NASGP December 2018

December 2018 In our 104th edition, Judith has been visiting some plastinated bodies, Zoe has given up Facebook, Louise has been reviewing contraception for the over-40s, Sara's been reflecting on continuity, Liz is offering advice on how to claim tax for CPD and Rachel has been looking into your doctor's bag. The  Sessional GP Supporting sessional GPs to  improve patient care image © Claire de Mortimer The power of a fresh pair of eyes Much is made of continuity of care, but little time is spent examining its weaknesses and exploring the alternatives. In the first of a two-part series, Dr Sara Chambers helps put continuity into context. I was recently asked a question by an eminent GP and academic researcher: “How often does a “fresh pair of eyes” really benefit patients?” And I think it’s an interesting question on several levels. There’s so much to say that this will be a two article series. In this first article, I shall give clinical examples from day to day locum work of differences that I perceive I make as a locums to the individual patients I come across. I invite you to add your own. In the second article, coming in the New Year, I’ll look at deeper structural themes of how the “fresh pairs of eyes” of locums could be used to bring about wider system changes that could ensure greater continuity of the right type and at the right time for all patients. The question was prompted by an article I wrote for the NASGP in 2103 - Does continuity of care need a reality check? - which explored the different types of continuity - relationship continuity vs continuity of patient management and information flow - how they are often confused; whether there might be potential disadvantages of relationship continuity and whether there might be benefits to seeing different doctors - the “fresh pair of eyes” scenario. I was interested in these issues in 2013 as it seemed that continuity of relationship, meaning care given continuously by one doctor, was elevated as the most important tool in general practice, to the exclusion of other factors and consequent hints of a dismissive attitude to those GPs who work as locums and are typically not likely to enter into long-term therapeutic relationships. From some angles, it looked like study after study set out to prove the hypothesis that continuity of relationship is a good thing, but did not look quite so acutely at either its disadvantages, or the potentially rich seam of other modifiable factors that affect quality of care and consultations, such as access to accurate consulting room level, non-clinical information, safer systems and clear lines of communication and responsibility when managing patients of concern, and how we can improve medical records to allow better continuity of management for the many patients who now have to see different GPs. Since my original article, the RCGP published a report in 2016, Continuity of care in modern day general practice, focusing on continuity of relationship but with recognition of the importance of informational and management continuity and how crucial this is to locums, with a small (little paragraph on page 26) but admirable mention of opening up avenues of enquiry into studying how these could be deployed to improve continuity of care where locums are involved. So, given the lack of published data, how should I answer my questioner? On a day-to-day level, with great enjoyment and ease: all I have to do is reflect on my last few sessions and locum group meetings, and the case examples of patients benefiting from seeing a different doctor come thick and fast. It’s even been fun putting them into the following categories. "Thank you for explaining that differently"; when patients benefit from a different doctor to check their understanding. I find this is a common scenario, occurring at least once in most of my sessions. Patients with ongoing symptoms, or chronic or relapsing conditions, who are perhaps on multiple medications but are distressed or confused by misunderstanding the nature of their condition or the treatment aims of their medication. Or the patient is not concerned because they are unaware of a gap in understanding, but this is exposed during an interaction with a different GP; the key role of the different GP being that, having not met the patient before, we have to actively check their understanding, sometimes as we build our own understanding, and this process often reveals misunderstandings about their illness or medication. Following this process, I often find myself amending previous or repeat prescriptions with ‘indication prescribing’, so that the patient understands why they are taking the medication and the anticipated duration of treatment. Here's a small, everyday example from a recent surgery which, once uncovered, was simple to solve and with great potential benefit to the patient: A mother of a child with eczema had not understood the difference between emollients for ongoing use, and steroid creams for flare-ups. She was frustrated that "this rash keeps coming back" when she stopped using the emollient. Occasionally more serious hidden misconceptions are revealed: a lady on a progestogen-only pill, who had previously been on the COCP, and so had assumed that she should continue the routine of having seven-day pill-free gaps. She had been seeing the GP partner and the practice nurse for three years at six-monthly reviews, and it took someone "going back to the beginning" to uncover the embedded error. "I wanted to see my usual doctor, but now I'm glad I saw you"; the opportunistic second opinion. A man in his 40s had repeatedly visited his GP with a persistent sore throat. A wait-and-see approach had initially been taken. After bloods and EBV serology