Report Summarised By Appraisal Categories
Appraisal categoriesbackground to activitywhat did you dowhat did you learn
  Good Clinical Care
   Publishing of NSF in heart failure audit by partner showed wide discrepancy in diagnosis and management within the surgery  small group discussion with other gps Best way to treat heart failure is to aggressively tackle RF before sx develop Although an echo can establish diagnosis it would overload dept if all were now sent up The rapid access chest pain clinic also has rapid access to angioplasty etc Careful how we label heart failure as diagnosis. NSF may be unworkable and not fully costed Began to plan to undertake diploma in cardiology this year, with a view to setting up community heart failure clinic
  Child protection Publication of Climbie report All GPs must undergo regular training in child protection issues  Arranged for rolling program of multidisciplinary meetings by senior nurse in child protection Became aware of policies in North Essex I now have a list of all relevant contacts Lent to record if I actively decide not to refer a child for child protection issues Disseminate primary health care team protocol within practice
  Patient reported from BUPA check as having excersize induced hypertension (BP raised to 230/100) Pateint fir marathon runner, recently lost 2 stone in weight secondary to training Clinic suggest I arrange echo and 24 hr ambulatory BP Search on internet Discussed with Consultant clinical pharmacologist These patents have an increased risk of LVH and ischaemic heart disease This is probally a factor of being hypertensive as opposed to any particlarly advers effect of excersize induced hypertension, this condition is probably just an early marker for hypertension In a young person treating the Blood pressure will reverse any LVH Echo to look for LVH not needed as is reversible, is more useful as guide to treatment by looking for end organ damage, however 24 hour ABPM will demonstrate need for treatment, so again echo not needed In an athelete B Blockers should be avoided as will reduce excersize toleranc Better for ACE, CCB, diuretic sequence If this not sufficient add in alpha blocker Nebivol is not supposed to have such an adverse affect on cardiac output so may be an option
  Review of hypertension management 1. A continuation from last years PDP, plus a part of new contract, practice purchased 24 hour ambulatory BP machine Own personal interest in becoming a GPSIE in cardiology   Audit of hypertension in practice Arranged meeting with Hypertension specialist from Addenbrookes Partners and nurses to attend  Surprise surprise we are not as good as we think we are! Significant proprotion of patients have inadequate bp control Arange meeting with local hypertension specialist See attached learning sheet detailing this learning activity and summary of audit Devised protocol of use of ABPM machine in practice + practice protocol for hypertension on discussion with nurses and partners. " To be used to diagnose all new hypertensives " Monitor unresponsive hypertensives " Review all diabetics " Nursing team empowered to run this protocol themselves before returning patient to Doctor
  SAFFRON WALDEN MEETING, arranged locally  attended meeting read papers around subject see atached summary created aromestase is clinically better in short term (marginally) but higher s/e, cost, and no long term studies
  Saffron Walden group lecture by local consultant.   Talk on treatment of common shoulder problems + open discussion regarding best practice + when to refer  Subacromial inj okay. instability-surgery for recurrent dislocators RC tears-surgerry for pain OA-surgery for pain Frozzzen shoulder-surgery for loss of movement
  continuation of audit from last year local and national priority Audit see enclosed sheet  Firstly, systematic review of all patients under secondary prevention has been instigated within the surgery. Patients with cholesterols not fulfilling all its standards have had their dose of statin altered accordingly. Patients "usual doctor" was checked and altered where appropriate to ensue ownership. Those without appropriate blood tests or review of blood pressure or hypertension are being recalled. The IHD templates have been updated on the computer and our Health care assistants/nurses are reviewing each patient systematically. Recalling for blood tests or review were appropriate Following a review of all the secondary treatments the Practice will then look further at primary hyperlipidaemia. It was decided to concentrate predominantly on secondary prevention in view of the much stronger evidence base and lower numbers needed to treat to prevent death or morbidity
  new gms contract has introduced quality points for chronic disease management this has finally given me leverage with my partners to implement good practice via audits over the 4 month period i carried out repeated small audits around diabetes, IHD, hypertension, epilepsy, strokes, COPD, asthma and mental Health Much of this was via small PDSA cycles I presented audits in exel format to members of the primary health care team maintained and created appropriate disease registers developed mail shots to recall patients partook in qualitive assesment of patient's attitudes to their diagnosis of asthma altered medications recalled patients for blood tests the enclosed word document shows the progression in disease quality points the maximun clinical points available are 587 at the beginning of this period the practice was on 324 points at the end of the period the practice was on 509 disease registers are now more accurate 2 audits are still in progress 1. I have audited patient's within the practice on bendrofluazide, but not labelled as being hypertensive (I have identified 13 patients smokers/ex-smokersn=18) this list is now being passed around the partners for their comments, those patients hypertensive will now be coded as such 2. I have identified 13 pateinets smoker/ex-smokers, labelled as asthmatic they have all been invited in for spirometry to try to identify those actuall with copd, not asthma
  opportunistic learning. Chance to meet new consultant interactive lecture notes attached
  saffron walden hospital meeting.opportunity to meet local consultant . U/sound -hands show inflam. changes around joint surfaces in early RA -colour doppler shows halo in temporal arteritis pre steroids. -shoulders in PMR. -sacroileitis in sero-ve arthritis. -some OA has inflam component,showson u/s. Treatments: 1. Oa-some rspond to 7.5 mg pred + fossamax cover. -hydroxyquinine will effect some OA. 2.Early RA-can give 7.5 mg pred + fossamax whilst waiting referral as still slows progression joint changes. -salazopirine -methotrexate+ folic acid 5mg/w to dec s/e + nausea.Is best DM drug but several deaths c pneunmonitis. -hydroxyquinine-less s/e, not DM drug. -anti TNF £10,000/y.Available Addenb if failure 2 DM drugs.Given early in disease in USA shown to turn off RA progression. 3. PMR-120mg depo IM, then wait for Sx to return after 6w,80mg etc as some don't return. Has steroid sparing potential.  Use of u/s-? have local resourses for diagnosis. IM steroids for steroid sparing. 2w wait physio Addenb.!
  saffron wsalden meeting talk by new Addenbrookes consultant Addenbrookes developing new ways of Ix chronic headaches with cerebral angiography
Count:11
 
