Letters

Response to Wishful pharmaceutical thinking S Hartley, G Bello and W J D McKinlay 59 Authors response
A Lenox-Smith 57 A very different life? P McEvoy 61
A Russell 59 Correction 61
Just a GP
Changing roles All letters are subject to editing and may be
E Purves and C Gunstone 57
D Chase 59 shortened. Letters should be sent to the BJGP
Delayed prescriptions not a good option for office by e-mail in the first instance, addressed
Condemned to education by telemedicine
infants D Syme 60 to [email protected] (please include your
R Damoiseaux 58 Dream or nightmare vocational training postal address). Alternatively, they may be sent
A Blyth, S Cembrowicz, J Norman, D Bailey, by post (please use double spacing and, if pos-
A clinical indication on every repeat prescription
N Taylor, D Goodland, G Rawlinson and sible, include a MS Word or plain text version
N Masters 58
T Smyth 60 on an IBM PC-formatted disk). We regret that
Accuracy of electronic sphygmomanometers F Smith and P Lane 60 we cannot notify authors regarding publication.

Response to Wishful making it more akin to acute References

pharmaceutical thinking anxiety. The definition of DSM-IV 1. olde Hartman TC, van Rijswijk E, Lucassen
requires symptoms for at least PLBJ. Wishful pharmaceutical thinking
[Letter]. Br J Gen Pract 2003; 53: 971.
Dr Hartman raises an important issue 6 months, which makes it a 2. European College of
in the November issue of the BJGP, chronic condition. Thus, it may Neuropsychparmacology. Consensus
not be appropriate to compare meeting March 2000. Guidelines for
namely the clinical interpretation of investigating efficacy in GAD. Eur
studies in mental health based on rating results from older trials to the Neuropsychopharmacol 2002; 12: 81-87.
scales.1 newer ones. 3. A double-blind, randomised, placebo-
Older studies were not analysed controlled study of venlafaxine XL in
A consensus meeting on how to patients with generalised anxiety disorder
investigate generalised anxiety disorder with the same vigour as current in primary care. Br J Gen Pract 2003; 53:
(GAD) was published last year that studies and often used protocol 722-777.
analyses without carrying forward 4. Pollack MH, Zaninelli R, Goddard A, et al.
raised the same question A signifi- Paroxetine in the treatment of generalised
cant difference registered on a pivotal data in the normal way these anxiety disorder: results of a placebo-
scale between a treatment and placebo days. Thus, larger differences controlled, flexible-dosage trial. J Clin
Psychiatry 2001; 62: 350-357.
may not necessarily be clinically rele- would be seen in older studies.
vant.2 It goes on to state that clinical The criteria of GAD has changed
relevance should be determined by in other ways, with the psychic
other outcome measures identified as symptoms given more promi- Just a GP
clinically relevant, such as response nence in DSM-IV, making the
rates (using Hamilton anxiety (HAM-A) HAM-A (which gives equal promi- As a GP registrar with a rather enthusi-
or clinical global impression (CGI) nence to both psychic and somatic astic trainer, I often find myself subject-
scores). In our study we looked at symptoms) rather insensitive to ed to various learning experiences.
response and remission rates using change, and thus differences Perhaps the most enlightening of them
both scales.3 We believe that remission between placebo and active treat- is when the result is unexpected.
rates are the most clinically relevant ments are likely to be small. My latest venture was a case study
endpoint, and these showed a 50% of three patients with a chronic illness,
increase on venlafaxine compared to The 2.1 difference seen with ven- in this case multiple sclerosis. The task
placebo, and although not statistically lafaxine is in line with the 2.8 difference was to find out what expectations and
significant, we believe that this is due to seen overall in our five pivotal studies requirements these patients had of
the low number of patients, and had submitted to the regulatory authorities their GP. So, hidden among others
the trial contained more patients then (who granted a licence for GAD), and was the question Which doctor has
this would have been statistically sig- also with a recent study of paroxetine. been a good doctor to you?. Expected
nificant. Quality of life scales are gen- In summary, we believe that the answers might have included the GP,
erally insensitive to change. Thus, study performed in the UK supports who was all-knowing, all-caring, avail-
there is good evidence that the results the use of venlafaxine in patients with able day or night with a listening ear,
are clinically relevant. GAD in primary care as demonstrated and the GP who was coordinator of
With hindsight, 4 points was not an by the statistical significance seen in the many NHS departments involved
appropriate figure for the power calcu- the primary endpoint and the clinical in such an illness, i.e. a really good
lation for several reasons as outlined relevance demonstrated by the 50% GP. However, my three patients uni-
below: reduction in remission rates and sup- formly and separately stated that it was
ported by the quality of life scales. their hospital consultant who was the
The definition of GAD in the 3rd best doctor. How annoying. But why?
edition of Diagnostic and statisti- ALAN LENOX-SMITH He made the diagnosis and sorts out
cal manual of mental disorders Senior Medical Adviser, Wyeth my treatment. Not to be outdone on
(DSM-III) used in most older Pharmaceuticals, Huntercombe Lane this venture, I then asked But what
studies only requires anxiety to South, Taplow SL6 0PH. about your own GP? to which I
have been present for a month E-mail: [email protected] received fairly positive replies of Oh

