Deep Breath In

The BMJ's long running "10 minute consultation" series is being questioned - can you do everything we suggest in 10 minutes? Can GPs really do any meaningful consultations in 10 minutes? That's the question that our three guests have been asking - and they join Tom Nolan, to discuss what they found.   Our guests; Alice Harper is a GP trainee in Bristol and an academic clinical fellow at the University of Bristol Carol Sinnott is a GP in Ireland, and a senior clinical research fellow at THIS institute at the University of Cambridge Jess Watson is a GP NIHR clinical lecturer in general practice at the University of Bristol   Reading list; Great expectations? GPs' estimations of time required to deliver BMJ's ‘10 minute consultations' The BMJ's 10-Minute Consultation      

Is cancer screening worth it, and how can GPs have that conversation? This episode of Deep Breath In explores the intricacies of assessing risks and benefits of cancer screening, featuring Michael Bretthauer's insights from a JAMA Internal Medicine study. That meta-analysis combined efficacy of various cancer screening studies - and found most screenings showed minimal gains in extending overall life expectancy, though some slightly reduced cancer-specific mortality. That leaves GPs with the challenge of communicating these nuanced findings to patients. Michael explains how he tries to convey complex concepts to patients, despite the societal inclination toward extensive testing despite low risks.   Reading list; Jama paper - Estimated Lifetime Gained With Cancer Screening Tests A Meta-Analysis of Randomized Clinical Trials The BMJ analysis  - Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit

As news about the climate breakdown hits, it's hard not to feel the stirring of climate anxiety. One way to mitigate that is by taking action, but it's hard to know where to start, and what GPs themselves can do. In this podcast, we hear about 5 ways in which you can start bringing a sustainable outlook to primary care, and engage colleagues and patients in making a difference.   Our guests; Tamsin Ellis, director of Greener Practice, and a GP in London Fran Cundill, chair of the south Yorkshire Greener Practice group, and GP in Sheffield.   Resources; Find out about how some clinical staff are starting to push their healthcare systems to be greener in The BMJ's podcast series Planet Centred Care For all the BMJ's coverage on tackling the climate emergency https://www.bmj.com/campaign/climate-emergency        

There have been so many conflicting views in the media lately on the management of menopause, and HRT has barely been out of the press at all in the last couple of years. As a result of the myriad uncertainties around menopause, many women are left feeling like they're having to fend for themselves, and that their concerns are not being heard by their doctors. Taking segments from The BMJ's webinar in May on known unknowns of menopause, we discuss the controversies around HRT; how we can give women balanced and realistic information about menopause and managing their symptoms; and how we can reframe the messaging around the menopausal transition in a more positive and hopeful way, in order to help empower women in navigating this normal life stage.   Our guests:  Martha Hickey is Professor of Obstetrics and Gynaecology at the University of Melbourne. Her clinical and research interest is around menopause. Margaret McCartney is a GP in Glasgow, and a freelance writer & journalist.   Resources: ‘Therapy for the effects of menopause' (webinar) https://www.youtube.com/watch?v=-hQX2SGlcvY ‘ Normalising menopause' BMJ 2022;377:e069369

There's never enough time in the day to be a GP, but it's still hard to say no to that one patient, or to a colleague who is asking for your help. In this episode of Deep Breath In, we'll hear from Rachel Morris, about why it's so hard to so hard to say no, particularly for doctors. She'll challenge us to think about what the real effects of piling on more work are, and give us some strategies to help us say no in our every day lives.   Our Guest; Rachel Morris trained as a GP, before leaving the profession to become a coach for GPs, and other medics. Her work focusses on burnout, and how to take practical steps to stop the process. She also hosts the You Are Not A Frog podcast.

Common themes for discussion on this podcast include overdiagnosis, approaches to the testing, the ins and outs of explanations, as well as other issues facing GPs who are overburdened, and have limited time and resources to treat patients. A topic which draws all of these themes together is prostate cancer screening. The BMJ recently published a feature which asked whether the UK is ready to roll out a nationwide prostate cancer screening programme, and the linked analysis paper, authored by Dr Andrew Vickers and colleagues, argued that the current model of screening, which determines testing by shared decision making, is the worst approach for detecting prostate cancer. We spoke to Andrew Vickers to discuss this further, and our second interview was with Dr Sam Merriel, regarding the emerging evidence that suggests that taking an MRI scan prior to biopsy could decrease harms associated with overdiagnosis and overtreatment of prostate cancer.   Our guests: Andrew Vickers is an attending research methodologist in the Department of Epidemiology and Biostatistics at Memorial Sloan Kettering Cancer Center, New York. Sam Merriel is a GP, and a researcher on cancer diagnostic testing at the University of Exeter.   Further reading: ‘Is the UK really ready to roll out prostate cancer screening?' BMJ 2023;381:p1062  ‘Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit' BMJ 2023;381:e071082   

While the pandemic has officially declared over, the ongoing effects of a covid-19 infection are still being felt in the community. In this Deep Breath In, Jenny, Tom, and Navjoyt are joined by two leading experts on long covid.  They discuss the changing profile of people being referred to specialist clinics, the way in which different strains may have different long term outcomes, and what can be done to limit the risk of developing long covid.   Our guests: Trish Greenhalgh is a former GP of 30 years who is now Professor of Primary Care Health Sciences at the University of Oxford.  Harsha Master is the GP lead in COVID rehabilitation at Hertfordshire Community Trust, and helped design the long covid clinical pathway there.

