Deep Breath In

The BMJ's long running "10 minute consultation" series is being questioned - can you do everything we suggest in 10 minutes? Can GPs really do any meaningful consultations in 10 minutes? That's the question that our three guests have been asking - and they join Tom Nolan, to discuss what they found.   Our guests; Alice Harper is a GP trainee in Bristol and an academic clinical fellow at the University of Bristol Carol Sinnott is a GP in Ireland, and a senior clinical research fellow at THIS institute at the University of Cambridge Jess Watson is a GP NIHR clinical lecturer in general practice at the University of Bristol   Reading list; Great expectations? GPs’ estimations of time required to deliver BMJ’s ‘10 minute consultations’ The BMJ's 10-Minute Consultation      

Is cancer screening worth it, and how can GPs have that conversation? This episode of Deep Breath In explores the intricacies of assessing risks and benefits of cancer screening, featuring Michael Bretthauer's insights from a JAMA Internal Medicine study. That meta-analysis combined efficacy of various cancer screening studies - and found most screenings showed minimal gains in extending overall life expectancy, though some slightly reduced cancer-specific mortality. That leaves GPs with the challenge of communicating these nuanced findings to patients. Michael explains how he tries to convey complex concepts to patients, despite the societal inclination toward extensive testing despite low risks.   Reading list; Jama paper - Estimated Lifetime Gained With Cancer Screening Tests A Meta-Analysis of Randomized Clinical Trials The BMJ analysis  - Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit

As news about the climate breakdown hits, it's hard not to feel the stirring of climate anxiety. One way to mitigate that is by taking action, but it's hard to know where to start, and what GPs themselves can do. In this podcast, we hear about 5 ways in which you can start bringing a sustainable outlook to primary care, and engage colleagues and patients in making a difference.   Our guests; Tamsin Ellis, director of Greener Practice, and a GP in London Fran Cundill, chair of the south Yorkshire Greener Practice group, and GP in Sheffield.   Resources; Find out about how some clinical staff are starting to push their healthcare systems to be greener in The BMJ's podcast series Planet Centred Care For all the BMJ's coverage on tackling the climate emergency https://www.bmj.com/campaign/climate-emergency        

There have been so many conflicting views in the media lately on the management of menopause, and HRT has barely been out of the press at all in the last couple of years. As a result of the myriad uncertainties around menopause, many women are left feeling like they’re having to fend for themselves, and that their concerns are not being heard by their doctors. Taking segments from The BMJ’s webinar in May on known unknowns of menopause, we discuss the controversies around HRT; how we can give women balanced and realistic information about menopause and managing their symptoms; and how we can reframe the messaging around the menopausal transition in a more positive and hopeful way, in order to help empower women in navigating this normal life stage.   Our guests:  Martha Hickey is Professor of Obstetrics and Gynaecology at the University of Melbourne. Her clinical and research interest is around menopause. Margaret McCartney is a GP in Glasgow, and a freelance writer & journalist.   Resources: ‘Therapy for the effects of menopause’ (webinar) https://www.youtube.com/watch?v=-hQX2SGlcvY ‘ Normalising menopause’ BMJ 2022;377:e069369

There's never enough time in the day to be a GP, but it's still hard to say no to that one patient, or to a colleague who is asking for your help. In this episode of Deep Breath In, we'll hear from Rachel Morris, about why it's so hard to so hard to say no, particularly for doctors. She'll challenge us to think about what the real effects of piling on more work are, and give us some strategies to help us say no in our every day lives.   Our Guest; Rachel Morris trained as a GP, before leaving the profession to become a coach for GPs, and other medics. Her work focusses on burnout, and how to take practical steps to stop the process. She also hosts the You Are Not A Frog podcast.   Links;   www.youarenotafrog.com www.shapestoolkit.com ***Click here for a bonus resource on how to design your ideal working week***