British Journal of General Practice, January 2004 57

 Letters

well hes lovely, always ready to visit, a feel that there is no problem in with- two years of age with acute otitis media.
Eur J Gen Pract 2000; 6: 48-51.
good listener etc. holding antibiotics for infants with 4. Cates C. Delayed prescriptions in primary
My trainer and I pondered these acute otitis media, since it has been care. Br J Gen Pract 2003; 53: 836-837.
findings and came up with a few spec- shown that the effect of antibiotics is 5. Rothrock SG, Harper MB, Green SM, et
al. Do oral antibiotics prevent meningitis
ulative conclusions. As GPs we are poor. But if you give the parents a pre- and serious bacterial infections in chil-
obviously not as important as we scription to be cashed when symptoms dren with Streptococcus pneumoniae
might think we are. A trip to see the persist, you place an unfair responsi- occult bacteremia? A meta-analysis.
Pediatrics 1997; 99(3): 438-444.
hospital consultant involves a long and bility on the parents. First of all, it has
much hyped wait, with an often difficult been shown that in these younger chil-
journey to get there, a very big and dren symptoms last longer, whether
imposing hospital, and a doctor wearing they receive antibiotics or not; half of A clinical indication on every
a white coat with lots of attendants the children in our study had symp- repeat prescription
speaking in very impressive jargon toms lasting more than 8 days. 3
and giving a life-changing diagnosis. Second, we cannot expect parents to Over the last 6 months I have been
Vastly different to the GP whos just be able to judge whether the child putting a clinical indication on every
around the corner, available within becomes toxic. Cates mentioned in his repeat prescription, and so I was inter-
48 hours at the most, and talks in very editorial that when a child is toxic, ested to read about the paper on
basic language that anyone can antibiotics are indicated.4 Most doctors automatic quality checks on repeat
understand. Not so surprising then know what is meant by toxic due to prescribing.1 The article in the BJGP
that little importance is attached to us. their clinical experience over many was driven by quality prescribing,
How nice to be just a GP. The pres- years. How can we expect to teach this whereas my aim was patient under-
sure is off no need to make clever clinical entity to the parents in 10 min- standing and education. Certainly, my
diagnoses or treatment plans, we can utes? The child with meningitis men- patients now assume that it is quite
forget national service frameworks, tar- tioned in our trial was already on normal to have a clinical indication on
gets, and guidelines. It seems that the antibiotics on the second day because their repeat prescriptions and they find
most a patient expects of us is to be his symptoms became worse. On the it extremely useful. In this post-millen-
available, be a good listener, and to third day, the signs pointed to menin- nium era of general practice, where