Talking about sexual health may be common-place with younger patients, but the sexual wellbeing of older adults is often neglected in a consultation. However it's important for doctors to be aware of changes to patients sex lives, given the link between intimacy and wellbeing. In this podcast, the team discuss how to create that culture of openness that encourages older adults to share problems they may find embarrassing, what signs may indicate that it's worth initiating a question about sexual health, and making sexual function a routine part of the discussion about the effects of medication. Our guests; Sharon Hinchliff is a professor of psychology and health at the University of Sheffield. Rebecca Mawson is a GP in Sheffield. Resources; Practice Pointer How to support the sexual wellbeing of older patients www.agesexandyou.com www.ageoflove.org www.joanprice.com 

This week, we're going to be returning to a guest we heard from a while ago - Claire Kaye. Claire was a GP before deciding to become a coach, and we found her way of thinking through our wants and needs so useful, we decided to invite her back. This week we're going to be talking about that holding onto that feeling of excitement you had at the beginning of your career, a feeling that's difficult to hold onto, as the pressures on general practice mount. Our guest: Claire Kaye, formerly a GP, is an executive coach. She specialises in career development. Instagram: @drclairekayecoaching LinkedIn: @drclairekaye Website: www.drclairekaye.com

The theory that depression is caused by serotonin deficiency has become embedded in our practice over the years, and can be a persuasive explanation of the condition for patients considering starting antidepressants. We talk to Tony Kendrick about the evidence (or lack thereof) to support this hypothesis, and what that means for the efficacy of antidepressants, particularly SSRIs. Later on, we speak to Mark Horowitz to discuss how to come off antidepressants safely, and manage withdrawal symptoms, and how to advise and support our patients as they gradually reduce, then stop, their medication. Our guests: Tony Kendrick is a retired GP, and NICE committee member for the 2022 guideline update on depression in adults. He is also a professor of Primary Medical Care at the University of Southampton. Mark Horowitz is a training psychiatrist, working as a clinical research fellow at North East NHS Trust, and as an honorary clinical research fellow at UCL, he is also the co-founder of outro.com. Further reading: ‘Antidepressants and the serotonin hypothesis of depression'. BMJ 2022;378:o1993 https://www.bmj.com/content/378/bmj.o1993 ‘Stopping antidepressants'. Royal College of Psychiatrists. 2020. https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/stopping-antidepressants

How long would it take GPs to enact all of the guideline recommendations that they might be expected too? Far more GP hours than exist in any healthcare system, but as medicine has turned its attention to primary prevention, and expanded the populations whose health we seek to improve, those guidelines are taking up more and more time. A recent analysis in The BMJ has proposed the concept of “Time Needed to Treat” and implores guideline makers to take account consultation time as a precious, finite, resource when thinking about their recommendations. In this episode of Deep Breath In, we're joined by Minna Johansson, family doctor and director Global Center for Sustainable Healthcare, who co-authored that analysis to talk about how the concept has gone down, and what it might mean for rethinking what primary care is supposed to do. Reading list: Guidelines should consider clinicians' time needed to treat https://www.bmj.com/content/380/bmj-2022-072953

Reproductive coercion may feel like something that we don't see very often in general practice, but a 2022 poll carried out for BBC Radio 4 of 1,060 UK women between the ages of 18 and 44 found that half of them had experienced some form of reproductive coercion. This week, we speak to returning guest Annabel Sowemimo about the various forms that reproductive coercion can take, and who might be at risk of experiencing it. We discuss how we, as GPs, can identify these patients, and, once we've done so, how we might be able to help them. Later on, we talk to our BMJ columnist, John Launer, about how narrative medicine approaches can help to reach a better & more satisfying resolution to a consultation “puzzle” for you and for the patient. Our guests: Annabel Sowemimo is a community sexual health registrar, based in Leicester. She is also a PhD candidate at King's College London, and is the co-founder of the charity Reproductive Justice Initiative. John Launer is a GP educator, working for Health Education England. He is also a freelance educator and writer, as well as being a columnist for ‘The BMJ'. Further reading: ‘How to recognise and respond to reproductive coercion'. BMJ 2022;378:e069043. https://www.bmj.com/content/378/bmj-2021-069043 ‘John Launer: The art of paying attention'. BMJ 2022;378:o2294. https://www.bmj.com/content/378/bmj.o2294 ‘Careful, kind care is our compass out of the pandemic fog'. BMJ 2022;379:e073444. https://www.bmj.com/content/379/bmj-2022-073444

In general practice, it can often feel like a lot is changing beyond our grasp. On top of this, the pandemic has left many healthcare professionals self-reflecting on their careers and lives, and trying to work out what they really want going forward. This week, we speak to Claire Kaye about her role as a coach for doctors. Claire talks to us about the benefits of coaching, including helping to get rid of internal & external noise, shaping the mindset, and coping better with change. She also offers advice on the best ways to approach coaching in order to achieve a positive outcome. Our guest: Claire Kaye, formerly a GP, is an executive coach. She specialises in career development. Instagram: @drclairekayecoaching LinkedIn: @drclairekaye Website: www.drclairekaye.com

The possibility that patients will suddenly have access to their notes has caused some anxiety for GPs in England. The department of health's plans to allow patients to prospectively access their medical record lead to fears about increased workloads, misunderstandings, and safety - and the plans have now been pushed back. In this podcast the Deep Breath In team are joined by the authors of a recent article in The BMJ to explore those fears, hear about the potential benefits, and understand the evidence behind open notes. Our guests; Charlotte Blease, and interdisciplinary health researcher at OpenNotes, Beth Israel Deaconess Medical Center/Harvard Medical School. Brian McMillan, a GP and senior clinical lecturer at the University of Manchester Gail Davidge, research associate at the University of Manchester The article they're discussing is a practice pointer on Adapting to transparent medical records: international experience with “open notes” https://www.bmj.com/content/379/bmj-2021-069861

This week, we're joined by Huseyin Naci to discuss the recent press release from Eisai and Biogen announcing the Phase III trial results for lecanemab for use in Alzheimer's disease, and the FDA's decision to accept the drug onto its accelerated approval pathway. We talk about the pros and cons of using surrogate endpoints to predict clinical outcomes. How can we strike a better balance in clinical trials between generating high-quality and trustworthy evidence, and the urgent needs of patients with life-limiting conditions and very few available treatment options? Our guest: Huseyin Naci is an associate professor of Health Policy at the London School of Economics and Political Science (LSE). He is also an advisor to the Analysis section of The BMJ.