  Health
  I have been a GP for 16 years, How am I coping? Am I at risk of burnout?  Read 2 papers on stres from the Lancet Performed a burnout self test to assess my risk of burnout I reviewed 2 Lancet papers on stress Stress and burnout in doctors 14 December 2002 (paper enclosed) "whereby perceived stress at work resulted in poor mental health. Job satisfaction protected consultants from burnout, in that it reduced the likelihood of emotional exhaustion developing, and was associated with higher personal accomplishment. Emotional exhaustion did lead to depersonalisation, but not low personal accomplishment. Burnout predicted psychiatric morbidity: emotional exhaustion increased the risk of psychiatric morbidity, whereas personal accomplishment reduced it. The causal links between stress and burnout in a longitudinal study of UK doctors. I C McManus, 15 June 2002 Emotional exhaustion and stress showed reciprocal causation: high levels of emotional exhaustion caused stress (ß=0·189), and high levels of stress caused emotional exhaustion (ß=0·175). High levels of personal accomplishment increased stress levels (ß=0·080), whereas depersonalisation lowered stress levels (ß=-0·105). The first paper suggested that personal acheivement increases stress, the second that it reduces it I performed a self test on my burnout risk, scoring 15/45 (full spreadsheet enclosed), placing me at low risk of burnout, despite perhaps me trying to over acheive
Count:1
 
  Maintaining Good Medical Practice
   Practice continues to provide methadone substitution for heroin addicts. No common policy I am a police surgeon and find it difficult establishing drug protocol in cells and protocol for establishing fitness for interview  1. Attended full day course on substance abuse organised by equip 2. Made notes of course 3. Developed practice protocol for methadone substitution 4. organised meeting at practice to be attended by custody sergeants, doctors and consultant in charge of substance abuse   Practice protocol developed for management of substance abuse All patients to be referred to cdat before starting treatment Realised that doses of methadone may need to be higher than I thought Maintenance treatment is fine Urine checks are supportive not policing
   Increasing number of patients within surgery with asthma, I am asthmatic, both our practice nurses are now asthma trained and are taking over increased management of asthmatics I have had two patients with hard to control asthma not responsive to steroids although hospital labelled them as asthmatic   arranged local consultant to speak to doctors and nurses small group work and lecture  Understanding that long term chronic asthma causes permanent damage hence apparent lack of response to steroids There are no effective treatments for acute Bronchiolitis (steroids may give short term relief) and it does lead to an increased risk of asthma Reduced infections in early life increase risk of asthma Patients with poorly controlled asthma have bronchial hyper reactivity and may respond to many allergens but are not actually allergic to them 1. Try and cut down patients on high dose chronic steroid use 9it probably is not helping them) 2. Consider different asthma phenotypes to select appropriate treatments 3. Arrange follow up practical vitallographs meeting 4. Get rid of our cheap spirometer and buy an expensive one that works
  Arrthymias are common in practise and I needed to update myself on the present cardiac electrophysiological techniques that are being performed at Papworth which my patients may be offered. Small informal presentation by Dr A Grace cardiologist at Papworth hospital with local GPs. see attached file
  I see patients on methadone as part of enhanced service This workshop is part of the formal on going training lectures and small group work See attached word document Sleep disturbance is very common and may persist for up to 8 months Hypnotics have no effect DO NOT prescribe hypnotics or diazepam to substance abusers If a user takes street heroin there are many metabolites that will then appear on urine testing (Opiates,6MAM, morphine and codeine) this does not therefore imply multiple drug usage. 95% of users on stable maintenance will be honest with you about what might be in urine, so why test? It is to protect you! Vital to do this quarterly There is NO indication for medical certification by patients on stable methadone substitution. Sudden withdrawal of large doses of BDZ can be fatal. If you have no choice but to give initial blind prescription, then give chlordiazepoxide at 2/3 of their BDZ dosage, divided over a 24 hour period
  Noticed interesting paper in BMJ on link between folic acid and confusion in the elderly  Critical appraisal paper search for similar papers+ literature review Meeting with partners and district nurses  Educational Activity. What did you do? Reflect… Have you changed practice or learnt anything new. Any beneficial outcomes for patients Low folate even in normal range can cause depression, cognitive impairment and dementia Study showed adding 500mg folate to younger women on Prozac improved depression scores Another study showed 50 mg methyl folate as effective as trazodone Impact of folate treatment is slow and cumulative 1. District nurses to check folate level whenever they take a blood test in patient 2. Partners to consider adding in folate supplements to any depressed elderly patient
  Personal Interest in Hypertension Conflict between latest bhs and NICE guidelines Arranged local consultant to lead interactive group session We have been using 24 hour abpm incorrectly, we should count daytime readings only Ignore NICE guidelines! Avoid b blockers
  Wife is GPWSI in PMB I wished to review my current knowledge completed bmj module nothing new scored 100% in questions my knowledge is up to date
  target area in new contract unclear with new medication I have a patient with difficult to control epilepsy who has commenced drugs about which I know little! arranged for local consltant to give small interactice talk at local hospital watched videos of faints, fits and seizures group work to try and identify diagnosis faints can cause marked twitching, very like a classical seizure frequent fainters get enhanced pulse rate then rebound up to 30 minutes later use b blockers or ssri behavoural tle however bizarre always think of this diagnosis if stereotypic petit mal can always be trigerred by hyperventillaion adult psychogenic tend to be adult onset vrery frequent attacks trigerred by emotions carpet burns purely daytime there is a 10% lifetime risk of an epileptic dying from a seizure see book "practical guide to epilepsy" Mark Manford
Count:8
 