visit when called upon. gitis and the child was admitted to poly-pharmacy is normal practice, it is
So its all really quite easy then, hospital. This boy turned toxic, and in becoming increasingly essential for
being a GP? this situation a doctor should decide patients to be able to identify the main
whether antibiotics are indicated or if use of each drug. To illustrate, some
EMMA PURVES the child should be admitted to hospi- examples:
GP Registrar, tal. Parents should not be given this
E-mail: [email protected] responsibility. If they have a prescrip- Take one simvastatin tablet at
tion they could decide to start oral night to reduce heart attacks and
CHRIS GUNSTONE antibiotics when the child should strokes.
already be receiving further treatment. Take alendronic acid once weekly
GP Trainer and VTS Course Organiser, Doctors should be aware that they to strengthen bones.
The Surgery, 72 Gordon Street, cannot buy safety with an antibiotic pre- Take fluoxetine, one daily to pre-
Burton-on-Trent, Staffs DE14 2JB. scription nor with a delayed prescrip- vent recurrence of depressive
tion. Oral antibiotics do not prevent all episodes.
cases of meningitis.5 Doctors should
Delayed prescriptions not monitor signs and symptoms and then This is printed out both on the white
a good option for infants judge on their clinical experience. and green parts of the repeat prescrip-
tion.
Infants with a respiratory tract infection ROGER DAMOISEAUX The local pharmacist, district nurses,
should not be sent home with a pre- General Practitioner, General Practice carers, and reception staff have found
scription to be cashed later. In the de Hof van Blom, Hof van Blom 7, it increasingly helpful, and I am sure I
November issue of the BJGP, three 8051 JT Hattem, The Netherlands. now have fewer interruptions for
papers dealt with the advantages of queries over repeat medication.
delayed prescriptions for reducing the References It seems such a powerful and simple
consumption of antibiotics. For the 1. Arroll B, Kenealy T, Kerse N. Do delayed way forward that I have been evaluating
older children and adults, it was shown prescriptions reduce antibiotic use in it further and there are additional spin-
respiratory tract infections? A systematic
that the amount of antibiotics for respi- review. Br J Gen Pract 2003; 53: 871-877. offs that I can see ahead. Firstly, it is
ratory tract infections could be safely 2. Damoiseaux RA, van Balen FA, Hoes AW, very useful in the validation of medical
reduced by at least 50%. Arrol et al et al. Primary care based randomised, summaries, as one can check that the
double blind trial of amoxicillin versus
mentioned that caution should be placebo for acute otitis media in children clinical indication correlates with an
displayed with infants, remembering aged under 2 years. BMJ 2000; 320: 350- appropriate medical item on the sum-
354.
the child in our trial that developed 3. Damoiseaux RA, van Balen FA. Duration mary of the patient. Secondly, it is
meningitis in the placebo group.1,2 I of clinical symptoms in children under extremely useful in providing education

