p000OK, what was this? Alright, so sorry about this, would normally be set up for the room was locked, er. Right, …
OK, what was this? Alright, so sorry about this, would normally be set up for the room was locked, er. Right, so, one of your starting points is gonna be, you can probably find the. First slide on Minerva, you need to write down the class of drugs for, so for folic acid, aspirin, methotrexate, um, ramipril, sertraline, think of what class of drugs they are, so that if you find the first slide on Minerva, whilst I set this up. I think that's the list. Methotrexate, folic acid. Sertraline, aspirin. Ramipril, what class of drug they are. And if we're still here, think about some potential side effects they can cause. Morning. Naproxen, I missed off naproxen. While Mr. Ostein's OK, I'm gonna give it another couple of minutes for this. If you've already gone through the list and said what class of each medication is, just think about some side effects. Um, Think about why we, we're gonna come back to this list in a minute, which is why we're looking at it. OK, let's think about starting, so sorry about the um delayed start with the room being locked and then me faffing about sorting out the computer um. So I'm Doctor Walker, so I'm the GP who leads the community and public health rotation, so for the next 6 weeks, that's the rotation you'll be completing. Um, Yeah, so keep these lists, cos you're gonna come back to these in a moment. So. Just as a pointer, so you should have watched the recorded introduction seminar which is on Minerva, so that's the recorded part that was taken out of this seminar because it's all the dry stuff about what you need to do to complete the rotation, so it should be telling you what you need to do to pass and to progress with the course. Some other pieces of information as well. So, If people watched the video, Yeah. Yep, OK, so if you have any questions about what you need to do during the rotation, please let me know. I'm available by email, um I'm MA.walker. Um, and I can answer any questions about the video, if there's anything which needs to be clarified. Um, but yeah, 6 week rotation, you need to complete all your placement based assessments, your end of placements assessments. LA assessments. So you need to prepare for IA one for Thursday. OK, so what this intro seminar is going to focus on is a bit of uh what's getting you to do some work, think about other aspects of medicine that GPs are involved with. Things that are not so obvious when you're in placements or maybe obvious if you go and see a GP. And we need you to do the medicines, you're going to think about this, so you're gonna be using your brains to get warmed up, um. Yeah, so basically we don't understand the principles of medication reviews, filing blood tests and filing correspondence. The practical application of your knowledge, um, and also think about additional ways to learn whilst on clinical placements. So if you're on placement, you can do these three activities in theory, and looking at how you would interpret someone's blood tests, how you would interpret someone's medication, is a medication correct for them, and you can debrief it with your supervisor GP. So these are ways that you can learn and process information. Having supervised 3A and 3B students for a number of years in 3 placement. Uh, both in primary care and in secondary care, because I still work at Chesterfield Hospital, um, I would say that the largest gap in knowledge I find in undergraduate medical students is the knowledge of medicines, things you're gonna prescribe. So being able to go through medicines or medication lists of patients is the best way for you to learn. Um, cos you'll find out what the most common drugs are, what they're prescribed for, side effects, interactions. And then you say to prescribers when you start work. I think it's the biggest gap in knowledge that there's a body of people undergraduate medical students have, and that's not just Sheffield medical students, there's other medical schools that I've come into contact with as well. So. Yeah, I think it's a big, a big space for learning. Um, so we're gonna work through some cases, we're gonna consider the possible actions that can be taken in each case. So it's very practical, this, uh, this seminar, um. Yeah, OK. So we're gonna start. So what is a medication review? So a structured critical examination of a person's medicines with the objective of reaching an agreement with the pers with the person about um treatment's optimisation, the impacts of the medicines that they're on, minimising the number of medication related problems and reducing waste. So this part of the seminar links in with your multi-morbidity polypharmac polypharmacy seminar which you're gonna have in the coming weeks, I think maybe even on Thursday. Um, And these are what you need to go through when you're doing a medication review. So, sometimes medication reviews are done without the person in the room, probably you know the patient quite well, um, you need to think about, Their views on the studies of the medicines. Any concerns or questions they have, any potential side effects will come up in that conversation. Are they taking any over the counter or complementary medicines? Um, every