had been checked and throat swabs taken, he'd been investigated by ENT who suggested a trial of PPI which didn't help. All this had taken months, and he was fed up that there seemed to be no diagnosis and relief for his discomfort. By starting from the beginning, we were able to identify that he was asthmatic and on a combination dry powder inhaler, but was not rinsing and gargling after using his inhaler. It's possible that his usual doctor would have also “gone back to the beginning”, and I am not claiming any great clinical acumen here. But another reason I highlight this interaction was that he was initially quite angry, and I think he had almost come to vent frustration at his usual GP with whom he had "baggage" of what he perceived as months of fruitless investigation. Being a new face, I was able to bypass and diffuse his frustration by using the fact I had never met him before to say "Let's start again." His anger visibly deflated as we went through his story in detail and found a possible low-tech, simple solution. I was also able to reinforce what a diligent job his usual GP had done in carrying out investigations to rule out other causes. He was delighted and more appreciative of his usual GP by the time he left. "I wanted to see a different doctor about this"; when patients seek a second, independent opinion In a routine booked surgery, I saw a lady in her mid-forties who had attended a few times over the years with anxiety, depression and headaches. Reviewing her notes before calling her in, I saw that her previous consultation with her regular GP two weeks earlier had again focused on her low mood, tiredness with some mention of "generalised aches and pains". From these notes, I assumed that I would be seeing her for a follow up of her depression. However, what she really wanted to talk about was the pain and aching in her arms. So we focused on that and I was very struck by how painful and tender her muscles were to the extent that blood tests were urgently arranged. Interestingly, at the end of the consultation, she thanked me and said that as much as she liked her usual GP who had been "very good with my depression" over the years, she had asked to see another doctor because she felt her usual doctor just wasn't picking up how painful her arms were and was attributing her pain to what he knew of her in the past. In particular, she was pleased that I was a locum as she had such a close relationship with her usual GP that she was afraid it would appear disloyal if she saw one of the other partners. PS Her blood tests were phoned in by the lab later that day with a CK in the thousands, and was referred to rheumatology to investigate myositis. "Please can you review this patient"; a second opinion sought by a practice-based GP One of my GP partner friends, who works in a smaller two partner practice and has worked as a locum herself, relies on a pool of trusted locums who help out sporadically. My friend will actively seek their second opinion if she is struggling with a patient by booking an extended appointment for the patient with the locum and even writing a mini-referral letter in the notes. She finds this hugely valuable and reassuring in either confirming her diagnoses and management plans or covering new ground with the patient, and the locums enjoy being asked their opinion When I have worked at a practice with enough regularity to become familiar with the partners, they will often thank me for seeing one of their patients and taking a different approach. So that’s my list drawn from my experience. I am confident other locums will be able to add their own categories and cases. To finish off my comparison of my work as a locum vs a patient’s “regular” GP, I should add that for many of my patient encounters, I find that if I am adequately equipped with an induction into practice-specific procedures, and able to safely navigate how the practice works and interacts with other services, leaving me to concentrate just on the patient's problem and building the all-important therapeutic relationship, brief though it may be, then I am an adequate stand in for the majority of patients. If being the operative word, which is where we start to dip our toe into the matter of system safety and how well systems work in supporting the wider continuity of management and information that all patients need. And that will be the theme of the next article in this series. Sara Chambers is a GP locum and is quality lead of the National Association of Sessional GPs sara@nasgp.org.uk By Sara Chambers @sara71chambers dis-continuity; putting care into context "Being a new face, I was able to bypass and diffuse his frustration by using the fact I had never met him before to say "Let's start again."" saying farewell to social media "I posted on Facebook that I was leaving Facebook. For the first time in ages, my Friends actually commented." By Zoe Neill The sign of something becoming mainstream and therefore uninteresting, was when it was adopted by the, er, mainstream. When your Gas Appliance Cover gets a Facebook page, for example. I was an early adopter of social networking, in the days when dial-up was it. I had to phone switchboard when I was on nights at the QE Hospital in King’s Lynn to get connected to AOL, to timewaste effectively before the next surgical admission arrived. I met my husband through Faceparty (so close, guys) in 2003, and when the first Facebook invitations came out, I signed up – late 2007. Fast forward to 2015, and I was fully fledged on Facebook with my kids’ pictures from zero to 6 years, GP survival and Tea and Empathy posts, school mum groups, and all kinds of shared articles and photos. What a great way to avoid doing anything I needed to get on with, and a really great way to stay in touch with my old and new friends. My list of Friends expanded reassuringly, including some long-lost people from my childhood who I’d thought I’d never wanted to see again. I was a regular Tweeter, with several accounts (Arvind – you’re not the only one who likes to play Devil’s Advocate) and lots of Followers, and no bots, of course! What better way to spend an evening Liking and retweeting, spreading those important edgy political messages about the junior doctors’ strike and Brexit? Echo chambers aside, the time it was taking was creeping up inexorably. This was not sociable, or networking: it was more like smoking, or drinking wine. I posted on Facebook that I was leaving Facebook. For the first time in ages, my Friends actually commented. Real feelings, such as ‘Don’t go! We’ll miss you moaning about lack of sleep!’ or ‘Who else will tell us how bad the NHS is?’ This, followed by ‘We have to meet up before you go!’. I wasn’t announcing that I was terminally ill, nor that I was leaving the country. Just not posting pictures of my boys covered in mud, or a GIF of Jeremy Hunt ringing a bell. It was so pleasant to encounter this desire to keep me Facebooking, that I didn’t leave. And then I heard that Chamath Palihapitiya, former vice-president of Facebook user growth, had left Facebook, expressing regret for his part in building tools that destroy ‘the social fabric of how society works’. And then in early 2018, Cambridge Analytica happened. It was time to think much more carefully about my internet footprint, and particularly those of my sons, which would likely outlast me by several decades at least. Suddenly, I began to wonder if I could discover that pre-internet past where phone calls, and actual face-to-face conversations, and – totally retro – letters existed. Perhaps my ennui would resolve, and perhaps I could find something more useful to do with my time. It took three long evenings to delete all my Facebook data. Post-by-post, photo-by-photo, like-by-like. Hemingway would counsel being superior to my former self – not difficult, according to my timeline of utter banality. And then the Twitter account. 12,300 retweets. Wtaf? Deleting them was an education and quite a challenge. Eventually, I stumped up $5 to delete 50 retweets a day for as long as it took. Luckily, my Instagram account was not blossoming, so deleting that was a cinch, although it has since been hacked by an Ebonics speaker with an interest in manga. I will deal with it eventually, when I remember the long password I used to prevent myself from logging back in. At first, it was really difficult. I pretended that Doctors.net wasn’t really social networking, for example, and even posted on the Pulse comments pages. But without the little blue bird and the white F, life starts to grow through the cracks again. I had lunch with a friend, I had coffee dates, I spent an hour on the phone to a friend one evening. We organised a night out by texting (does that count, or not, Your Honour?). I took photos that I knew would not be uploaded and that no-one would see except my immediate family. I didn’t have to update anyone. I sent cards for birthdays and anniversaries. I wrote a letter and a postcard for the first time in years. I dusted off the books I’d never quite got around to reading, and horrifically, got through two books a week in the time I’d been spending on Facebook and Twitter. A brief lapse into Whatsapp (for work reasons, obviously) provided another alternative suggestion – podcasts. Serial, by This American Life, along with Radio 4 podcasts, are reasons to have a commute to work. The end result? It is wonderful not to look at other people’s lives, their curated versions of themselves, and feel inadequate or sad or lonely or bored. The slope is slippery, though, and I think complete abstinence is unrealistic – although does LinkedIn count? I would recommend a trial, a cold turkey trial of #deleteFacebook. And if you send me a postcard, I promise I’ll reply. Dr Zoe Neill zoeneill@gmail.com When it's time to quell the din of  the echo chamber Training costs – what  can you claim? "There is a grey line between what is a new skill and what is an extension of an existing skill – and that needs professional advice when it arises." The rules for salaried GPs and self employed GP locums are different. By Liz Densley @honey_barrett Get this right and you'll be able to recoup some expenses; get it wrong risk the ire of HMRC. Liz Densley helps you navigate through what to claim. Salaried GPs If you are a salaried doctor you can only claim for courses that are ‘wholly, exclusively and necessarily’ in the course of your work. The ‘necessarily’ is the tricky bit – because that would mean absolutely anyone doing that job would have to do that course. The effect of this is that generally salaried doctors cannot claim training costs, so ideally get them built into the remuneration package so that the practice pay for them. Providing it is work related, it will not be a taxable benefit. There was talk of training being treated differently just before the 2018 Budget, but nothing came of it. Be aware that the rules may change in the future. Self-employed GP locums If you are a self employed doctor, you can claim for courses that are ‘wholly and exclusively’ for the purposes of your work. This gives much more scope. Generally any courses that are keeping you up to date or improving your existing skills will be deductible. Anything unrelated to your work won’t of course – so a GP couldn’t claim for a course on plumbing or bricklaying! A new qualification – or something that enables you to do something that you cannot currently do – will be treated as ‘capital’ and will not be deductible. There is