The GP crisis with Rebecca Rosen This week, we discuss the ongoing GP crisis, an ever-topical subject, in light of recent UK governmental changes. In early September, Thérèse Coffey laid out her plans for the NHS in the House of Commons, but, with general practice struggling so much as it is, is she proposing practical and feasible solutions, or will her initiatives be merely papering over the cracks? We're joined by Rebecca Rosen to discuss whether or not there's any real substance behind the proposed changes, how to manage patients' expectations around access to care, and how primary care practitioners might be best supported in order to help ease the strain on them. Our guest: Rebecca Rosen is a GP in South East London, and a senior fellow in Health Policy at the Nuffield Trust.

In this episode of Deep Breath In, we'll be considering how a physicians personal experience of illness - either themselves, or as a parent or carer, might affect their approach to management of it in a patient. We'll also have an update on the NICE guideline for treatment of Gout - particularly highlighting changes around uses of urate lowering therapy, and how often we should be testing patient's serum urate levels when they're experiencing flare-ups. Our Guests. Katherine Hall is the associate dean of medical admissions at the university of Otago, and has researched how physician experience affects their practice. Alastair Dickson is a GP, and lecturer at Hull York Medical School. He co-authored The BMJ article on management of gout. Reading Gout: diagnosis and management—summary of NICE guidance https://www.bmj.com/content/378/bmj.o1754

Musculoskeletal (MSK) pain and osteoarthritis are clinically common in general practice, but with the new draft NICE guideline on osteoarthritis (published in April 2022) recommending a move away from pharmacological treatments and instead promoting self-management, some GPs have been left wondering how best to manage MSK pain going forwards . In this week's episode, Dr. Imran Sajid talks to us about the importance of educating patients on what arthritis really is – moving away from the term “wear and tear” – and of taking a thorough history of a patient's pain journey in consultations. He also gives practical advice on how we might approach non-pharmacological management of MSK pain with our patients. Our guest: Imran Sajid is a GP with a special interest in MSK medicine. He is the clinical lead in MSK & Diagnostics for NHS North West London, an adjunct lecturer in Health Policy at the University of Global Health Equity, as well as being a qualified personal trainer. Further reading: ‘Osteoarthritis: assessment and management, draft for consultation, April 2022'. NICE. 2022. https://www.nice.org.uk/guidance/gid-ng10127/documents/draft-guideline ‘The tear, flare, and repair model of osteoarthritis'. BMJ 2022;377:o1028. https://www.bmj.com/content/377/bmj.o1028

Despite the Conservation party manifesto for the 2019 general election promising to deliver 6,000 additional full-time equivalent GPs, worryingly, the NHS lost 717 FTE GPs between March 2019 and March 2022, and the Health and Social Care Committee's July 2022 report on workforce was scathing about the Government's failure to act decisively on the chronic staff shortages across healthcare in the UK. This week, we speak to more colleagues from the RCGP conference: first, we talk to Pamela Curtis about the challenges of returning to general practice after a break; secondly, we speak to a group of GP trainees about their innovative platform, The Big GP Consultation, and hear their thoughts on shaping the future of general practice. Our guests: Pamela Curtis is a salaried GP working at NHS Bristol, North Somerset and South Gloucestershire ICB. Veena Aggarwal, Devina Maru, Liam Loftus and Rachel Weaver are all GP trainees, and are part of the team for The Big GP Consultation. Further reading: House of Commons Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care. 2022. https://committees.parliament.uk/publications/23246/documents/169640/default/ The Big GP Consultation. https://thebiggpconsultation.co.uk/

In this week's episode, we share our experiences of attending the recent RCGP Annual Conference, and our thoughts on the topics that were covered in the talks at this year's event. We talk to RCGP Chair, Martin Marshall, about continuity of care, which he states is one of the defining features of general practice. Evidence has shown that continuity of care is associated with better health outcomes for patients, but how can doctors convince politicians and policymakers of the benefits of it? We also speak to Emma Gladwinfield, a GP in Rossendale, about how connecting with schools, churches and community centres is helping to build relationships with patients and deliver care in her local community. Our guests: Martin Marshall is the Chair of the RCGP, a GP in Newham, East London, and Professor of Healthcare Improvement at UCL. Emma Gladwinfield is a GP in Rossendale, East Lancashire. Further reading: ‘Tackling the crisis in primary care'. doi:10.1136/bmj.o1485. https://www.bmj.com/content/377/bmj.o1485

As more and more pharmaceutical products come onto the market, there are so many potential drug interactions, and adverse reactions, to bear in mind during a consultation in primary care. In this week's episode, we speak to Anders Holt, the author of a recent research paper looking at co-prescribing nitrates and sildenafil, which is surprisingly common, and adverse events associated with this. We also discuss the neuropsychiatric side effects of montelukast with Corine Ekhart, and talk about the challenges of striking the right balance between highlighting a rare but important side effect and causing the patient anxiety about taking the medication. Our guests: Anders Holt is a PhD candidate at Copenhagen University Hospital, Denmark. Corine Ekhart is a pharmacist at the Netherlands Pharmacovigilance Centre Lareb in 's-Hertogenbosch, the Netherlands. Further reading: ‘Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study'. doi:10.7326/M21-3445 https://www.acpjournals.org/doi/10.7326/M21-3445 ‘Neuropsychiatric reactions with the use of montelukast'. doi:10.1136/bmj-2021-067554 https://www.bmj.com/content/376/bmj-2021-067554