night again you come across a little Uh, bombshell, which kind of. Catches you off guard when people are taking things. One example from my clinical practise which really caught us off guard, there was a lady. At South Dog. Say form of thyroxine, so she's basically Um. Probably explained from the symptoms that she was presenting with, but if, if we're not prescribing it, we don't know about it, but she was still taking it, so it's really important to, to ask about these things. Um, are the medicines appropriate for each person, so that's really important. Um, so can you justify the ongoing prescribing of a medicine, is there a reason for it to be there? history, and figure it out, um. Have their risk factors changed? Are they getting at risk of adverse drug reactions? So if somebody's, so as people get older, their physiology changes, the drugs that they might have required when they were 50, 60, they might not need when they're 70 or 80, the priorities of care change and somebody's physiology might change as the background. An obvious example would be renal function changing. If your kidney function changes, you might have to alter doses of medications or stop certain things. E So yeah, um, if the person changes their medications might change. So these are the things you need to factor in, and then last but not least, which is quite important, any monitoring that's needed. So most medications need some form of monitoring. So here we go, straight into it for you guys, so here's our case, you're gonna be working with the people sitting around you. Um, you're gonna have a conversation for 5, 10 minutes, just think of it like a big tutorial. Um, so yeah, here's our, here's our medication review. Do you have a 70 year old man? He has a background of rheumatoid arthritis, hypertension, CKD3, ischemic heart disease, and depression. And that medication list is the one that you should have. I had a quick look at at the start of the seminar, it's exactly the same medication list. This patient is on aspirin, folic acid, methotrexate, naproxen, ramipril, and sertraline. And you're gonna do a medication review. And this is the sort of thing you can do in placement, remember, so we're talking about identifying things you can do in placement. If you find yourself at a loose end, um. If you have a longer break in the middle of the day between clinics, I've had some patients of some patients rather some students come and they go home. Green. I mean, I, you can, but I just think you're better off staying in a place. How So You're not driving Because I've had students tell me they're driving home. Go back out You're driving Ra ther than twice, just strikes to be a bit odd. So I would suggest trying to fill the time up in the middle of the day, um, because this will teach you how to be good doctors, and you're also gonna have clinical exams at the end of the year, so if we're writing questions involving medicines, it's a good way to. Get a good baseline of knowledge, um. Yep, OK, so try and utilise your time while in placement is what I'm saying. And you can just get some if you see some patients in the morning with complex medicine. Regimes, just sit and have a look at it and just go through this process, so figure out what the class of each drug is, so you should have already done that or most of you would have done that, then you have to justify the medication, is each drug appropriate for this person? So you can go through each medication, can you find the indication for it? Can you justify its continued prescription? Are there any monitoring requirements? So each, like I say, each medicine that you're prescribed normally has some sort of monitoring, um, so how are you gonna monitor these drugs? And obviously in here there's a very specific one with very specific monitoring. And are there any other drugs indicated, so this is another aspect of medication reviews, is there something missing? Do they have an indication which. So The patient might decline it, but you can offer it. Um, Yeah. So that's what you're going to be doing with the people around you. So which slide would you like me to leave up? This one, yep, you should have the slides in front of you as well, most of you have laptops. OK, yeah, be working with the people around you. Seem to be lacking Yeah, Yeah, yeah, we'll talk more about it. Yeah I was Yeah Me Yes Yeah, so you have to check Right A couple I don't know if you figure out which Mm Right, we'll bring it all back together, just for the interest of time. So we've got a couple of the cases to do after this as well. So I think everyone's talking in around. The correct ideas. Um, Right, so aspirin, why's the aspirin prescribed? Give us the answer. From back will give an answer. Yeah, OK, so it's gone to the skin car. So aspirin is a, what class of medication, it could be somebody else who answers. It's Linz, OK, so it's Linz, it's got a high degree of antiplatelet function, so it's used for these people with heart disease to try and stop them having an MRI, OK? Folic acid. What is for the calcium? Climbing 36, a. Be on? It's been on. Is it? You look it up? B6, P9, P1. Looking to past 10 minutes. What Benign, OK, so folic acid thing with B9, while everyone's looking that up. Uh, methotrexate, what class of