a grey line between what is a new skill and what is an extension of an existing skill – and that needs professional advice when it arises. What does ‘wholly and exclusively’ mean? Generally there won’t be personal benefit in a course, but beware ‘holiday’ courses where HMRC could argue that the holiday element is more than an incidental part of the cost. Once there is ‘duality of purpose’ (such as a holiday with some training), HMRC are within their rights to refuse the whole of the claim. What is the cost of the course? That will be the course cost itself, any related reading material etc, travel to get there, subsistence and reasonable accommodation (if it is not reasonable to return home). What if you are both salaried and self employed? It will normally be acceptable to claim course costs against the self employed income.If HMRC want to be awkward, they could argue duality of purpose – because you can’t learn something and only use it for your self employed work. We had this point made in an investigation some years ago, but HMRC did back down and agree the cost in full against the self employed work (but on a reasonable basis, rather than under the letter of the law). If you are trying to claim for a £5k course against £5k of locum work when you are employed full time, expect it to be questioned! Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk The doctor’s bag Opinions vary amongst sessional GPs as to what medications should be carried in the doctor’s bag. Dr Rachel Birch, medicolegal consultant at Medical Protection, outlines factors to consider when stocking your doctor’s bag and offers practical advice to safely managing those medications. Picture the scene…. it is a cold snowy night in rural Scotland and Dr S is called out to a patient who is having a myocardial infarction. The road to the town is blocked and the ambulance can’t get through. Dr S calls for the air ambulance and gives the patient aspirin, clopidogrel, GTN spray and intravenous morphine. The air ambulance has not yet arrived, so Dr S administers pre-hospital thrombolysis. Imagine a different scenario…. Dr G works in an urban practice, situated next to a pharmacy and over the road from the hospital. He visits the patient, and when it is apparent the patient is having a myocardial infarction he calls the ambulance - it arrives in less than 5 minutes, and the patient is in hospital shortly afterwards. As the above scenarios suggest, Dr S and Dr G are almost certain to carry different medications within their doctor’s bags. An inner city GP’s bag is likely to be very different to that of a rural GP. What factors should sessional GPs consider when stocking their doctor’s bags? There are no specific regulations about the items that should be carried in the doctor’s bag. However, doctors should ensure they have access to emergency equipment and drugs, so that they can provide timely and effective treatment to patients. Drug and Therapeutics Bulletin has published guidance on drugs for the doctor’s bag for both adult patients and children. The guidance outlines that although paramedics are trained and equipped with medication for emergencies, many GPs still need to carry a range of medicines for use in acute situations when on home visits; advice is provided on such medications, outlining the guidelines and recommendations for their use. Individual practices may choose to provide an emergency bag for the duty doctor, or have an emergency store of drugs in-practice available to all doctors, as an alternative to doctors having individual stocks within their bags. The practice’s decision may be influenced by factors such as location, the availability of the local ambulance service, proximity to hospital and 24 hour pharmacies, as well as cost implications of having a large stock of medications. It is important to consider factors such as shelf life and storage requirements for drugs, as well as the doctors’ familiarity and experience of the particular drug. Before working at a practice, locum GPs should seek clarification on the practice’s availability of emergency drugs. Some practices may have pre-stocked bags for locums to use, checked regularly by practice nurses; others may expect locums to bring their own drugs. If working in the out of hours setting, similarly, they would be well-advised to enquire whether they are expected to stock their own doctor’s bags. This will assist locum GPs in planning what emergency drugs they feel they should individually carry. Reducing the risk Develop a system for checking expiry dates for drugs held in your doctor’s bag. Twice yearly would be appropriate, although some drugs may have even shorter shelf lives. Check expiry dates for needles and syringes too and replenish any supplies. Consider using a computer spreadsheet to make this task simpler. Ensure you have a sharps box, gloves and alcohol hand gel. When administering medication from your doctor’s bag, record the batch number and expiry date in the patient’s record. If medication is provided to the patient, more than is immediately necessary, you should give the patient a printed information leaflet about the medication. Be aware of the storage requirements for the medication - many medicines should be stored between 4 and 25 degrees Celsius. Consider a silver coloured bag or a cool bag as an alternative to the traditional black bag. You may wish to place a maximum-minimum thermometer in your bag to record any extremes of temperature. Keep the bag closed whenever possible, as bright lights can inactivate some medications, eg prochlorperazine. Ensure that the bag is lockable and not left unattended. If left temporarily in a vehicle, it should be locked in the boot and out of sight. To protect your safety, in areas of high