A recent investigation, by The BMJ, showed a worrying increase in incidence of violence, directed to wards GPs, and reported to the police. In this episode of Deep Breath in, Tom and Jenny are joined by Gareth Iacobucci, assistant news editor for The BMJ who broke the story. They'll hear from a GP affected, and get some advice on preventing violence, and deescalation, from two mental health experts, who deal with the most agitated patients. Our guests: Adam Janjua, a GP in Fleetwood, Lancashire. Marcela Schilderman, a consultant psychiatrist at South London and the Maudsley NHS Foundation Trust and Anita Bignell, a mental health nurse, at South London and the Maudsley NHS Foundation Trust Reading list Violent incidents at GP surgeries double in five years, BMJ investigation finds https://www.bmj.com/content/377/bmj.o1333

Consultations about suspected cow's milk protein allergies are quite common in primary care, but these allergies can be a challenge to diagnose, particularly as symptoms can manifest in many different ways, and testing can be complicated. We talk to Dr. Nicola Brathwaite about the diagnosis and management of cow's milk protein allergies in infants, and our discussion includes how to navigate consultations with parents who may be distressed and fraught with anxiety over their baby's symptoms, and how best to manage the reintroduction of milk back into the diet. Our guest: Nicola Brathwaite is a paediatric allergy consultant at King's College Hospital, London. She completed her specialist training in Paediatrics and Paediatric Allergy in Cape Town, South Africa.

Parosmia – a distorted sense of smell, and a delayed post-covid symptom – affects approximately 50% of people who experienced loss of smell during their initial covid infection, and it is currently attracting a lot of media attention. We hear from Emily Woodroofe, a third year medical student, about what it's like to have parosmia, before we speak to Professor Claire Hopkins about what GPs need to know about it, and how they can best support their patients who are experiencing what can be a distressing symptom. Our guests: Emily Woodroofe is a third year medical student at Barts and The London School of Medicine and Dentistry. Claire Hopkins is an ENT consultant, and professor of Rhinology at Guy's and St. Thomas' NHS foundation Trust. Further reading: ‘Parosmia—a common consequence of covid-19' https://www.bmj.com/content/377/bmj-2021-069860

With the focus on covid, and the pressure on hospitals, it may be easy to overlook what's happening in general practice in the UK - but changes are afoot. Our new health secretary Sajid Javid doesn't seem to like our long standing GP practice arrangement, NHS England has imposed new weekend working arrangements on the already stretched service, and the workforce pressures continue. In this episode of Deep Breath In, our GP panel of Tom Nolan, Navjoyt Ladher, and Jenny Rasanathan are joined by Gareth Iacobucci, The BMJ's assistant news editor, to give them the lowdown on what's happening around primary care, who some of the key players are, and what his predictions for 2022.

We see patients all the time who ,more than any drug or cure, just want an explanation for their symptoms, to understand why they feel the way they do. But giving an explanation isn't necessarily straightforward, we're unsure of the diagnosis, we might worry about how the explanation might be received, or a 10 minute appointment just isn't time to go into all the details. In today's episode, we've enlisted the help of consultation skills expert, Roger Neighbour, and hear how important a great explanation is from The BMJ patient editor Amy Price. Our guests: Roger Neighbour is a retired GP and a former president of the Royal College of GPs. He has written the books on consultations skills, and teaches courses on how to put those skills into practice. Amy Price is a patient, a researcher editor for The BMJ's patient and public partnership, and a senior research scientist at Stanford School of Medicine.

Diagnosis is a complex categorisation task driven by mental models that reside in long term memory. Through education and experience, clinicians form scripts that encapsulate their knowledge of specific conditions and develop diagnostic schemas that structure their approach to a specific health problem. This cognitive process also intersects with systems, teamwork, and social factors that can enhance or reduce diagnostic accuracy. In this podcast, we hear about five techniques that can help with the accuracy of those mental models, and mitigate against some of the external factors which may reduce diagnostic accuracy. Our guests; Hardeep Singh trained as a GP before moving to becoming a general internist and professor of patient safety research at Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston. Denise Connor is an associate professor of medicine at University of California San Francisco and a practicing internist at San Francisco Veterans Affairs Medical Center. Gurpreet Dhaliwal is a general internist at the San Francisco Veterans Affairs Medical Center, and a clinician educator.

As Ramadan draws near, clinicians may be approached by their Muslim patients to discuss managing their health conditions during the month of fasting. How should someone with a chronic condition, such as diabetes or epilepsy, time their medications during this period? Can a person who's pregnant or breastfeeding partake in fasting? What alternative options are available to someone whose health needs make participating fully in fasting too risky? In this week's episode, we discuss the many questions doctors and patients may have around this topic with Ammad Mahmood and Sahira Dar, authors of a recently published article in The BMJ on advising patients with existing conditions about fasting during Ramadan, and talk about the importance of individualised advice and shared decision making. Our guests: Ammad Mahmood is a neurological trainee, currently undertaking a PHD in stroke imaging at the University of Glasgow. Sahira Dar is a GP, practising in Glasgow, with special interests in lifestyle medicine and mental health issues. Further reading: ‘Advising patients with existing conditions about fasting during Ramadan' by Ammad Mahmood, Sahira Dar et al. https://www.bmj.com/content/376/bmj-2020-063613

There was a proposed vaccine mandate for NHS staff in the UK (now abandoned) but in other countries mandates continue, but are they without harm, and do we have evidence about how effective they are? In this episode, we'll be discussing how a proposed vaccine mandate would have affected GP practices in the UK, particularly when it comes to the demographics of staff who have not accepted the vaccine. We'll also be discussing direct and indirect evidence which might have helped us assess the efficacy of a mandate. Our guests; Steve Mowle is a GP in South London, and honorary treasurer, of the Royal College of General Practice. Juan Franco is a GP at the Hospital Italiano de Buenos Aires, Argentina, and Vice-Chair of the Research Department at the Instituto Universitario Hospital Italiano (IUHI), where he is also Director of the Cochrane Associate Centre.