medication is methotrexate? Female, very good, excellent, and prescribed for Very good. Take a step backwards, so I jumped forward so then we can go back and say, so the folic acid is prescribed because. Yeah. folate agonists, so it will drop your folic acid level, so you take it um on a day. Isn't the same day as the methotrexate? Stop it functioning And also, practically, so you put the days of the week on so they don't interact, and. Also put them on, I think, cos it's partially helpful if someone's admitted to hospital, do you know which day of the week they're prescribed the methotrexate. If you're the admitting junior doctor on the ward, it's very practical to help you put it on the right day. OK, it's also so you don't take the folic acid and the methotrexate on. Naproxen. Is a NZ in this case would be prescribed for the. Rheumatoid arthritis, good choice for rheumatoid arthritis because it's anti-inflammatory effect, so obviously rheumatoid arthritis, inflammatory arthritis, it should help. Ramipril. ACE inhibitor, a common side effect of an ACE inhibitor. Dry cough, it's very good, in this case, it's prescribed with hypertension, and sertraline is a. It's all right. Common electrolyte abnormality of this. One was to occur, so. Low sodium, yeah, yeah, so you've got somebody with a sort of mildly low sodium and they're on SSRI that could well be the cause. OK, good, so if Cardiff thought, yes, they've all got a justification for them being there, um. Let's think about monitoring or any possible interactions, so does anybody want to sort of say what they're talking about, any possible interactions? I've heard various things. Yes. Good, so the NZ's might be impact his renal function, very good, so I think a lot of them coming out, but thank you very much for answering. Um, so the NZ's could be impacting his renal function. How could we unpick just thinking about the NZs by themselves, how are you going to practically unpick that? I think practical application. 6 Can the aspirin be stopped. That would be a poor choice, I think, to stop the aspirin because we're trying to stop it. So, the naproxen, we can think about that as a single entity. So how would we Think about the naproxen for this chap. We've talked about it a little bit here, if we want to share our thoughts or if anyone else got any thoughts about the naproxen. Good. Oh yeah, so excellent, so two excellent questions, so how else have you taken it? And is he still needing it, so. If he's taking it every day of the week, twice, 2 times a day, every day of the week, you might be thinking, OK, is that really necessary? He might have started methotrexate fairly recently within the last 6 months, it might have kicked in and had a good effect. He might be left on the naproxen, sort of a habitual state where he just thinks he has to keep taking it. You might be the first doctor who turns around and says, you can stop that. You have to think about your sort of how you're going to approach this. He might be taking it just sporadically through the week, a few times a few times a week cos he might have a manual job and he might need his hands to work or they might flare up a little. So, it depends on your comfort levels, but if he was taking it, if you didn't need it anymore, the methotrexate kicked in, I might say you can try stopping it. If he's needing it, because he likes gardening or does a manual job or something and he's using it a couple of times a week, I might feel that's OK. You kind of have to, you know, the individual tailoring of the of the management plan. So I'll ask him a few questions around that and then. Which are the drugs? So the non-steroidals, another drug up here which would affect the renal function in conjunction with the non-steroidals. No It's gonna be the ACE inhibitor, the sertraline. Which one would and. Yeah, the rama poodle. So together, ACE inhibitors and non-steroidals are not the best for renal function, they, the cumulative effect is it will drop your EGFR due to the way they constrict the efferent arterioles entirely. Constrict the afferent arterioles and dilate the efferent arterials, OK, that would decrease your. EGFR. So they're not necessarily the best of friends for renal function. If the renal function was stable on a UNE, you might say, OK, it's stable, he's using the naproxen a few times a week, we'll continue. If the renal function was dropping, you might be pushing to stop the naproxen. Right, so Any other thoughts in there about the other drugs? We've talked about the non-steroidals. They can, very good. And the, very good, and the sertraline can also inhibit platelet function, so increasing bleeding risk, so you're now on aspirin and we've identified sertraline as possible increase in bleeding risk. So how, what might you um do to help manage. Yep, good, so we can add the PPI we can offer him a PPI because we're worried about gastro er. Uh help them with that, so very good, good thought process. Can you think of a, any side effects of PPIs if we're throwing another drug in there? GPRs are not 100% safe, they do have issues, I would still offer it. We have to think about the issues Um, B12 deficiency, osteoporosis, because they affect uh calcium absorption, and they can also cause hyponatremia through an SIADH