Common themes for discussion on this podcast include overdiagnosis, approaches to the testing, the ins and outs of explanations, as well as other issues facing GPs who are overburdened, and have limited time and resources to treat patients. A topic which draws all of these themes together is prostate cancer screening. The BMJ recently published a feature which asked whether the UK is ready to roll out a nationwide prostate cancer screening programme, and the linked analysis paper, authored by Dr Andrew Vickers and colleagues, argued that the current model of screening, which determines testing by shared decision making, is the worst approach for detecting prostate cancer. We spoke to Andrew Vickers to discuss this further, and our second interview was with Dr Sam Merriel, regarding the emerging evidence that suggests that taking an MRI scan prior to biopsy could decrease harms associated with overdiagnosis and overtreatment of prostate cancer.   Our guests: Andrew Vickers is an attending research methodologist in the Department of Epidemiology and Biostatistics at Memorial Sloan Kettering Cancer Center, New York. Sam Merriel is a GP, and a researcher on cancer diagnostic testing at the University of Exeter.   Further reading: ‘Is the UK really ready to roll out prostate cancer screening?’ BMJ 2023;381:p1062  ‘Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit’ BMJ 2023;381:e071082   

While the pandemic has officially declared over, the ongoing effects of a covid-19 infection are still being felt in the community. In this Deep Breath In, Jenny, Tom, and Navjoyt are joined by two leading experts on long covid.  They discuss the changing profile of people being referred to specialist clinics, the way in which different strains may have different long term outcomes, and what can be done to limit the risk of developing long covid.   Our guests: Trish Greenhalgh is a former GP of 30 years who is now Professor of Primary Care Health Sciences at the University of Oxford.  Harsha Master is the GP lead in COVID rehabilitation at Hertfordshire Community Trust, and helped design the long covid clinical pathway there.

Talking about sexual health may be common-place with younger patients, but the sexual wellbeing of older adults is often neglected in a consultation. However it's important for doctors to be aware of changes to patients sex lives, given the link between intimacy and wellbeing. In this podcast, the team discuss how to create that culture of openness that encourages older adults to share problems they may find embarrassing, what signs may indicate that it's worth initiating a question about sexual health, and making sexual function a routine part of the discussion about the effects of medication. Our guests; Sharon Hinchliff is a professor of psychology and health at the University of Sheffield. Rebecca Mawson is a GP in Sheffield. Resources; Practice Pointer How to support the sexual wellbeing of older patients www.agesexandyou.com www.ageoflove.org www.joanprice.com 

The theory that depression is caused by serotonin deficiency has become embedded in our practice over the years, and can be a persuasive explanation of the condition for patients considering starting antidepressants. We talk to Tony Kendrick about the evidence (or lack thereof) to support this hypothesis, and what that means for the efficacy of antidepressants, particularly SSRIs. Later on, we speak to Mark Horowitz to discuss how to come off antidepressants safely, and manage withdrawal symptoms, and how to advise and support our patients as they gradually reduce, then stop, their medication. Our guests: Tony Kendrick is a retired GP, and NICE committee member for the 2022 guideline update on depression in adults. He is also a professor of Primary Medical Care at the University of Southampton. Mark Horowitz is a training psychiatrist, working as a clinical research fellow at North East NHS Trust, and as an honorary clinical research fellow at UCL, he is also the co-founder of outro.com. Further reading: ‘Antidepressants and the serotonin hypothesis of depression’. BMJ 2022;378:o1993 https://www.bmj.com/content/378/bmj.o1993 ‘Stopping antidepressants’. Royal College of Psychiatrists. 2020. https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/stopping-antidepressants

How long would it take GPs to enact all of the guideline recommendations that they might be expected too? Far more GP hours than exist in any healthcare system, but as medicine has turned its attention to primary prevention, and expanded the populations whose health we seek to improve, those guidelines are taking up more and more time. A recent analysis in The BMJ has proposed the concept of “Time Needed to Treat” and implores guideline makers to take account consultation time as a precious, finite, resource when thinking about their recommendations. In this episode of Deep Breath In, we’re joined by Minna Johansson, family doctor and director Global Center for Sustainable Healthcare, who co-authored that analysis to talk about how the concept has gone down, and what it might mean for rethinking what primary care is supposed to do. Reading list: Guidelines should consider clinicians’ time needed to treat https://www.bmj.com/content/380/bmj-2022-072953