A recent case against a GP in England has worried the profession - does the fact that a patient, born with a neural tube defect, successfully sued their mother's GP open up the floodgates for litigation? How will that effect the way that you practice? In this episode we're joined by Claire Dyer, The BMJ's legal correspondent, who explains how that case unfolded. We also have a clinical update on childhood constipation, and the authors of a recent article in The BMJ give their tips on getting kids to drink movicol. Show jumper wins case against mother's GP for “wrongful conception” that resulted in her disability https://www.bmj.com/content/375/bmj.n2999 Childhood constipation https://www.bmj.com/content/375/bmj-2021-065046

With Christmas 2021 only just around the corner, we round off the year by chatting about our ‘Deep Breath In' highlights, and by sharing some of the great feedback we've received from our listeners. We talk to Inga Usher and Aswin Chari, whose study comparing neurosurgeons with aerospace engineers (“It's not brain surgery” vs. “It's not rocket science”) was featured in The BMJ's 2021 Christmas issue. Finally, we end the episode with a quiz on ICU slang (what on earth does ‘closest crocodile to the canoe' mean?), 2021 NICE guideline updates, and, finally, the Bristol stool chart. Merry Christmas! Our guests: Inga Usher is a final year clinical PhD student at UCL Cancer Institute, studying a rare bone cancer, chordoma, and an aspiring neurosurgeon. Aswin Chari is a neurosurgical trainee at Great Ormond Street Hospital, London. Further reading: SEED Eating Disorder Support Services: https://seed.charity/ Mitchell and Webb brain surgeon & rocket scientist sketch: https://www.youtube.com/watch?v=THNPmhBl-8I “It's not rocket science” and “It's not brain surgery”—“It's a walk in the park”: prospective comparative study: https://www.bmj.com/content/375/bmj-2021-067883 Just a smidge, or a bridge too far? Slang use in the ICU: https://www.bmj.com/content/375/bmj-2021-067900

Following the recent COP26 Climate Change Summit, we discuss, in this week's episode, the announcement that some 50 countries have committed to reach net zero carbon emissions within their healthcare systems by, or before, 2050. We talk about the role that GPs can play in reducing the carbon footprint of their practice, how to tackle climate anxiety, and how integrating greener practices into our healthcare systems aligns with better health benefits for our population as a whole – both now and in the future. Our guests: Richard Smith is the chair of the UK Health Alliance on Climate Change, and former editor of ‘The BMJ'. Aarti Bansal is a GP, working in Sheffield, and the Net-zero NHS GP lead for the Humber, Coast and Vale Health and Care Partnership. She is also the founder of Greener Practice. Further reading: Greener Practice website: https://www.greenerpractice.co.uk/ Greener Practice guide to inhaler prescribing: https://www.greenerpractice.co.uk/greener-practice-guide-to-inhaler-prescribing https://www.bmj.com/content/375/bmj.n2416 https://www.bmj.com/content/375/bmj-2021-067199

Primary care in the UK is in crisis. General practice was already under huge strain, as a result of the pandemic, high levels of seasonal respiratory viruses, as well as chronic understaffing and underfunding, but recent negative media campaigns against GPs, amidst the health secretary's plans to publish ‘league tables' of GP practices, have added to this and have led to increased demoralisation among doctors. In this week's episode, we discuss the current political climate affecting the NHS, perceptions of our healthcare system, and how this has changed over the last 10-20 years. If GP ‘league tables' are not the answer, what creative solutions are needed in order to encourage new GPs into primary care, and to retain doctors in the workforce? Our guests: Gareth Iacobucci is the assistant news editor for ‘The BMJ'. Lucy Martin is a GP, working in Dudley, as well as the acting medical director for Dudley Integrated Health & Care NHS Trust.

Over the past 18 months, eating disorder specialists have seen a huge rise in the number of referrals, and experts have said that the pandemic has created “the perfect storm” for eating disorders, especially among children and young people. As GPs, what do we need to know about eating disorders? What red flags should we look out for, and how do we approach this thorny issue with our young patients? In this week's episode, we talk to Dr. Simon Chapman about spotting the signs of an eating disorder, and we get advice on management. We also chat to Zoe John and Victoria Adeniji, who are both in recovery from their eating disorders, about their experiences and about how GPs may best support people with a history of eating disorders in their care. Our guests: Simon Chapman is a consultant in paediatrics and adolescent medicine at King's College Hospital, London. He is also the medical lead for the Maudsley Centre for Child and Adolescent Eating Disorders. Zoe John and Victoria Adeniji are ambassadors for Beat, the UK's eating disorder charity. Further reading: The MARSIPAN guidelines: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr189.pdf?sfvrsn=6c2e7ada_2 Online resources on the Beat website: https://www.beateatingdisorders.org.uk/get-information-and-support/get-help-for-myself/downloads-resources/

Fatigue is one of the most common presenting symptoms GPs see in a consultation, and it feels like, during the pandemic, more of us than ever have been experiencing excessive tiredness. With our guests this week, Sophie West and Robert Koefman, we discuss the new NICE guidelines on obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome, and how sleep apnoea seems to be both under-diagnosed and over-diagnosed in primary care. We talk about the diagnostic challenges of this condition, particularly with the limitations of the available screening tools, the long list of comorbidities that may be linked to OSA, and the difficulties of remote consultations, as well as the huge benefits using a CPAP machine may provide to a patient. Our guests: Sophie West is a respiratory consultant, based in Newcastle upon Tyne. She is also the lead of the Newcastle regional sleep service. Robert Koefman is a GP at Binfield Surgery in Berkshire. He has also been involved in ENT and community sleep clinics for over 20 years.