process. So you're then you're on two drugs that can potentially lower your sodium a little bit, probably not critically, probably not dangerously, but if you see a low sodium, the two could be involved. So yeah, uh, increased GI, uh, infection risk, so if you're a PPI you've got a high risk of having C. diff. So, PPI is a very commonly prescribed drug, however, not 100% safe. And then, um, OK, so that was very good, so that, so a PPI is one of the drugs I was up there I said point number 4 was coming off of this person the drugs and a PPI was one. Any other thoughts about this medication? Now we're gonna monitor the surgery. The guys in front of you. Yeah, how are you? Good, excellent. So that's how you basically monitor this is, you're gonna ask him how he's getting on. If he's saying his mood's stable, it's been stable for 6 months on the SSRI, you might be discussing trying to wean it down. So if someone's on an SSRI for 6 months and things have been stable, that might be a time to look for change, we don't like to continue them forever, but if the person's very much wanting to continue them. I'm not gonna have a massive argument over it, because that's gonna be disruptive. relationship No Um, OK, so that's a sertraline. Have you monitor the methotrexate, cos that's a big thing to monitor a kid. Yeah, good, so what you've described there is how someone's initiated the methotrexate, so that's really good. Um, so for the people who didn't hear it, so, so secondary care, so doctors in the hospital will start methotrexate, as a GP I'll never start on methotrexate, so the one or two weekly monitoring is correct, but that'll be done in secondary care, and once they're stable on it, so once somebody's stable and the secondary care doctors feel it's an effective medication, and they can tolerate it and their bloods are staying OK. They then complete what's a shared care protocol, so you might hear this word shared or phrase shared care protocol in practise, and that's when secondary care doctors pass over the monitoring of their drugs. OK, if there's a problem with that medication, the GP would maybe stop the medication, wouldn't change the dose, we normally stop it and then go back to the parents. Um, so we're gonna check bloods every 3 months, you said full blood count, LFT. So why do we need to check the full blood count? Maori oppression. LFTs because it can be hepatotoxic. There's a slide coming in a moment which will tell you about um pulmonary fibrosis which can occur and GI irritation. If somebody's ill in between their 3 month. Scheduled drugs, you may do urgent bloods on the same day somebody presents with a fever. Because you wanted to check the Maori suppression hasn't happened. So you would check it Which drug should you never prescribe with methotrexate? We'll be OK. Trimethoprine, I never co-prescribed trimethoprine. Um How are we monitoring the ramipril? Did we talk about monitoring the Ramipril? It doesn't help. There's also another drug which will be offered. How are we monitoring Yeah, blood pressure, good. So the way we monitor any drug is just what is it prescribed for, so the methotrexate has got very discrete sort of guidance what you have to do. So all the other stuff, it's like why is it prescribed, and then I just check it, OK, so I'm checking the blood pressure, is it working? I wouldn't switch him to uh a calcium channel blocker if his blood pressure's stable. And we would check a UNE. If he didn't have the methotrexate, I'd check his UNE every year, it's stable. Basal methotrexate, we begin every 3 months. Which of the medication can be offered to me? We got PPI to discuss that. Yeah, statin, he's got ischemic heart disease, so we know he's high risk uh for a cardiovascular event, so. Yeah, we don't have to do a risk. He's got established vascular disease already. He may wish to say no, so that's why we say offering it. So how many jobs have you got there, 123456. So Is 6 a lot of drugs? Some people Yes, some patients, it'd be about 1/3 of them. But even so, The point is, even on 6 medications, fairly slim past medical history, there's quite a lot to do with it, if you do a full medication review, there's actually quite a lot to think about. So it's a good way, so, so that's important for you to understand what the process is, so if GPs are a medication reviews, all these things should be happening. Your pharmacists and placement will be doing these kinds of medications. Time to try and link And if you've got time yourself and you've seen a patient in the morning with a complex medication regime. Get hold of the Medication list, a past medical history, get a printout, get a log in to the computers, make sure. Sit and through this process with that long medication list and you'll just start to learn medicine so quickly and it gets easier the more you do it, OK, so it's harder to start and the more you do this, the easier it is, so when I supervise 3B students at Chesterwood Hospital, every time we see a patient, We go through the medicines like this. And at the start, and there's lots of I don't knows. Uh, by the end, because you're seeing the same medications on repeat, you see the same medications a lot cos they're commonly prescribed, by the end it's a very quick process, so if you start it