What is informed consent?

#GPFUQ 166 How to question people in power? Tony Benn had five questions

What power have you got? Where did you get it from? In whose interests do you exercise it? To whom are you accountable? How can we get rid of you?

If you cannot get rid of the people who govern you, you do not live in a democratic system.

#GPFUQ 167 What is informed consent? Its not informed if the numbers that describe risk are a mystery to most people? Doctors usually don’t know the numbers needed to treat (NNT) and numbers needed to harm (NNH) and don’t explain the true benefits and harms of tests and treatments. Patients usually consent with only a poor understanding of their risks. Other numbers to explain overall benefits and risks like numbers needed to benefit (NNB) and numbers needed to damage (NND) are used even less.

Patients usually overestimate the benefit of treatments. For example, many people using statins or antihypertensive’s believe they are substantially reducing their risk of heart attack or stroke. Assuming that the treatment is safe and used for 5 years, only a few patients would take a drug if they thought that they had a 5% chance or less of benefiting (NNT 20). Half of the patients would take a drug if the chance of them benefiting was 20% (NNT 5). If the benefit was 5% or less then the number of patients willing to take a preventive drug was doubled if their doctor recommended the treatment. Most interventions are not that good.

Different doctors and patients cope with the same risk differently and the subsequent management of the same conditions varies widely.

#GPFUQ 168  How can risk and consent become better informed? GPs need to know and explain the frequency of benefits and harms of the tests and treatments that they recommend to patients. To be able to do this risk scores like NNT, NNH, NNB, NND for tests and treatments need to be easily accessible to inform everyday decision making and GPs need to benchmark their own understanding and tolerance of risk and make this clear when they make recommendations to patients.

If patients can make sense of their risk they will make more informed and personal choices about their care, and may not consent to overtreatments.

#GPFUQ 169 How do you reduce emergency hospital admissions? This should focus on all the people (patients, carers, and clinicians) at higher risk. Better care is needed outside of hospital for patients with chronic conditions. It is the weakest link in a chain of people at risk that’s important. Links are weak and the risk of emergency admission high when patients, carers, and clinicians struggle to cope with a mix of complex medical and social conditions, the plethora of services available, perverse incentives that confuse best practice, and the lack of effective feedback loops to inform choices about care.

For example, the GP is one of many factors in the mix. A series of studies of GP out of hours services in Bristol showed a fourfold variation in emergency referrals between the top and bottom quarter of referrers and a 10-fold difference between the top 10 and the bottom 10 referrers. A low “tolerance of risk” by the GP seemed to be the weak link that predicts emergency referrals. Weak links can be strengthened by making differences in behaviour visible through better feedback to patients, carers, and clinicians. Such an approach might reduce variation in performance and improve quality.

What’s the theory of everything?

#GPFUQ  160  What’s the theory of everything  ‘The need to seeks causes has been put into the soul of man’ Tolstoy

#GPFUQ 161 How do you get the balance of care right? In practice the dual provision of care by a personal GP and a chronic disease management focussed nurse gives a tension to provide balanced care for both a person and their disease.

#GPFUQ 162 Why do patients always come at the wrong time?  Its impossible for them to come at the right time its always going to be either too early or too late. A paradox is that whilst GPs and hospitals are overwhelmed by patients who have minor self limiting conditions, we are told that patients with clear signs of early cancers either don’t seek help or are under treated.

#GPFUQ 163 Why does it take three years to train a GP but more than three to train any other speciality? General Practice can either be considered too easy because you don’t need to know too much about anything or too difficult because you do need to know something about everything. The NHS funding for a three year training scheme simply reflects reluctance of Government and the NHS to move on from the old models of training of specialist doctors.

#GPFUQ 164 Why does working abroad for 2 years enhance your reputation in hospital medicine but trigger remedial training in general practice? If you work abroad for more than 2 year then before you can return to work as an NHS GP you have to prove your competence by being supervised working in a general practice until your competence is assured. Is this because GP is too easy or too difficult?

#GPFUQ 165 Why is it important to plan sabbaticals in your career?  We all work best doing the jobs we enjoy and feeling like a volunteer rather than a conscript. A sabbatical gives you a chance to review where you are in your career and either change it or continue it and stay a volunteer

Whats the laws of mistakes?