personal risk, you may wish to use a bag that doesn’t look like a traditional doctor’s bag. When replacing your medication stocks, take expired medication back to the pharmacist for safe disposal. If you carry controlled drugs (CDs) in your doctor’s bag, ensure that your practice is consistent with controlled drugs legislation and NICE guidance. You must keep a separate CD register for the stock held within your bag. Restocking of the bag from practice stock should be witnessed by another clinical member of the practice staff, and you should both make appropriate entries into the practice’s CD register as well as your own. Where a prescription is written by a doctor following the administration of a CD to a patient, the doctor should endorse the prescription form with the word 'administered' and then date it. CDs that are date-expired should be destroyed and witnessed by an authorised person, for example a pharmacist. The destruction should be recorded, and signed by both, in a separate book set aside for this purpose, as well as the CD register. Rachel Birch rachel.birch@medicalprotection.org By Rachel Birch @MPSdoctors What you keep in yours might be dependent on where you work "An inner city GP’s bag is likely to be very different to that of a rural GP. " "If we have a good support network both at work and outside work, we are more likely to enjoy our work and home life and have a safety net for those more challenging times. " Our working environment has changed enormously over the last few decades. The workload, intensity and patient complexity have grown exponentially. In parallel, the time and space that we have at work and at home to recharge and support each other has become massively compressed. My last post looked at the factors that make doctors vulnerable to mental ill-health. Today, I want to share some ideas looking at what we can control, strategies that might help keep us buoyant, happy and thriving, rather than just surviving. These ideas are not exhaustive and come from a mixture of sources and people. They are what I use to keep myself afloat. 1. Invest in activities that allow you to re-charge and have fun There are many things that we do that we know ought to make us feel happy, but in reality don’t, or can actually leave us feeling worse. For example, dashing off on a Friday night for a weekend away to ‘recharge’. The reality often being that we put ourselves under more pressure to get away from work on time, with a tiring and stressful journey there and back. As we have seen before with the exhaustion funnel, when we are busy, or things are getting on top of us, the first things to go are the activities that seem optional; the activities we enjoy; the very things that energise us and keep us in balance. 2. Develop positive life habits Positive life habits are the routine behaviours that are beneficial to our physical and emotional health. This means prioritising sleep, paying attention to what we eat (more in another post!), getting regular physical activity and making time to see friends and family that energise us. And avoiding those that drain us! It is also about avoiding negative habits such as the alcohol/caffeine cycle and excessive screen time. Optimising our physical health puts us in a better position to cope with the pressures in our work and home lives. 3. Build our support networks at home and work This may seem obvious, but often when we are under pressure we often see less of the people that we most want to spend time with. Or we isolate ourselves more at work, staying late, or arriving early, not feeling that we have enough time for even a brief conversation. An old colleague recently told me that he would have left medicine after a particularly nasty complaint if it hadn’t been for the support of his colleagues around him. They buffered the battering his confidence and self-esteem took. If we have a good support network both at work and outside work, we are more likely to enjoy our work and home life and have a safety net for those more challenging times. A recent study in the BJGP looked at resilience in GPs working in areas of socioeconomic deprivation. Three main themes emerged; one being that resilience was enacted through teams rather than through individual strength. This highlights the importance of nurturing those connections at work. And those connections don’t just need to be within our immediate workplaces but may be with other colleagues further afield who share similar interests. Social media (not without its warnings) can also be a good way to do this. When I was struggling I connected with others through social media, who had been in a similar boat but were further on in their journey than me. Many are now friends and the support they gave me was invaluable. 4. Be kind and compassionate to others As doctors, we are usually pretty good at being compassionate to our patients. But often, we give so much to our patients that we have nothing left in the tank for our colleagues, or we fear taking on their problems or supporting their time off for what it might do to our own perhaps fragile state. We may not even notice a colleague is struggling as we are so absorbed with our own workload and problems. A cup of tea, a few nice words, small things that don’t have to take up a lot of time might make a huge difference to someone’s day. Dr Steve Robson’s moving story about how what he thought was a chance visit from a colleague saved him from taking his life and the follow-up from the doctor who saved him, illustrates this so well. 5. Be kind to yourself We all have an inner critic. That voice inside that can judge us mercilessly. And when we are feeling low, that critic usually gets more air time. Being kind to yourself is about giving yourself a break and extending the same kindness, care and compassion that you would give a good friend. Kristin Neff, founder of the self.compassion.org has extensively researched this field and her website has lots of guided meditations, tips and exercises to practice. 