58 British Journal of General Practice, January 2004

 Letters

to patients and all members of staff. results for the whole practice were had to negotiate on an equal basis.
As we are a training practice, my new 10.5/7.8 (n = 52 patients). Now it seems to me that you have
registrars find it very useful, when sign- This practice currently has 981 lost most of the initiative and in the
ing bunches of repeat prescriptions, to patients registered as hypertensive, not too distant future, I suspect, our
see the clear clinical indication. I am from a total list of 8650. Clearly there political masters will seek to replace
sure that it must enhance prescription is need for more research into this you with the cheaper option of nurse
safety. Further phrases that I use area, as electronic sphygmomanome- practitioners. This is already happen-
which may help this are: ters are becoming universally adopted. ing in some areas, and the personal
If our suspicions are correct it could service is already discouraged by this
as directed by anticoagulation mean very substantial resources government.
clinic; being directed towards treatment of With minimal visiting and no out-of-
regular blood checks required; incorrectly diagnosed hypertension, hours work, it must be a very different
under hospital supervision; particularly in the light of the new life and, I suspect, less interesting,
and contact doctor if sore throat GMS contract. more confrontational, but still well paid
or illness. but for how long?
STEPHEN HARTLEY
I am also planning to start to trial a GP Registrar ANDREW RUSSELL
prescription-history feature; for exam- GLADSTONE BELLO Retired General Practitioner, Kent.
ple, a start date could be added to
HRT repeat prescriptions and also, in a GP Registrar
similar way, to tamoxifen prescriptions. W J DAVID MCKINLAY
In conclusion, I suspect that clinical GP Principal Changing roles
indications on every repeat prescription Pendleside Medical Practice,
will become a valuable, essential part of The Health Centre, Railway View Road, Douglas Jeffries raises an important
modern general practice in the future. Clitheroe BB7 2JG. issue about whether the new contract,
http://www.pendleside.com with its focus on quality indicators a
NIGEL MASTERS population issue will detract from
Highfield Surgery, Highfield Way, References the personal issues that GPs have
Hazlemere, Bucks HP15 7UW 1. British Hypertension Society. traditionally focussed on. 1 What is
http://www.bhsoc.org (accessed 2 Dec particularly difficult for many GPs is
2003).
References 2. O'Brien E, Waeber B, Parati G, et al. Blood that the doctorpatient relationship,
1. Rogers JE, Rowe CJ, Roberts A, et al. pressure measuring devices: recommen- which derives from dealing with these
dations of the European Society of
Automated quality checks on repeat pre-
Hypertension. BMJ 2001; 322: 531-536. personal issues, is not only central to a
scribing. Br J Gen Pract 2003; 53: 838-844.
3. O'Brien E, Pickering T, Asmar R, et al. GPs effectiveness but is also, for
Working group on Blood Pressure many GPs, the most rewarding part of
Monitoring of the European Society of
Hypertension International protocol for the job. Consequently, there is a per-
Accuracy of electronic validation of blood pressure measuring sonal reluctance to take on this new
devices in adults. Blood Pressure Monit
sphygmomanometers 2002; 7: 3-17.
task, especially if it is at the expense of
the traditional role. However, it is pos-
The Pendleside Medical Practice, in sible that by switching the focus from
line with national directions arising the GP to the practice and using the
from the need for disposal of mercury, A very different life? resources of its practice team (such as
changed to electronic sphygmo- by expanding the role of nurses and
manometers in 2002. Being retired from general practice for receptionists) to develop a system that
Several doctors have been con- 11 years, I watch with astonishment the both delivers the targets and protects
cerned about apparent higher readings transformation that has been visited on those GPs who wish to continue to
with electronic sphygmomanometers, the job that I enjoyed for 33 years. My focus on the more traditional roles.
in spite of the brand used (Omron M5-I) generation were not all paragons of What is, in my mind, a much more
having been validated by the British virtue, but we sought to deliver a car- worrying development is the increasing
Hypertension Society.1-3 A snapshot of ing, personal service 24 hours a day, 7 access that patients are being given to
a mean of 10 patients for each of the days a week. I know that many factors services without going through their
authors produced a mean difference have made this ideal no longer sustain- practice. This is being done in the
between electronic and mercury able, but we were still a profession name of patient empowerment and will
sphygmomanometers of 11.8/8.7. On deciding ourselves how best to do the result in an expensive free-for-all
the basis of concern around these job and monitoring our own standards. supermarket approach to health care.
findings, we asked all members our The two bastions of our freedom This trend erodes not just the traditional
primary healthcare team to record from excessive outside interference role of the GP, but even that of the
blood pressures using both electronic were the 24-hour commitment and our practice itself a role that contains
and mercury sphygmomanometers for independent contractor status. We distress, provides continuity of care,
5 days in November 2003, and the had political power, and governments makes sense for patients of symptoms