now, you will learn a lot very quickly. OK. So this is a bit about methotrexate, uh we've talked about it really, just to make you aware so you the blood counts, you have to check that, um, GI toxicity, so if somebody starts with diarrhoea, just think it could be the methotrexate if you're struggling to find a reason. liver toxicity, we talked about monitoring the LFTs and pulmonary toxicity, so if somebody presents with breathing issues. OK. We are, so we've got about 20 minutes on this 1, 20 minutes on the last one. So over to you guys again in about 5 seconds, so you're going to be, you're now the GP filing uh abnormal results that have been returned to the practise, so. GPs in the morning might sit in front of the computer, the patient is not in the room in this scenario, you can see the blood test results. See written information in the notes. That's how this Would be. Um, So you can see from the previous encounter, this is a 49 year old man, he tends to feeling tired all the time. So tired all the time is a common presentation you're going to see in the next. With no symptoms to suggest hyperthyroidism, you're a smoker. Um, morbid obesity, and some blood tests were requested to try and Figure out why he's feeling tired. And these are the results, the important results, I couldn't put all the results on the slide, it'd be too busy, so. Yeah, there we go over to you, you can interpret this. do you think it means If someone's tired all the time with a raised BMI, what could these be telling you? Yep, so just work with the people around you. Mhm. Yeah Yeah Yeah. K OK, we'll bring it back together, because we've got a 3rd case to get through. So. So yeah, so even within the 6 erroneous blood test results, there's quite a lot to think about. The really important, one of the important learning points with this, and which you get to practise doing interpreting uh. Everyone's blood test results come back into practise, you can sit and look at these when you've got a bit of spare time between clinics. This, so interpreting blood test results. It's a very important skill. Um, which you'll also need to do when you're a junior doctors. So whether you want to be a surgeon, psychiatrist, whatever, walk of medicine you want to take. In this. It's an important skill to learn wherever you Um, I think the headline is there's something going on and we need to have to take a closer look. If you only sort of like put it in a sentence, and there's something is occurring, so we're gonna have to see this person again and these blood tests are gonna help us think of a few conditions. Ask about if we take a slightly more focused history, so these, these. Blood tests will give us more information, we have to interpret them correctly and then we can apply it to the person in front of us. Um, so yeah, you have to interpret the blood test results for each individual. Uh, yeah, so we've already done that, I forgot to put side. So just thinking about some causes of polycythemia. Um, the idea being we're gonna see the common themes that crop up over here. So we've got primary cause of polycythemia, a JAK2 gene mutation. I don't think the blood tests are really deranged enough to suggest this, this happens later in life. Secondary causes, OSA stand standing for obstructive sleep apnea, COPD could be a factor because he's got smoking, chronic heart disease, um, he's probably got chronic heart disease because he hasn't, he got his past medical history. EPO, anabolic steroids, I've told you his BMI's high. I've told you he's obese, but he could just be getting jacked at the same time as well, um, which could be causing polycythemia. Um, diuretics. Alcohol, obesity, so apparent polycyphenia, where my, my understanding is, it's more of a concentration effect. Cause of macrocytosis, so let's see what crops up here, B12 and folate deficiencies, so maybe we need to check those. Uh there's an extra blood test, alcohol. Drugs, I'm afraid methotrexate has cropped up again, um, which would linking to the first bullet point there. I don't think we've got a haematological disorder, I'll just put that up there for completion of the slide. Liver disorders and cells can cause microcytosis, so that could be one of the reasons. You've got deranged LFTs, you've got a raised MCV, the two can be interlinked, and again, smoking itself can cause microcytosis. Pregnancy, he's not pregnant. Cause of hypocalcemia, it's, it's hypo, his, his calcium level's only slightly low, so you can have hypo uh parathyroidism, low vitamin D, so we'll check his vitamin D status, CKD, liver disease can cause. Decreased calcium levels, and for completion, sclerotic uh bone mets. Um, plastic bone that's There's two different types of bone mets, the sclerotic theme one where bone is laid down so you have low calcium because it's been used to lay down the bone met. Um, he doesn't have cancer. Just put it there. So then, let's see what common themes have alcohol turns up again to raise down the GT, as does obesity, pancreatic disease, MRV will probably diabetes, so a couple of people said to check his check he's diabetic, good thought. And some changes to the ALTs. Fatty infancy, alcohol turns up again. So we started to think there's a, there might be a common theme linking some of his blood