary closure was advised and carried out in this case.

COPD Exacerbation

I saw a lovely 89 year old lady with a fever, cough with purulent sputum and shortness of breath for the last 4 days. She has been commenced on amoxicillin by her GP 2 days ago but had deteriorated slightly. She denied any significant smoking history but was on salbutamol and tiopropium which suggests a diagnosis of COPD has been made. Her chest demonstrated a diffuse wheeze but no signs of consolidation and her CXR showed emphysematous change only. On this basis I diagnosed an infective exacerbation of COPD which should normally be treated with at least 10 days of steroids in addition to antibiotics. This was commenced and she was observed overnight and discharged home the following morning.

RIF Pain

The final case that springs to mind was a 14 year-old boy who complained of vague abdominal pains that were worst in the RIF. He was off his food but had normal bowels, no nausea or vomiting, no urinary symptoms and no fever. On examination he was not tachycardic or febrile. He did declare tenderness over McBurney's point but there was no guarding here and psoas sign and Rovsing's sign were negative. Urine dipstick was also negative.

Although RIF pain alerts us to appendicitis, the history suggests it probably isn't because of minimal systemic upset and no clear migration of the pain from the midline. The examination virtually rules this diagnosis out although some would argue that it could be a very early appendicitis but discharge with a warning to come back if things get worse would still be adequate.

The final part of the examination of this child was crucial because we should never forget that gonadal pain is usually vague in the lower abdomen because of their embryological origin. Examination of the testicles showed a high riding, transverse and tender right testicle. Exploration under anaesthetic revealed testicular torsion so ipsilateral and contralateral orchidopexy was performed.

Delay in the diagnosis and treatment can lead to infertility so it is incredibly important to consider in any male with RIF pain Common misdiagnoses include renal/ureteric colic and appendicitis.

Upper Respiratory Tract Infections

In the last week it feels like I've seen more URTIs than I've had my lifetime! URTI is the posh word for the common cold. Because the ambient temperature is lower in winter the viruses involved survive for longer in droplets in the air so are more readily transferred between hosts. Needless to say one of my patients seems to have already given me a cold!

So what causes an URTI?

Most are caused by starins of the rhinovirus group (picornaviruses) although the list of causative viruses is long and includes adenoviruses, coronaviruses, coxsachie viruses, echoviruses, influenza and parainfluenza viruses and RSV.

If the larynx, trachea and major bronchi are affected the likely viruses are the adenoviruses, influenza and parainfluenza (I & II) viruses and RSV.

Symptomatic Relief

The debate over antibiotics will probably never end but there is no clear benefit of using antibiotics for URTIs because the cause is viral. Possibly they shorten the duration of illness by 24 hours but they always carry the risk of side effects and resistance. In cases of a proven secondary bacterial infection they are of course indicated and also probably in patients who are not improving after a couple of weeks.

This leaves us with treatments that target the symptoms rather than the cause which the body will fight in due course.

• Steam inhalation (and spicy foods!)
  • loosens mucous so cleared more easily
    • can reduce cough due to postnasal drip
    • can improve sinus pain and earache as they drain better
• Decongestants (norephedrine, oxymetazoline, or pseudoephedrine)
  • helpful for up to 10 hours
  • nasal vasoconstrictor leads to reduced oedema and mucous production
    • helps sinus pain and earache by opening up eustacian tubes and sinus ostia so improving drainage
  • no more than 2 weeks as withdrawal can then make things much worse (rhinitis medicamentosa)
  • can cause tachyarrhythmias
• Paracetamol +/- NSAID
  • good for aches and pains and for reducing fever
• Cough suppressants (antitussives)
  • theoretically increase chance of sputum retention and chest infection but good symptomatic relief
    • not in very young or in COPD sufferers
  • dextromethorphan
    • cough suppressant, not addictive
  • diphenhydramine (Bronylin)
    • cough suppressant, antihistamine (sedative & decongestant) and anticholinergic (dries up secretions)
  • combination of above = Benylin Dry Cough
  • opiates
    • powerful cough suppressants but chance of addiction
• Mucolytics
  • no help, reserved for chronic asthma and COPD

Complications

Sinusitis and otitis media are probably the most common complications of the common cold. They both should resolve with conservative management but occasionally require antibiotics if not settling after 2 weeks. Otitis media sometimes leads to rupture of the typanic membrane which would lead to a resolution of pain followed by purulent fluid from the ear.

Those with asthma and COPD often suffer exacerbations (it may herald the diagnosis) and this should be treated with steroids and antibiotics (commonly amoxicillin) if there is any reason to suspect bacterial infection.

Occasionally a common cold leaves patients simply more vulnerable to a LRTI (ie pneumonia) which should be treated with antibiotics. This would be suspected if they are not getting better for over a week, are short of breath, coughing up purulent sputum or compain of pleuritic chest pain. Auscultation of the chest should demonstrate signs of consolidation but if the history is convincing do not rely on the absence of crepitations!

General Practice

I've just started working as a General Practitioner for 4 months so will be adding some of my experiences.

At the heart of general practice is the consultation and there are many models to assist us in perfecting this art. One common one is the mnemonic ICE which prompts us to explore the patient's agenda (Ideas, Concerns and Expectations). This is especially useful if it is not immediately obvious why the patient is attending because they seem quite well. In guiding us towards a hidden agenda it is also important to respond to any cues which may be verbal but are often non-verbal.

The points described above relate to patient-centred consultations in which we ask open questions, actively listen and challenge and reflect patients words and behaviour to promote their unique input.

In contrast, a doctor-centred consultation is dominated by the doctor who asks closed questions, rejects the patient's ideas and evades questioning. While this style seems to go against a lot we have been taught, it is often necessary to some degree and it is often useful to 'mix and match' according to the situation.

Animal Learning Psychology

It is very interesting to consider the way animals learn because this opens a window onto the complex learning strategies we employ.

The Russian physiologist Ivan Pavolv famously demonstrated respondent conditioning (associative learning) in dogs. In his experiment he associated a meaningless stimulus (bell ringing) with a meaningful stimulus (food) and demonstrated that the dogs made a stimulus association (acquisition of knowledge/meaning) because salivation eventually occurred only to the bell ringing.

Later, Burrhus Skinner, an American psychologist described operant conditioning (instrumental learning) which defines the modification of a voluntary behaviour (unlike the involuntary salivation Pavlov described). For the first time he showed that if an animal is consistently given good consequences to an action it will incorporate this action into it's activity.