A slightly different spread of this episode of Deep Breath In, Navjoyt Tom and Jenny are discussing two separate topics, headaches and team debriefings. Firstly headaches, the team discuss why so many GPs find headaches to cause the most anxiety in their practice, and get some advice on migrainous headaches from Heather Angus-Leppan, consultant neurologist at the Royal Free London NHS Foundation Trust (also discussed vaccinations and CVST in our covid vaccination episode). Secondly, team debriefings - seeking support from colleagues is essential, but the way in which teams discuss problems can be helpful or harmful. Michaela Kolbe, psychologist and director of University Hospital Zurich's simulation centre joins us to give some tips on how to make those team meetings work better. Reading list Team debriefings in healthcare: aligning intention and impact https://www.bmj.com/content/374/bmj.n2042

Doctors are taught from medical school about the benefits of IUD, and are often advocates of them to patients. However, recent media attention on the pain that some women suffer when having their IUD's fitted have started conversations about the need for cervical blocks, and more honest counselling of women about the procedure. Rebekah Fenton, adolescent medicine fellow at Lurie Children's Hospital of Chicago joins us to talk about how she councils her patients, and why the most important thing is to make sure women are in charge of their reproductive healthcare decisions.

As the scientific community in the UK still debates whether to vaccinate kids under 16, that leaves us as an outlier to the rest of the world where parents are being encouraged to seek the vaccination of the children. In this episode Tom, Jenny and Navjoyt discuss the questions that they're getting in their surgeries, and get some advice on how parents regard vaccinating their children, how to think about transmissibility vs severity when it comes to childrens' risk, and some ways of helping to motivate vaccine uptake. Our guests; Amanda Kvalsvig is a senior research fellow at the University of Otago, and her work as an epidemiologist has helped to inform the New Zealand government's covid-19 response. Greg Zimet is a clinical psychologist and professor in the Department of Pediatrics at Indiana University. His work has focussed on vaccination in children - particularly the HPV vaccine.

There's a plan from the Royal College of General Practitioners, to stop the profession buckling under the huge pressure applied by the workforce crisis and covid 19. The steps outlined are very practical, but do they really get to the heart of the problem with the way in which primary care is practiced in 2021. In this episode, Tom, Jenny and Navjoyt are joined by Rani Lill Anjum, a philosopher from the Norwegian University of Life Sciences who thinks about causation in healthcare - and what this means for the doctor patient relationship.

A borderline hba1c result will initiate a conversation with a patient - but how useful is that "prediabetes" check-in, and can GPs ever adequately describe what the elevated risk of having a risk factor actually means for a patients health? Our guests in this episode are Sam Finnikin, an academic GP from the University of Birmingham, who gives some helpful tips on explaining that risk, and reminds Tom that fear is not a good motivator of behaviour change. Seamus O'Mahoney is a retired gastroenterologist, and author. He explains the process which births a new diagnosis, and why he feels that creeping disease definitions are undermining the medical profession. Further reading A borderline HbA1c result https://www.bmj.com/content/365/bmj.l1361 The epidemic of pre-diabetes: the medicine and the politics https://www.bmj.com/content/349/bmj.g4485 Time to question the NHS diabetes prevention programme https://www.bmj.com/content/351/bmj.h4717

The pandemic had a high mortality toll in care homes, but measures to try and reduce that, through extreme social isolation, has had its own cost. Social interaction, particularly with close family, is more than just a quick hello - evidence shows that mental stimulation can help with cognitive decline, and the lack of that interaction may have hastened progression of dementia in some patients. In this podcast, the team talk about what GPs can do to support patients in care homes, and we find out about some non-drug interventions patients can try. Our guests; Jason Karlawish, is a geriatrician, and co-director of the Penn Memory Center, he's also author of the book "The Problem of Alzheimer's How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It" Jennifer Watt is a geriatrician, and assistant professor at the university of Toronto, and one of the authors of the recent systematic review and meta-analysis of comparative efficacy of interventions for reducing symptoms of depression in people with dementia - https://www.bmj.com/content/372/bmj.n532 Reading; Washington Post article: https://www.washingtonpost.com/health/2020/09/16/coronavirus-dementia-alzheimers-deaths/?arc404=true Jason Karlawish and his book https://www.jasonkarlawish.com/the-problem-of-alzheimers This American Life episode: https://www.thisamericanlife.org/737/the-daily The Daily episode on aducanumab, "some hope is better than having no hope" https://www.nytimes.com/2021/07/07/podcasts/the-daily/aduhelm-alzheimers-fda-drug.html

Our environment moulds our brains, and alters development, and so there are culture-bound ways that our bodies express distress. In this week's episode, we discuss the mysterious phenomenon of Sweden's ‘sleeping beauties': asylum-seeking children who were affected by resignation syndrome, which led them to become completely inert. We talk about the pros and cons of applying medical labels to people's symptoms – are we applying labels too easily, and over-medicalising things which could be classed as normal? Being given a diagnosis may provide some relief to a person experiencing certain symptoms, but, in doing so, are GPs actually creating more patients? Our guest: Suzanne O'Sullivan is a consultant in clinical neurophysiology and neurology, based at the National Hospital for Neurology and Neurosurgery in London. Her specialist interests are in epilepsy and functional neurological disorders. She is also the author of ‘The Sleeping Beauties: And Other Stories of Mystery Illness'.

Burnout has become something of a buzzword recently, but has now been officially classified as a syndrome caused by the workplace. Over the course of the pandemic, clinicians have been under more stress than ever, and evidence shows that burned out doctors are more likely to make medical errors. As the pressure being piled onto GPs, and other medical professionals, is only increasing, the adage of ‘put your own oxygen mask on first' has never been more apt, but many of us feel that we simply do not have the time or energy to devote to self-care. In this week's episode, we discuss how to recognise the early signs of burnout, and how struggling with stress can feel like a personal failure. We also talk about practical measures we can take to build resilience within teams, and to safeguard our own mental health, in order to help lessen the burden on individuals and on healthcare systems more widely. Our guests: Rachel Morris is a GP and educator, leading training courses in leadership and resilience, and she is also the host of the You Are Not a Frog podcast. Cat Chatfield is the research integrity editor for The BMJ, and the wellbeing campaign lead, as well as being a ‘resting' GP. She hosts the BMJ Wellbeing podcast. Abi Rimmer is a reporter, and the editor for BMJ Careers. She co-hosts the BMJ Wellbeing podcast with Cat.