test results together, yeah, and this is just a very easy way to think about, well, what links all this together and what do we need to ask our patients. So alcohol's sort of running through the theme there, isn't it? What else was in there that we need to ask this man about? We're gonna ask him about his alcohol, what this question. I'll go and figure out Diet, OK good, so he's obese, so what's happening there, talking about lifestyle changes, the lifestyle change is super important, we'll talk about that at the multi morbidity seminar later this week. Again, we do case work again from Um, What else? Medications, good, so we need to cover that, we'll get that from the from the record, what questions do we need to ask you about symptoms? Uh. Potentially think about Fantastic, but I'm trying to think, think of the questions that are gonna help us sort out the polysy the music. Sleep, good. So, yeah, so you're thinking about. Yeah, so the OSA the obstructive sleep apnea is really important here. So sometimes that gets overlooked. Oh Um, so good, so you can ask him if he snores, he might not know if he snores, and who else might. Don't shared the bedroom with anybody, or you can have in the family house hearing snoring from different rooms, so snoring, um. Whether people are aware that he's waking up short of breath, does he wake up like. Pause in the breathing and then continues, that's the apneic episode, that's the sleep apnea, so, it might be that, someone's noticing that, so yeah, so sleep apnea can cause polycythemia because your oxygen levels can drop when you're over, when you're sleeping overnight, and because you don't sleep properly, you know, with sleep apnea you never achieve a deep sleep, you never feel rested, so you can fall asleep. I've come to realise, having done a medicine degree that my driving instructor has sleep apnea, because, and everyone in the town who had Ralph as their driving instructor realised he just fell asleep. Big obese guy, clearly had sleep apnea, wouldn't be just driving around without any instruction. Very easy to fall asleep on a warm sunny day, in a car, driving around, so he clearly had sleep apnea. I didn't realise it at the time, I was only 17, but now I know, um, yeah, so, yeah, so, yeah, I'm not sure if I can drive properly or not really. told me, but yeah, so he had sleep apnea symptoms, OK, um, so this is back, so he comes back in to see you, you bring him back in, so the important thing is, you know there's a problem so you've got to bring you back in to see him, so he had symptoms of sleep apnea, drank high quantities of alcohol in the evening. Um, diabetes, and was smoking like 20 a day. So this is a real case. So I teach for real cases. The first case is real, this case is. And it's having a raised blood pressure as well, so we're thinking about the diabetes, cardiovascular disease risk. Um, if you have sleep apnea, your blood pressure's gonna go up as well, so if you manage the sleep apnea. The blood pressure might help So we have. So the focus of the consultation was trying to Consider lifestyle change Good And he did not want to change a thing, so this is sometimes the things you get sort of in medicine. So I sat there, had a long chat with him, so I really think over a few consultations, you can't do it all in one consultation, you just scare the patient away. Over a few consultations I said well I'll come back, we've talked about what it is today, come back and see me in a couple of weeks, we can talk about some positive changes, with a dietician involved, like do some like referrals out to other teams to try and help. And then, I could still see his face, this is a few years ago now, I could still see his face, he's like, no, I've always been overweight, I've always drank, I've always smoked, definitely none of these things. And then he decided he had long COVID, that was his diagnosis. And I was like, you might not. What? So he was very resistant to change because his mindset was I've always been this way and I've been fine before. So, sometimes you try and talk to patients about cumulative effect over a period of time, your physiology changes, especially. 49, so it's not how he is when he was 25. And it's gonna start taking its toll. Just for balance There was one patient I had when I had one conversation with her about being overweight, and she was probably similar to BMI. I saw her six months later. She just went off and just did it, so sometimes you people at other ends of the spectrum are just like, oh the doctor's told me to lose some weight, I've had to go and do that, and she's went and did it. So, yeah. And there's a GP in Sheffield. Oh this is going back about 8 years. She was like white rice before but. It's a really good story actually. So she was the Ladbrokes and she bet she could lose 5 stone in 6 months and they gave her 50 to 1. And she made about 5000 out of it, and now Ladbrokes won't take weight, won't take bets on weight loss. So her name is uh Libby Collins. Um, yeah, so like, yeah, she was on the she was on BBC Radio 2, I heard her talking about it cos she got on national radio. Yeah, so like, yeah, so I think that's a really good way to get you to lose weight, just give them some. wrote a book on it, maybe. I don't know, but she lost