6. Recognise and minimise stress where possible As doctors, our drive to do well or please others means that we often ignore stress through habit, overriding our awareness and leaving us open to taking on too much and feeling overburdened. However, most of us are good at problem solving. So if we can make the time to step back a bit, we might be able to work out ways that we could reduce our stress. This might be by identifying triggers, organising our time better, or addressing the causes that we can change and learning to accept the things we can’t. Doing this with someone else - a friend, a family member, or perhaps better, someone external such as a mentor or coach to see where we might be stuck, and come up with some practical solutions and actions can really help. 7. Change the way that you think Sometimes, we focus on all the negatives of modern day practice and forget what we actually enjoy about our jobs. I recently did an appreciative enquiry exercise looking at what made us happy at work. It was incredibly energising and the whole atmosphere in the room shifted. So flipping our thinking round by reframing and looking at the positive is one way to change the way that we think and feel about our situation. Practising gratitude is another. Gratitude is about taking the time to notice the good things in our lives. All too often we spend our time worrying and ruminating about what is wrong and we forget about the small things that might have brought a smile to our face or that made us feel good. Research shows that focussing on the positive helps boost us psychologically and socially. Finding three good things each day is the way that I do this. Learning to accept imperfection and being “good enough” are also key. I find this hard, as do many of us. Not helped by the current culture of increasing public scrutiny and rising complaints. For me, challenging my thoughts helps, asking myself what a colleague would say or do, what the worst case scenario might be or thinking about how I will feel about something in six months time. 8. Housekeeping and managing our emotions Working as a clinician can be challenging and require a lot of mental energy. The emotional labour is high - we may switch from breaking bad news, to an angry patient, to a problem in the practice all in the space of a few minutes. As health professionals, we still have to maintain a professional, external state regardless of what we might really be feeling inside. Taking a pause and a few deep breaths when we feel stressed or overloaded can help recalibrate. It might be enough to help us think more clearly about our next move or to focus more effectively. The pause might stop us reacting unproductively or having a negative conversation with someone that we might regret later. Dr Roger Neighbour calls this ‘House Keeping’, recognising in his landmark book, ‘The Inner Consultation’ that “a consultation is not over until you are ready for the next one.” 9. Tapping our inner strength One of the hallmarks of burnout is feeling a lack of personal accomplishment. When we are finding things difficult, we often lose our self-confidence - I know this has taken ages for me to build back up. It is still not back to where it was. Shame and guilt have been big hurdles to overcome. Reflecting back objectively on times that we have done well (the wall of achievement) and learning from our mistakes helps build back our sense of self worth. 10. Seek help There are many barriers to seeking help, one of which might be our own lack of insight or the expectation that we should be able to treat ourselves. In addition, shame and guilt, concerns about confidentiality or simply getting the time off to see someone are amongst the challenges. Once we do access help however, and take off that metaphorical white coat, it can be transformational, as data from the Practitioner Health Programme has shown. ******************************************************* In reality, we all want to be doing more of what we enjoy and most of us will recognise that making time and space for ourselves to do this is important. However, when we are feeling under pressure, particularly in the current climate, self-care is often the first thing to go. Yet it is perhaps the most important thing that we can be doing to help maintain our wellbeing and prevent chronic stress and burnout. Dr Kate Little, a GP Clinical Champion for Physical Activity and the founder of physicianburnout.co.uk, a resource for doctors that are feeling fed-up, stressed, anxious, depressed or burnt-out. Kate has worked as a GP in the NHS for the last 16 years in a variety of roles – partner, salaried & locum. She has also worked in medical education as a GP trainer and facilitator, and as a GP appraiser. By Kate Little @katelittle71 Thriving, not just surviving Some simple habits can go a long way to you being a happier GP © Claire de Mortimer, GP locum, detail, acrylic a trip to see plastinated bodies could be a cost-effective health intervention As I was shepherded into a dimly-lit lift, I was expecting an exhibition designed to titillate and shock. How do you react to seeing a man standing, flayed of his skin, his internal organs on view, his muscles brick red, his blue eyes staring out at you? Or what about the trio posed round a table playing poker? You may have seen them in the film Casino Royale. James Bond stays cool. His interest is not the plastinates but how the villain manipulates their chips. There was no Daniel Craig