In general practice, doctors commonly see patients who are experiencing varying degrees of health anxiety, which can be difficult to navigate. GPs often want to offer reassurance, but reassurance can be like a drug to these patients: the more reassurance they receive, the more they need. In this week's episode, we discuss how new technology which allows patients to check symptoms at home (such as pulse oximeters) may increase anxiety levels, and how our stock phrase “keep an eye on it” may be the worst thing we could say to patients with health anxiety. We also talk about the therapeutic value of a GP visit, and the importance of letting anxious patients know that all of their symptoms – physical and mental – will be taken seriously. Our guests; Guy Edwards is a patient who developed health anxiety around five years ago. Helen Tyrer is a former GP, a senior research fellow at Imperial College London and is the author of ‘Tackling Health Anxiety: A CBT Handbook'. Peter Tyrer is a professor of Community Psychiatry in the Centre for Mental Health in the Division of Experimental Medicine at Imperial College London. Reading list; https://www.bmj.com/content/364/bmj.l774

In this episode, we're bringing you the full interview, a deep breath, with Whitney Robinson, a social epidemiologist and associate professor at UNC Chapel Hill. Whitney gives us her take on how we should be thinking about risk when it comes to covid-19 infection and vaccine rollout. This is a nuanced conversation about the health and economic disparities of covid-19 the consequences of failing to reach the most vulnerable groups, and the importance of tackling this from a community level.

There is a common perception of surgery that it's an old boys' club, and that anyone joining the profession is expected to match the archetypal personality type in order to fit in. Whilst this is starting to change in some specialities, it does still present a challenge, especially to junior staff trying to establish themselves. The relationship between primary and secondary care can be quite remote, and approaches towards patient care can sometimes seem at odds with each other. In this week's episode, we discuss the paradigm shift that COVID-19 has caused in the management of specialist consultations, as well as the obstacles to having successful open conversations between GPs and specialists, and how we might overcome them in order to provide better care for patients. We also ask, should we refer a patient with a suspected hernia for an ultrasound? Our guests: Clara Munro is a general surgeon based in the North East of England and a clinical fellow at the Faculty of Medical Leadership and Management. She is also the editorial registrar at The BMJ. Sarah Robinson is an upper GI surgeon at the Northumbria Healthcare NHS Foundation Trust. Her areas of interest include hernia surgery and upper GI cancers.

Two topics currently being hotly discussed in the media and in clinical practice are headaches after the COVID vaccine, and the impact that structural racism is having on vaccine uptake. Headache and fever are common symptoms after a vaccination, but there are concerns about the potential link between the AstraZeneca vaccine and blood clots, and these concerns, exacerbated by the recent frenzy of media coverage, may be damaging the general public's faith in the vaccination programme, and impacting uptake. In this week's episode, we discuss how GPs may safely assess for cerebral venous sinus thrombosis (CSVT) in a patient presenting with a headache post vaccine, and the difficulty of gauging the scale of the risk of blood clots. We also talk about the controversial Sewell Report, which concluded that institutional racism is no longer a problem in the UK, and how, once we reach a post-COVID world, we need to focus more on wellbeing and work towards a fairer healthcare system for all. Our guests: Heather Angus-Leppan is a consultant neurologist, and epilepsy lead at the Royal Free London NHS Foundation Trust, as well as an honorary senior lecturer at UCL and Imperial College London. Whitney Robinson is an associate professor of epidemiology in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. She is also the co-host of the Acadames podcast https://www.acadamespodcast.com/ Further reading: - "Black people need better vaccine access, not better vaccine attitudes" by Rhea Boyd, https://www.nytimes.com/2021/03/05/opinion/us-covid-black-people.html - "The health-care industry doesn't want to talk about this single word," by Ron Wyatt, https://www.washingtonpost.com/opinions/2021/04/05/health-care-racism-medicine/ - "The Sewell report cited my work - just not the parts highlighting structural racism," by Michael Marmot, https://www.theguardian.com/commentisfree/2021/apr/07/sewell-report-structural-racism-research - "Black Memes Matter: #LivingWhileBlack With Becky and Karen," by Apryl Williams, https://journals.sagepub.com/doi/10.1177/2056305120981047