weight. That was an incentive for her, and she made some money out of it. So yeah. Um yeah. So yeah. Cool, so yeah, finally us, but the important thing for you so in this in the next 6 weeks and for the rest of your undergraduate course. If you see some unusual blood test results, just take some time to interpret them and think about what's causing it for the patient and what you're going to do about it, so just try and interpret. And this one we haven't really focused on how medicines could be changing blood test results as well. So for different people, you're gonna have different outcomes, but starting to get used to this thought process is really important. OK, well, we've got 15 minutes to finish. Off OK, so filing correspondence. Again, this is something you can have a look at letters coming into the practise, um. And see how you'd factor it into patient care because sometimes the letters aren't always as straightforward. So you're the GP and you're reviewing incoming correspondence from secondary care, so letters coming from the doctors in the hospital uh passing on information to the GP's. So this is your first letter, so you don't know this person? The letter's coming in. So, sometimes, just to put it in context, sometimes the GP's are just CC'd into letters, so this letter you can see from the metabolic bone team to the oncologist, but the GP you the GP have been, you've been. Um, copied it as a third person. OK, so, so Doctor oncologist is saying, uh, he's receiving this letter, and you're reading it as well. So thank you for referring us as patients to the Metapo bone team for fracture risk assessment. She's declined to attend the appointments, so she hasn't turned up. Uh, in any case, it would be best to consider osteoporosis treatment on a pragmatic basis at this age. She is likely to have an osteoporotic T-score, uh, degenerative changes at the spine, and she is taking eczemastane. Exczemastane will cause osteoporosis, it is a, uh, hormonal drug for breast cancer. Uh, if no contraindication, she go for an oral bisphosphonate treatment to protect her bone strength. In any case, vitamin D should be prescribed, um, from GPs and copied into this letter, so. Some ambiguity in here. Imagine you're the GP trying to, this is a real letter state as well, so this, this, this, this happened, um, so, are you as the GP supposed to be prescribing the bisphosphonates? Oncologist's going to be prescribing the bisphosphonate. It's just a bit messy at the minute. It doesn't feel quite straightforward. Anyway, so you look at the blood, uh, you look at the patient's, uh, record, hypothyroidism, CKD3, folic acid deficiency, breast cancer, calc exeta, folic acid, levothyroxine, so you have to decide can I prescribe this person the bisphosphonate or not. I'll give you some information as well on there. Why do you think I've given you weight in a UNE? What do you have to calculate? We can do this in bigger groups Normally I would have Run a bit longer. So why would I have given you a We Yeah, you gotta pick out the classic food, so if somebody wanna look up. Somebody wanna do a quick, I can't remember what the answer is off the top of my head, does somebody wanna go onto med everyone familiar with Medcalp? Yeah, so medcal creatinine clearance. So you can see how the kid is a. And you can decide whether she can have a bisphosphonate. How old was she? Was she 90? It was 90 something, 91. What does it have to be to prescribe, so it's 27 fucking clearance, so what does it have to be above to prescribe it for bisphosphonate? 35, so can she have it? No. So she can't, well she can't have it though, because the bisphos her creatinine clearance is is good enough for an organ bisphosphonate. So the reason I did that in a sort of a long winded way rather than me just putting it up on the screen is to sort of, again, just sort of cementing the idea is that if somebody from secondary care, who may not know the patient as well, offers a drug to prescribe, you as the GP or you as somebody who might know the patient can say well actually. And also, you also have to be aware of what the medication entails, you can't just put it on the repeat prescription, you know, you yourself as the prescriber have to check the creatinine clearance and know that the bisphosphonate requires the correctly clearance. So it's processes to go through, so it's just making you aware that you have to stop and think. You can't just do things like a knee jerk reaction. So she can't have an oral bisphosphonate. So we're talking about what you consider. So what action would you take? What could you do? You could write back and be like, what's going on here? So, the pharmacist, so this is from uh uh Miss Medication, who's the GP pharmacist at our GP practise, so she wrote to the oncologist, um, we've recently covered into the metabolic bone team's clinic letter, can you confirm if the oncology team is following up with this plan, because at the minute we don't know who's who's doing this plan, we've just been sort of copping into it. The metabolic bone team recommended a pragmatic approach and suggested Mrs. Patient should take an oral bisphosphonate, appropriate. We'd like to make you aware Mrs. patient has a reduced pressing clearance. grammes up. of less than 