Reproductive coercion may feel like something that we don’t see very often in general practice, but a 2022 poll carried out for BBC Radio 4 of 1,060 UK women between the ages of 18 and 44 found that half of them had experienced some form of reproductive coercion. This week, we speak to returning guest Annabel Sowemimo about the various forms that reproductive coercion can take, and who might be at risk of experiencing it. We discuss how we, as GPs, can identify these patients, and, once we’ve done so, how we might be able to help them. Later on, we talk to our BMJ columnist, John Launer, about how narrative medicine approaches can help to reach a better & more satisfying resolution to a consultation “puzzle” for you and for the patient. Our guests: Annabel Sowemimo is a community sexual health registrar, based in Leicester. She is also a PhD candidate at King’s College London, and is the co-founder of the charity Reproductive Justice Initiative. John Launer is a GP educator, working for Health Education England. He is also a freelance educator and writer, as well as being a columnist for ‘The BMJ’. Further reading: ‘How to recognise and respond to reproductive coercion’. BMJ 2022;378:e069043. https://www.bmj.com/content/378/bmj-2021-069043 ‘John Launer: The art of paying attention’. BMJ 2022;378:o2294. https://www.bmj.com/content/378/bmj.o2294 ‘Careful, kind care is our compass out of the pandemic fog’. BMJ 2022;379:e073444. https://www.bmj.com/content/379/bmj-2022-073444

In general practice, it can often feel like a lot is changing beyond our grasp. On top of this, the pandemic has left many healthcare professionals self-reflecting on their careers and lives, and trying to work out what they really want going forward. This week, we speak to Claire Kaye about her role as a coach for doctors. Claire talks to us about the benefits of coaching, including helping to get rid of internal & external noise, shaping the mindset, and coping better with change. She also offers advice on the best ways to approach coaching in order to achieve a positive outcome. Our guest: Claire Kaye, formerly a GP, is an executive coach. She specialises in career development. Instagram: @drclairekayecoaching LinkedIn: @drclairekaye Website: www.drclairekaye.com

The possibility that patients will suddenly have access to their notes has caused some anxiety for GPs in England. The department of health's plans to allow patients to prospectively access their medical record lead to fears about increased workloads, misunderstandings, and safety - and the plans have now been pushed back. In this podcast the Deep Breath In team are joined by the authors of a recent article in The BMJ to explore those fears, hear about the potential benefits, and understand the evidence behind open notes. Our guests; Charlotte Blease, and interdisciplinary health researcher at OpenNotes, Beth Israel Deaconess Medical Center/Harvard Medical School. Brian McMillan, a GP and senior clinical lecturer at the University of Manchester Gail Davidge, research associate at the University of Manchester The article they're discussing is a practice pointer on Adapting to transparent medical records: international experience with “open notes” https://www.bmj.com/content/379/bmj-2021-069861

This week, we’re joined by Huseyin Naci to discuss the recent press release from Eisai and Biogen announcing the Phase III trial results for lecanemab for use in Alzheimer’s disease, and the FDA’s decision to accept the drug onto its accelerated approval pathway. We talk about the pros and cons of using surrogate endpoints to predict clinical outcomes. How can we strike a better balance in clinical trials between generating high-quality and trustworthy evidence, and the urgent needs of patients with life-limiting conditions and very few available treatment options? Our guest: Huseyin Naci is an associate professor of Health Policy at the London School of Economics and Political Science (LSE). He is also an advisor to the Analysis section of The BMJ.

The GP crisis with Rebecca Rosen This week, we discuss the ongoing GP crisis, an ever-topical subject, in light of recent UK governmental changes. In early September, Thérèse Coffey laid out her plans for the NHS in the House of Commons, but, with general practice struggling so much as it is, is she proposing practical and feasible solutions, or will her initiatives be merely papering over the cracks? We’re joined by Rebecca Rosen to discuss whether or not there’s any real substance behind the proposed changes, how to manage patients’ expectations around access to care, and how primary care practitioners might be best supported in order to help ease the strain on them. Our guest: Rebecca Rosen is a GP in South East London, and a senior fellow in Health Policy at the Nuffield Trust.