the day I visited the exhibition, but a crowd of people, all intensely curious and fascinated. Body Worlds, the controversial exhibition of plastinated human bodies, isn’t voyeuristic. It isn’t the Chamber of Horrors. It turned out to be earnestly educational. And compelling. The only plastinate I personally found disturbing was the man holding his flayed skin in his hands, but I had recently seen much the same in Jusepe de Ribera’s painting of Apollo flaying Marsyas. Ribera painted to disturb. Plastinates are made to intrigue and inform. They are the brainchild of anatomist Dr Gunther von Hagens of Heidelberg. Looking for improved teaching aids for his students, he had the idea of impregnating anatomical specimens with plastic. Lay people were intrigued, so he created exhibitions for the general public. He worked out how to plastinate whole bodies, not just of humans – this exhibition includes a man on a rearing horse. I was surprised that all the human bodies appeared so slim. But they have been stripped of their fat. Forty years ago most people were that lean. Since then we have become accustomed to a population with a thick padding of adipose tissue. Doctors know how few patients understand the working of their own body. Body Worlds aims to change that. It seems to be succeeding, to judge from the rapt attention visitors bestowed, not just to whole bodies, but to specimens of individual organs. How many people know where their kidneys are and how they work? Or how black a smoker’s lungs are? The information content is serious and substantial, but leavened with videos, cartoons, interactive demonstrations and quotes from sages from Confucius to Kant. You can’t take photos in the exhibition so visitors really engage with what’s on show. From start to finish the emphasis is on the damaging effects of modern life and what you can do to mitigate them. I did not expect to go to Body Worlds and find myself encouraged to take deep breaths to reduce stress. But I did – and some weeks later I still do. Around 50 million people around the world have seen versions of Body Worlds, and the overwhelmingly positive comments on TripAdvisor justify Dr von Hagens' mission. As always, there are some who claim to have got nothing out of the experience. And some who complained about the cost. It isn’t cheap – £24 for a ticket bought online, £28 at the door, although curiously entry to the shows in continental Europe is less than €20. Yes, I was made uneasy. But it wasn’t squeamishness that disturbed me. It was speculating about the provenance of the bodies. In China the lucrative market for kidney transplants was, and may still be, fed by ‘donations’ from executed prisoners. Suspicions have been voiced that Body Worlds’ bodies come from the same source. The trafficking of cadavers and the manufacture of plastinated bodies and body parts are big business in China, particularly in the city of Dalian. The general manager of Dalian’s biggest company was taught plastination by Dr von Hagens, who also seems to have been involved in the business. So, were the bodies in Body Worlds obtained from what we would regard as an ethical source and with full voluntary consent? Voluntary donations, unclaimed bodies and judicial executions could not possibly supply sufficient fresh corpses for China’s plastination industry. So where do they come from? Many new prisons and a cadaver processing plant have been built near the plastination factories in Dalian. Falun Gong, the large spiritual movement which has become a focus of Chinese government oppression, claims that the size of the plastination programme parallels the persecution and disappearance of hundreds of its members. No-one apart from the Chinese authorities knows the truth. However, Dr von Hagens has taken steps to distance himself from these murky waters. He stopped using Chinese bodies in 2007 and established a donation programme which apparently has more than 18,000 potential or actual donors on its list. Body Worlds’ website claims that nearly 80% of them are German, and all but 26 are European or American. Donors consent to the use of their bodies for public as well as medical education; some sign up because they see plastination as a more dignified and useful end to their corporeal existence than burning in a crematorium or rotting in the ground. Donors are guaranteed anonymity, which makes it impossible to marry up specimens with consent forms, but a 2017 review by the Ethics Advisory Committee of the California Science Centre, an exhibition and educational establishment, assessed Body Worlds’ documentation on donors and was reassured that appropriate consent was being obtained. And the committee commended the project’s educational aims. As you leave the exhibition, you pass six containers, each labelled with a health resolve. You drop in tokens to indicate whether you intend to stop smoking, cut down alcohol, exercise more . . . As GPs we know that giving patients health advice is easy, but keeping them motivated is hard. So, do the good intentions expressed at the end of a visit to Body Worlds translate into changed behaviour? A review of visitors six months after their visit to Body Worlds in Vienna was cautiously encouraging. Most felt much better informed and up to 33% claimed to have modified their lifestyle. If a third of visitors actually make long-term changes, a visit to Body Worlds is more effective than many interventions offered by the NHS. So how about a partnership with Body Worlds? What about subsidising tickets for whole families, including a year of repeat visits and follow-up questionnaires and incentives? Lifestyle changes are more effective if everyone in the household is involved. It might just work. Judith Harvey judith.harvey12@gmail.com