  Relationships with Patients
  Part of appraisal process carried out Improving practice questionnaire in the surgery. questionnaires handed out to 40 patients Reassuring to see that I score above average in all categories My overall score is 82% compared to 62% average for all doctors in study My lowest scores were for reassurance (77% cf 69% average( and time for visit (77% cf 61% average) I would like level of reassurance felt to be higher I must work more on this aspect of my consultation skills
Count:1
 
  Working with Colleagues
   Patient presented at surgery with bad sore throat, initrially requesting visit. Given 250mg penicillin qds Subsequently developed septicaemia of unknown cause, patient in early 30s with young family, subsequently died  Significant event meeting, partners, practice manager and practice nurses  Discussed management of urgent requests for visits Iannpropriate for all requests to go to one doctor If we use penicillin in adults we should give 500mg qds
   Publication of NSF for the elderly Critically reviewed paper in BMJ showing value of a pharmacist reviewing repeat prescribing over 65 yrs within a surgery  Discussed with PCT and prescribing adviser Developed IT links for local pharmacist to review patients notes from within his sugery Checked caldecot guardianship Presented to partners and staff Trained local pharmacist in use of IT Developed template for pharmacist to use Developed way of pharmacist feeding back changes to doctors  Policy is now finally starting after much priority work Appropriate audit mechanism have been set in place to review performance, prescribing, compliance, quality and cost markers
  An 84 yr old man had made a routine appointment for afternoon surgery and was waiting in the waiting area to be called by the doctor. He suddenly stood up and collapsed. The receptionists immediately alerted the doctors to the situation. Three doctors and the practice nurse were present. The waiting area was cleared of patients, a screen erected and CPR established. An ambulance was called to the scene, but at their arrival the patient was pronounced dead after 30 minutes of active CPR. A subsequent postmortem showed he had died of a ruptured thoracic aneurysm. SEA with partners 1. It is essential that all staff are aware of the location of the resuscitation tray and defibrillator - this should be documented in the practice handbook and highlighted at resuscitation training. Action: JM 2. All clinical staff are up to date with advanced CPR training and the reception staff undergo basic CPR training once a year as a minimum. The ideal time for this is at an in-house practice shutdown. Action: RH to arrange shutdown 3. Written procedure on how to manage a collapse, documenting how to manage the patient if no doctor is present e.g. give oxygen, call an ambulance, and how to manage other patients in the surgery. A copy should be kept in the reception area and in the practice handbook. Action: EP/MR to write procedure 4. A debriefing session is essential after the event for all the staff. 5. Medical confidentiality needs to be respected at all times with regard to such an event. 6. Location of equipment needs to be documented so that items can be found promptly by all members of staff - this could be kept on the treatment room doors.
  Lack of appointments in surgery and funded time to attend advanced access program attended 5 hour workshop on advanced access  Came away inspired, discusses with partners and practice staff at in house shutdown Devised reflective learning diary to be shared by doctors and praactice nurses to try and assess which patients could have been managed by different type of consultation (place or consulter) Each Patrner and nurse completed diary, results discussed as prqctice Began to distribute Improving practice questionnaire amongst individual patients consulting at surgery to assess patients attitudes to our surgery and my consultation technique Prasctice planned to start advanced access July 2003
  Practice involved in advance access program. Need to review effective use of consulations Devised reflective learning diary. Shared this among team memebers reviewed own consulations See 2 attached examples 
Count:5
 
Total Count:26