In this episode of Deep Breath In, we'll be considering how a physicians personal experience of illness - either themselves, or as a parent or carer, might affect their approach to management of it in a patient. We'll also have an update on the NICE guideline for treatment of Gout - particularly highlighting changes around uses of urate lowering therapy, and how often we should be testing patient's serum urate levels when they're experiencing flare-ups. Our Guests. Katherine Hall is the associate dean of medical admissions at the university of Otago, and has researched how physician experience affects their practice. Alastair Dickson is a GP, and lecturer at Hull York Medical School. He co-authored The BMJ article on management of gout. Reading Gout: diagnosis and management—summary of NICE guidance https://www.bmj.com/content/378/bmj.o1754

Musculoskeletal (MSK) pain and osteoarthritis are clinically common in general practice, but with the new draft NICE guideline on osteoarthritis (published in April 2022) recommending a move away from pharmacological treatments and instead promoting self-management, some GPs have been left wondering how best to manage MSK pain going forwards . In this week’s episode, Dr. Imran Sajid talks to us about the importance of educating patients on what arthritis really is – moving away from the term “wear and tear” – and of taking a thorough history of a patient’s pain journey in consultations. He also gives practical advice on how we might approach non-pharmacological management of MSK pain with our patients. Our guest: Imran Sajid is a GP with a special interest in MSK medicine. He is the clinical lead in MSK & Diagnostics for NHS North West London, an adjunct lecturer in Health Policy at the University of Global Health Equity, as well as being a qualified personal trainer. Further reading: ‘Osteoarthritis: assessment and management, draft for consultation, April 2022’. NICE. 2022. https://www.nice.org.uk/guidance/gid-ng10127/documents/draft-guideline ‘The tear, flare, and repair model of osteoarthritis’. BMJ 2022;377:o1028. https://www.bmj.com/content/377/bmj.o1028

Despite the Conservation party manifesto for the 2019 general election promising to deliver 6,000 additional full-time equivalent GPs, worryingly, the NHS lost 717 FTE GPs between March 2019 and March 2022, and the Health and Social Care Committee’s July 2022 report on workforce was scathing about the Government’s failure to act decisively on the chronic staff shortages across healthcare in the UK. This week, we speak to more colleagues from the RCGP conference: first, we talk to Pamela Curtis about the challenges of returning to general practice after a break; secondly, we speak to a group of GP trainees about their innovative platform, The Big GP Consultation, and hear their thoughts on shaping the future of general practice. Our guests: Pamela Curtis is a salaried GP working at NHS Bristol, North Somerset and South Gloucestershire ICB. Veena Aggarwal, Devina Maru, Liam Loftus and Rachel Weaver are all GP trainees, and are part of the team for The Big GP Consultation. Further reading: House of Commons Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care. 2022. https://committees.parliament.uk/publications/23246/documents/169640/default/ The Big GP Consultation. https://thebiggpconsultation.co.uk/

In this week’s episode, we share our experiences of attending the recent RCGP Annual Conference, and our thoughts on the topics that were covered in the talks at this year’s event. We talk to RCGP Chair, Martin Marshall, about continuity of care, which he states is one of the defining features of general practice. Evidence has shown that continuity of care is associated with better health outcomes for patients, but how can doctors convince politicians and policymakers of the benefits of it? We also speak to Emma Gladwinfield, a GP in Rossendale, about how connecting with schools, churches and community centres is helping to build relationships with patients and deliver care in her local community. Our guests: Martin Marshall is the Chair of the RCGP, a GP in Newham, East London, and Professor of Healthcare Improvement at UCL. Emma Gladwinfield is a GP in Rossendale, East Lancashire. Further reading: ‘Tackling the crisis in primary care’. doi:10.1136/bmj.o1485. https://www.bmj.com/content/377/bmj.o1485

As more and more pharmaceutical products come onto the market, there are so many potential drug interactions, and adverse reactions, to bear in mind during a consultation in primary care. In this week’s episode, we speak to Anders Holt, the author of a recent research paper looking at co-prescribing nitrates and sildenafil, which is surprisingly common, and adverse events associated with this. We also discuss the neuropsychiatric side effects of montelukast with Corine Ekhart, and talk about the challenges of striking the right balance between highlighting a rare but important side effect and causing the patient anxiety about taking the medication. Our guests: Anders Holt is a PhD candidate at Copenhagen University Hospital, Denmark. Corine Ekhart is a pharmacist at the Netherlands Pharmacovigilance Centre Lareb in 's-Hertogenbosch, the Netherlands. Further reading: ‘Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study’. doi:10.7326/M21-3445 https://www.acpjournals.org/doi/10.7326/M21-3445 ‘Neuropsychiatric reactions with the use of montelukast’. doi:10.1136/bmj-2021-067554 https://www.bmj.com/content/376/bmj-2021-067554