By Judith Harvey @judithharvey12 getting under your skin "I was surprised that all the human bodies appeared so slim. But they have been stripped of their fat." Updated advice from FSRH "If women over 50 are amenorrheic AND using a progesterone only method of contraception, then you can measure their FSH to gauge when to safely stop contraception. Only a one-off measurement is now advised." contraception in the over 40s By Louise Hudman This was an updated guideline from the FSRH on contraception in the over 40s. It came out in Nov 17, but as it is so useful, I thought it worth doing a summary. There were a few things that were new for me: If women over 50 are amenorrheic AND using a progesterone only method of contraception, then you can measure their FSH to gauge when to safely stop contraception. Only a one off measurement is now advised (they used to suggest two). Depot injection. There are circumstances where you can continue to use the depot after age 50. See below. COC. There are circumstances where the COC can be continued for non-contraceptive benefits after age 50. See below. Women can safely stop contraception after age 55, even if they are still having menstrual bleeding. What is the rate of pregnancy in the over 40s? 10 - 20% per year if 40 - 45 12% per year if 45 - 50 Very rare in the over 50s Why do over 40yr old women need to be considered separately? The background risks of various diseases increase, hence the contraception that is appropriate changes. CVD risks. Start to rise in perimenopause. An early menopause is associated with an increased risk. VTE risk rises 10 fold between age 40 and 60 (from 1 in 10,000 to 1 in 1000). Breast, ovarian and endometrial cancer rates increase. Osteoporosis risk increases. What contraception can women over 40 use? Any, though the: combined oral contraceptive (COC) is contraindicated over 50. depot should be discouraged over 50 (though can sometimes be used - see below). HRT and contraception use Sequential HRT can be used alongside any progesterone only method of contraception, though the depot injection should be discouraged. The COC can be used instead of HRT until age 50. It should not be used with HRT. When can women stop contraception? At age 55, even if they are still having menstrual bleeding. At age 50 or over if there is no bleeding for 1 yr (if on no contraception). Under age 50 if there is no bleeding for 2 yrs (if on no contraception). Can you use a blood test to determine when contraception can safely be stopped? FSH > 30 suggests some ovarian insufficiency, but doesn't preclude pregnancy. If a woman is over 50 and is using a progesterone only method of contraception (including the depot), AND if they are amenorrheic, then you can you check FSH. If it is > 30, then continue using contraception for a further year and then it can be safely stopped. If it is < 30, then consider retesting again in a year. If women are under 50, then using FSH to try to estimate when contraception can be stopped is unreliable. Advice regarding specific methods of contraception Copper coil If they have over 300m2 of copper and they are inserted over age 40, then they can stay in until 1 yr after the LMP in over 50s and 2 yrs after the LMP in under 50s. They shouldn't be left in indefinitely as they become a focus of infection. Mirena coil If used as the progestogenic component of HRT, they must be replaced every 5 yrs. There are increased risks if used after endometrial ablation (eg of perforation). If they are not being used for HRT and are inserted after age 45, they can be used for contraception until age 55, though should not be left in indefinitely as they become a focus of infection. Implant Can be used until age 55 and can be left in after that if wanted. POP Can be continued until age 55. COC They should be stopped at age 50. However, they do advise that if women want to continue to use it for 'non-contraceptive benefits', that they should be considered individually using 'clinical judgement and informed choice'. Choice of COC. Levonorgestrel and norethisterone pills should be first line as they have the lowest VTE risk. Use 30mg or less of ethinylestradiol first line as they have lower VTE, CVD and CVA risks. Regimes. You can advise extended use regimes to help with menstrual or menopausal symptoms. The VTE risk is greatest on starting the COC, so if women stop for a month and then restart, the risk is higher again. Women over 40 should be counselled about the signs and symptoms of VTE. Benefits and risks. The COC lowers the risk of ovarian and endometrial CA and this effect lasts decades after cessation. It may help to maintain bone mineral density compared to women using no hormones in the perimenopause. There is a small increase in breast CA, but this effect has disappeared within 10 yrs of cessation. The VTE risk is described above. DMPA - depot injection There is initial loss of bone mineral density when DMPA is started. There is then very little extra loss at menopause. The loss is recovered when it is stopped. Assess patients' risk every 2 yrs. Women over 40 with other risk factors (eg smoking, inactivity, a family history of osteoporosis, vitamin D deficiency etc), should be advised to consider other methods. After age 45, it becomes UKMEC 2. Women over age 50 should be counselled on other methods. However, if they wish to continue the depot, then it can be considered. The risks and benefits for the individual should be discussed. The decision to continue should then be reassessed regularly at review visits. Louise Hudman louisehudman@gmail.com Supporting sessional GPs to improve patient care www.nasgp.org.uk Promises, promises This magazine is supported by an educational grant from the Medical Protection Society.