The past year has seen an increase in antibiotic prescriptions, especially for broad-spectrum antibiotics. This might be due to the rise in teleconsultations, which limit the ability to examine patients, causing GPs to experience higher levels of uncertainty in making diagnoses. This week, we discuss the impact that COVID-19, and COVID tests, have had on access to healthcare, the risk of antimicrobial resistance, and how the pandemic has altered the presentation and case mix seen in GP surgeries. With teleconsulting likely here to stay, how do we adjust to the changes in primary care provision, in order to prescribe with confidence? And how do we become good antibiotic stewards? Our guests: Geva Greenfield is a research fellow in the Department of Primary Care & Public Health at Imperial College London's School of Public Health. His research focuses on primary care and health policy, and big healthcare data analytics. Benedict Hayhoe is a London-based GP, and a clinical lecturer in the Department of Primary Care & Public Health at Imperial College London's School of Public Health. His research interests include digital health and antimicrobial resistance. Further reading: https://www.expmedndm.ox.ac.uk/step-up Armitage A, Nellums L. Antibiotic prescribing in general practice during COVID-19. The Lancet Infectious Diseases 2020. https://doi.org/10.1016/S1473-3099(20)30917-8 de Lusignan S, Joy M, Sherlock J, Tripathy M, van Hecke O, Gbinigie O et al. PRINCIPLE trial demonstrates scope for in-pandemic improvement in primary care antibiotic stewardship. medRxiv. 2021. https://doi.org/10.1101/2021.02.02.21250902 Han SM, Greenfield G, Majeed A, Hayhoe B. Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review. Journal of Medical Internet Research 2020; 22(11):e23482. https://doi.org/10.2196/23482 Hayhoe B, Butler C, Majeed A, Saxena S. Telling the truth about antibiotics: benefits, harms and moral duty in prescribing for children in primary care. Journal of Antimicrobial Chemotherapy 2018; 73(9):2298-2304. https://doi.org/10.1093/jac/dky223 Hayhoe B, Greenfield G, Majeed A. Is it getting easier to obtain antibiotics in the UK? British Journal of General Practice 2019; 69(679):54-55. https://doi.org/10.3399/bjgp19X700829 Morrell L, Buchanan J, Roope L, Pouwels K, Butler C, Hayhoe B et al.. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics 2020; 9(608). https://doi.org/10.3390/antibiotics9090608 Shah S, Wordley, Thompson W.. How did COVID-19 impact on antibiotic prescribing across England? British Dental Journal 2020; 229(9):601-604. https://doi.org/10.1038/s41415-020-2336-6 van de Pol A, Boeijen J, Venekamp R, Platteel T, Damoiseaux R, Kortekaas M et al.. Impact of the COVID-19 Pandemic on Antibiotic Prescribing for Common Infections in The Netherlands: A Primary Care-Based Observational Cohort Study. Antibiotics 2021; 10(196). https://doi.org/10.3390/antibiotics10020196 Zhu N, Aylin P, Rawson T, Gilchrist M, Majeed A, Holmes A.. Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves. Clinical Microbiology and Infection 2021. https://doi.org/10.1016/j.cmi.2021.02.007

The use of telemedicine is on the rise, and the pandemic has led to an increased demand for this service, due to the availability of face-to-face appointments being severely limited. In this week's episode, we discuss the benefits and pitfalls of teledermatology. With long waits for secondary care referrals, teledermatology allows dermatologists to fast-track patients requiring urgent investigations, and to direct them to the most appropriate care, which helps to alleviate some of the pressure on GPs. We talk about the common concerns around missing a skin cancer diagnosis, and the importance of empowering our patients to understand when to seek further help. How do we take good photos of skin lesions to aid diagnosis, and what is the vital information that dermatologists need from a GP referral? Our guests; Lucy Thomas is a consultant dermatologist at Chelsea & Westminster Hospital NHS Foundation Trust, she was also part of the Dermatology Team of the Year in the 2020 BMJ Awards, for the creation of a teledermatology service. Afzal Ansari is chair of the Royal Photographic Society's medical committee, and a medical photographer with decades of experience. For more on teledermatology https://www.bad.org.uk/healthcare-professionals/teledermatology

Suddenly 1.7m extra people have been told to shield from coronavirus, thanks to the QCovid algorithm, and that's causing confusion - ethnicity is one of the risk factors in QCovid, and yet there is a signal that there is lower update of the vaccine amongst ethnic minorities in the UK. In this week's episode, we discuss how particular factors, such as age, ethnicity, and comorbidities, affect your QCovid score, and why a GP can help people interpret that population level risk to themselves. We also discuss how institutional barriers may be preventing people from accessing the vaccine, and the active role that GPs should play in engaging with their at-risk patients, and how they might best support the communities they serve in promoting vaccine uptake. Our guests: Kevin Fenton is the Regional Director of Public Health England for London, and Regional Director of Public Health NHS London. Kamlesh Khunti is a professor of Primary Care Diabetes & Vascular Medicine at the University of Leicester. He is also the co-director of the Leicester Diabetes Centre, and co-developer of the QCovid algorithm.

In the UK, we are currently in the midst of our third lockdown since the pandemic began, and there has been a huge surge in people experiencing mental distress, anxiety and depression during the past year. The novelty of the first lockdown, in which people optimistically took up a variety of new activities, such as learning a language or baking endless loaves of banana bread, has long worn off, and many people now feel like they've used up their “coping resources”. Confusing public health messaging has led to great uncertainty, a feeling that we're having to put our lives on hold, and dwindling hope. In this week's episode, we discuss the difficulty of measuring the mental health impact of the pandemic, and how other issues (such as financial strain or bereavement) may cause long-term mental health problems. We also talk about loneliness: how to approach the subject with our patients, and the role that social prescribing may play in tackling it. Our guests; Daisy Fancourt is an associate professor of psychobiology and epidemiology at UCL. She is the lead researcher on the COVID-19 social study, (https://www.covidsocialstudy.org/) which looks at the psychological and societal impact of the pandemic, and she is also the director of the COVID-Minds Network (https://www.covidminds.org/). Dr. Farhana Mann is a psychiatrist in London and Wellcome Clinical Research Fellow at the Division of Psychiatry, UCL. She has been on the government advisory group on tackling loneliness, and is part of the UKRI Loneliness and Social Isolation in Mental Health Network, led by UCL. Additional resources/further reading: 'A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems' https://link.springer.com/article/10.1007/s00127-017-1392-y 'Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study' https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513993/ 'Understanding loneliness in the twenty-first century: an update on correlates, risk factors, and potential solutions' Social Psychiatry and Psychiatric Epidemiology (2020) 55:793–810 https://doi.org/10.1007/s00127-020-01889-7 UCL Network is @ucl_loneliness on Twitter, and they are a good place to start if looking for updates on the field. People are very welcome to get in touch via the website too: https://www.ucl.ac.uk/psychiatry/research/epidemiology-and-applied-clinical-research-department/loneliness-and-social-isolation