British Journal of General Practice, January 2004 59

 Letters

within the wider context of their lives Dream or nightmare any proposals for new educational
(and thereby makes appropriate refer- vocational training work or process should have to pass a
rals) in essence provides at best a scrutiny to ensure that bureaucracy
well resourced and skilled team who As a group of experienced grass- and duplication are minimised.
can care for patients facing complex roots trainers, we have read and dis- Our final proposal echoes that of
medical and social issues. cussed the editorial from Patrick Howe et al and calls for a career struc-
International comparisons show that McEvoy.1 We identify with and recog- ture for GP educationalists.3 This is an
robust, well-developed primary care is nise all of the issues that the article essential ingredient to ensure that a
cost-effective. It is also central to any raises and we have attempted to identify flow of suitably qualified and motivated
system that purports to provide health some possible solutions. GPs continue to provide a professional
rather than just disease management. Firstly, we recommend the applica- teaching and training service. Their
tion of stern realism to the issues of proposal was for this role to be consol-
DEREK CHASE training and teaching capacity, both idated into the General Practitioners
Cavendish Health Centre, 53 New human and physical. Most of the lean with a Special Interest policy, and to
Cavendish Street, London W1G 9TQ. and competent training practices so do this would ensure that future educa-
E-mail: [email protected] aptly described are at physical capacity, tors would not suffer financial penalty
and yet there is no secure and recur- for their interests.
Reference ring identified funding stream for the
1. Jeffries D, Save our soul [Letter]. Br J building of teaching facilities within or ANDREW BLYTH
Gen Pract 2003; 53: 888. around GP surgeries in our locality. STEFAN CEMBROWICZ
Investment now in teaching facilities JAMES NORMAN
within surgeries will at least give us the
space to meet future demand. DAVID BAILEY
Condemned to education by NIGEL TAYLOR
telemedicine We are aware that becoming a train-
ing practice can be perceived by non- DUNCAN GOODLAND
I see from The Back Pages that doc- trainers as an arduous process, not GRAMHAM RAWLINSON
tors who work in towns are again attractive in the current climate of
organisational change. Until current TOM SMYTH
telling those of us who work in the
recruitment problems are overcome Northavon Trainers.
sticks how we should organise our
there are only two ways of increasing E-mail: [email protected]
education by telemedicine. 1 (And I
know the objection will be that theyve teaching capacity: either more group
been there, but for how long?) and less individual teaching, or the References
Anything is better than nothing, but the recruitment of more non-teaching 1. McEvoy, P. General practice vocational
training a victim of its own success. Br
same sort of strictures apply to learn- practices into the fold. To achieve the J Gen Pract 2003; 53: 675-676.
ing as to providing care. Just because latter will require realism in the funding 2. Kramer A, Jansen K, Dusman H, et al.
of start-up costs, and the provision of Acquisition of clinical skills in postgradu-
cover is difficult to find doesnt mean ate training for general practice. Br J Gen
we should abandon the attempt. Im funded sessions to provide teaching Pract 2003; 53: 677-681.
afraid that the prospect of sitting in without compromising service delivery. 3. Howe A, Baker M, Field S, Pringle M.
Enhanced service payments for teach- Special non-clinical interests GPs in
front of a monitor in our own practice, education, research and management. Br
which is what we increasingly do any- ing may be the way forward; funding will J Gen Pract 2003; 53: 438-440.
way, doesnt compare favourably with certainly need to be non-discretionary
spending a few days away from the and recurring. This will have the
telephone, having discussions with advantage of delivering resources to
the coal-face. The recent editorial by McEvoy on
colleagues, and maybe even going to general practice vocational training 1
the theatre or a movie! Its a truism that The piecemeal development of GP
training activity has led to complexity, was thought provoking but perhaps
a lot of the learning that occurs at bewildering.
courses takes place outside the formal fragmentation, and bureaucracy in
our organisational and assessment His editorial starts by highlighting
sessions. We have enough isolation in the lack of published evidence of the
our lives, dont condemn us to it in our structures. Positive strategies must be
created and implemented with the effects of a training programme, and
educational activity as well! then paints a nightmarish scenario in
So, an angry letter for you? specific aim of tackling these issues.
Our current competence assessment which increasing and complex
processes should be simplified to the demands are made upon the traditional
DAVID SYME educational training structure. We think
minimum necessary to achieve their
Killin, Perthshire. purpose. Kramer et al have demonstrat- it was useful to outline the challenges
ed that training schemes can work,2 and possible pitfalls ahead, but believe
References and duly accredited schemes should the message is unduly pessimistic.
1. Thornett A, Evans A, Sandars J. On
be left with minimum interference to do The challenges to be met in offering
videoconferenced consultations
lessons from Australia [Viewpoint]. Br J their work. Just as new building devel- a general practice component to foun-
Gen Pract 2003; 53: 898-899. opments face a planning inspection, so dation programmes are huge but we