#GPFUQ 158 What are the laws of mistakes? The first is that mistakes are inevitable and learning from mistakes will make you a better doctor. The second is that repeating mistakes makes you a bad doctor. Not learning from mistakes is the worst mistake possible.

#GPFUQ 159 When it reflection always worthwhile? You have to learn from all mistakes but can’t reflect (the what? so what? what now? questions) on everything but its always worth reflecting on anything that provokes an emotional reaction in you.

Why is it bad for you if everything seems to be going well?

#GPFUQ 152 What’s it mean if there aren’t any problems? It usually means you have not been paying enough attention to everything around you and have not noticed the problems that are there.

#GPFUQ 153 Why may it be bad for you if everything really seems to be going well? If you’re not having any bad experiences it usually means you aren’t getting out enough or challenging yourself.

#GPFUQ 154 Can complex problems have simple answers? In real general practice for every complex problem there is always an answer that is clear, simple and wrong.

#GPFUQ 155 What do we need to do when the guidelines have no good answer? GPs have to us their judgement to help patients decisions about their care. This judgement is a major sink for risk in the NHS but we have to be careful because the risk we are taking is with other peoples lives.

#GPFUQ 156 When do guidelines and technology cause most problems?  It’s when they make us ask our patients questions that neither of us really want asked.

#GPFUQ 157 When is a patient’s urgent problem not an emergency for a GP? It’s not an emergency for the GP if the only failure is that the patient hasn’t planned their day.

Why is there a crisis in GP numbers?

#GPFUQ 149 What’s the big crisis in GP numbers? The recruitment problem is that not enough junior doctors want to train in general practice and not enough want to train in the under-doctored parts of the UK. The retirement problem is that too many GPs are aged over 50 and too many are deciding either to retire early or not continue working after the age of 60. The retention problem is in response to the changes in work that too many GPs are quitting careers in general practice too early.  The returner problem is that GPs who leave UK practice for more than 2 years but want to return have to have a period of low paid retraining. The regulation problem is that the bureaucracy of payments processes like the Quality Outcome Framework, and accreditation processes like the Care Quality Commission make GP work unpopular. It's clear that we have to challenge and change current recruitment, retention, retirement, returner and regulation practices if we want the NHS to continue with the primary care registered list that provides care for all patients and protects the secondary care from too many referred patients.

#GPFUQ 150 Why is there a crisis in GP numbers? The accumulation of past errors and current circumstances has created a perfect storm! These probably include the structural and process problems that allow the largest UK specialty (General Practice) to be relatively under-represented in all the organisations that influence the choice of medical careers; the rapid expansion in numbers of hospital specialists (possibly at the expense of general practice) with more sub-specialists who need more junior doctors to, the relative underfunding of primary care (compared to secondary care) at a time when workload is increasing, all the other portfolio jobs that can divert GPs away from clinical practice, the changes in GP workforce that necessitates more parental leave and more part-time working, the reduced pension cap that means many older GPs reduce how much they work to match their pension cap,  the burden of over regulation with revalidation and Care Quality Commission, the weekly onslaught of bad news about general practice in the media and the increasing demands that mean a GP’s day is often a busy 11-12 hour day.

#GPFUQ 151 How do you solve the crisis in GP recruitment? Hold the feet of the politicians, civil servants and medical speciality leaders to the fire on consequences of a NHS without effective primary care. Ensure each and everyone responsible is held accountable for their actions and inactions. Some suggestions include placing more medical students and Foundation doctors in the practices where they are most likely to be inspired to become GPs. Its not surprising that if medical students and Foundation doctors spend most of their time in hospitals, and have straight forward career paths in hospital they may be biased towards a career in hospital medicine. The status quo has failed to provide the balanced workforce we need.  A better way may be for medical students, Foundation doctors and GP trainees to spend at least 50% of their time in general practice learning medicine by following patients who have the specific health problems listed in their medical curriculum on their journeys though the health and social care services.  We must also promote Foundation and GP training in the under doctored areas otherwise the NHS will collapse in those areas. The NHS and Health Education England must use all the carrots and sticks at their disposal to get junior doctors working in the right numbers in the right specialities in the right areas.