35. would make alendronic acid of licence, so not to Um, Would you want to confirm ibradronic acid in postmenopausal women with breast cancer, um, so they could think about an alternative, which she could have, and she would have that once a year, once every 6 months, I'd have to double check. So we're still trying to do these letters are flying around, so we're trying to still figure out what's going on. In the meantime, another letter pops up to the GP. Could you arrange to see Mrs. Patients have an oral bisphosphonates as suggested by the metabolic bone team? Her next appointment with us is in 6 months' time, so the oncologists aren't really stepping on this. Um, So now there's just more, more people are getting involved, so this low creatinine clearance information has now been passed back to the metabolic bone team. So no one's really owning this situation are they, it's all a bit circular and sometimes it's, this is what happens. So how would you get out of this circular situation, do you think? What would you do as a GP? Good, let's get the patient involved, that's a good start. And what are you gonna do about patient? Talk to them. Yeah, good. So that's the way to get out of this circular conversation, because at the minute, everyone's suggesting things that nobody's actually thought about. Um, So the reason she didn't want to go to metabolic bone in the first place is because she didn't want any more tablets, she was sick of it. 91 breast cancer, she was just thinking. tablets or in the treatment anymore. So the reason she didn't go, she didn't. So that's an important thing as well, there's a lot of work going on, people firing letters around, but nobody actually involved the patient, so quite often, uh, treating a patient involves talking to them and asking what they want. So again, that's just an important principle. To bring back in, um, but do have a look at letters coming in and out of practises, again if you've got some time between clinics so you can have a look at some of the letters that you filed today, because sometimes you find these areas of ambiguity and it's really important for you to learn, How to Get between the boundaries of primary care and secondary care, whichever way you look at it, because if you're going to be a secondary care doctor, you need to know how to communicate with primary care. As a primary care doctor, you need to understand. OK, so the boundaries between primary care and secondary care can sometimes be quite difficult to navigate, but the earlier you understand how it works and some of the, and see some of the issues with it, it's not it's quite far away from the perfect. So whichever side you're going to sit on in your in your later career, it's worth understanding it. In a bit more depth I asked to see some letters. Um, it'd be a really good learning point for you. And the practises have um. Debriefed to try and give you some of these learning insights, so I've tried to push it a bit more, I can't go into each GP practise and tell them exactly how to manage your time and your placements. GP practises Our own businesses, but I can have some. And highlight, can you find some patients. Medications you By yourself, you can't sign off by yourself in the notes because you're not qualified. the theory of it and debriefed it. Medication reviews, blood test results, and for finding correspondence, I'm just thinking about these things. Um, So yeah, so get the most out of placements, if things aren't, you know, I hope your placements all set up well, most of the practises, I don't think we've got any new practises on board this year, so everyone's been visiting to shoot for at least 12 months, so everything's. Sometimes practises do experience difficulties if staff go off sick. Pro Unexpected difficulties at practise, please let me know, drop. Yeah, if you're having any difficulties of any kind, just let me know as soon as I know a problem, the sooner. Um, Find learning opportunities and do seek out what we've talked about today, try and find stuff to learn from, um. The more you see, the you get. Medical school is not just passing exams. You need to learn to be a doctor, you only get that by being in placement, so if you want to be a good doctor, you need to go in and sometimes you might have a day where. You've got to be there Please take the opportunity that's in front of you and enjoy the rotation. If you want to be a GP find out more about it. If you don't want to be a GP take the learning opportunities. They're all there, there's a lot of generic transfer. Patient So yeah, just enjoy it. OK. And that's it, I think. So have a break. here I Sheffield says it does, but Minner says it doesn't. Uh, I do apologise. It's alright. Yeah, I've been, I've been restructured and things aren't as smooth as they used to be, um. I will go up to the placement team now to their office and I'll ask them to ping an email out to you in the next 5 minutes, OK, so watch this photo, I don't know the answer, but I'll find it. No I expect I suspect you're in here, normally you're in here, so I wouldn't rush off. I'll get an email out to you in the next 5 minutes, let me go to the postman team and find out. I hope Well, I don't start until tomorrow.
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