60 British Journal of General Practice, January 2004

 Letters

should not shirk from the opportunity Deanery, Winchester. E-mail: teachers at all levels know this to their
and responsibility for providing it. A [email protected] personal cost, a matter deserving of
recent editorial in another journal has research.
outlined the opportunities and skills that PAT LANE Trainers know the realities of trying to
general practice can offer, reviewing Director of Postgraduate GP balance service delivery and training,
the evidence from GP pre-registration Education, Don Valley House, Sheffield but feel excluded from the lofty circles
house officer (PRHO) posts. 2 These that debate and formulate policy. They
studies have shown that a general References have yet to find an effective voice at
practice attachment offers a unique 1. McEvoy P. General Practice Vocational national level. They have a great deal
environment to gain skills and under- Training a victim of its own success? to contribute. Groups of trainers, such
standing that are useful both immedi- Br J Gen Pract 2003; 53: 675-676. as Blythe et al, meet regularly in train-
2. Smith F, Rickenbach M, Pitts J et al.
ately on the PRHO rotation, but later in Unfinished business: an opportunity for ers workshops throughout the length
a hospital career. These advantages general practice? Education for Primary and breadth of the UK. Indeed, they
Care 2003; 14: 15-17.
were seen by both the doctors them- 3. Ealing J, Van Zwanenberg T,Cunningham are probably the most comprehensive
selves and their consultant education W, et al. Pre Registration House Officers and representative network of activity
supervisors.3 in General Practice: a review of the evi- that this, or any profession, can claim.
dence. BMJ 2003; 326: 1019-1023.
Advances in innovative GP registrar 4. Worrall P. Innovative Training Posts; third It should not be difficult for this network
posts combined with hospital trust cohort evaluation. Leicester: University of to organise itself into an intelligent and
attachments4 and improved manage- Leicester, 2003. forceful entity. Is anyone up there tap-
5. Rickenbach M, Smith F. The hospital
ment of GP senior house officer posts component of vocational training. ping into the wealth of experience they
have been published. 5 Undoubtedly Education for General Practice 2000; 11: collectively represent?
453-456.
there are implementation obstacles to Does anyone else out there want to
overcome, and it may be the model for join the conversation represented by
foundation programme teaching is these two constructive responses to
closer to that seen in undergraduate Authors response my editorial and contribute towards
students than GP registrars. In the for- It is indeed an exciting and challenging shaping the future of education in, and
mer, placements often take place in time to be involved in general practice for, general practice?
pairs, with a larger group forming to education and these contributions from If so, l am sure the Editor would be
meet for joint learning and case dis- trainers and directors, respectively, happy to hear from you.
cussions. Problem-based learning ably illustrate complementary perspec-
approaches could encourage more tives. PATRICK MCEVOY
self-direction, and developments in Blythe et al make three points that l General Practitioner, Aberfoyle Medical
computer and web-based sources wish to applaud: Practice, 120 Strand Road, Derry,
would reduce the need for face-to-face Northern Ireland BT48 7NY.
teaching. Some investment in rooms the need to deliver resources to E-mail: [email protected]
and equipment will be necessary, but the coal-face;
may not be needed in every training to streamline the appointment of
practice. trainers and the expectations of
The Department of Health and the them;
Correction
General Practitioners Committee have In the November 2003 issue, in Coid J,
and to enhance recruitment and Petruckevitch A, Chung WS, et al. Sexual
recognised that a single basic training retention through a proper career violence against adult women primary care
grant does not reflect the panoply of structure. attenders in east London (Br J Gen Pract
tasks and sophistication expected 2003; 53: 858862), there is a correction to
from GP trainers. A new system of pro- There is some good news, as out- Table 2 on page 860. The bottom three
viding a training payment has been lined by Smith and Lane. The latter is rows of odds ratios have Yes and No in
proposed by the Committee of GP negotiating a constructive career/pay the incorrect order. The left-hand column
Education Directors, which should ladder with the Department of Health. labels should read as follows:
provide a postgraduate GP teacher The process is well advanced but, curi-
adequate reward and support to Forced sex
ously, does not include trainers. They
develop and expand his or her skills No
continue to be treated as if they were Yes
appropriately. outside the loop. Rape
We do not claim the Nobel prize Our system of training has long No
offered by McEvoy for this work so far, depended on the idealism of GP Yes
or even a gold star, but are excited by teachers and their partners who have Sexual assault
the opportunity to work with innovative had to redirect a significant proportion No
primary care educators to meet these of practice resources to support the Yes
challenges. training commitment. The more entre-
preneurial our professional ethos An amended version of this paper is
FRANK SMITH available on the journal website:
becomes the more strain this places
http://www.rcgp.org.uk/rcgp/journal/index.asp
Director of GP Education, Wessex on practice partnerships. Many GP

British Journal of General Practice, January 2004 61