There is something rather magical about watching an experienced GP focus in on a problem, elicit the patient’s perspective and then dispense simple practical advice simply and fluently. Take hay fever (seasonal allergic rhinitis). Patients will often have experienced years of misery before they attend their GP for help. They are likely to have tried antihistamines – either oral or a spray – that they have procured over the counter from their local pharmacy or supermarket. It is not uncommon for the patient to have already sent away samples for unnecessary blood allergy testing. The experienced GP focuses in on history, ascertains seasonality, excludes red flags and provides straightforward tips that can reduce exposure and limit the need for medication.
As medical students we learn a particular way of assessing and managing a problem, mainly on the hospital wards. With the luxury of time and learning good habits for exams we take detailed histories, perform thorough examinations, request a panoply of blood and radiological tests. Our management is focused on medication, right through to the discharge letter that neatly lists prescriptions that are handed on like a baton to primary care colleagues. This approach becomes more accentuated with time. At handover or the ward round we learn to anticipate the questions that are likely to follow, adding even more questions to our history and further tests. In addition to the expectations of others we are driven by our own experiences – the spot diagnosis that saved a life, or the patient where the diagnosis was delayed.
It is therefore refreshing to see that simple approaches work for many problems, though the route to that knowledge is not always obvious. The way we access evidence has changed a lot since I first became a doctor in 1995. These changes have become very apparent to me as I prepare for General Practice exams as part of a mid-career change. In the mid-1990s classes of medications that had barely been mentioned at medical school became standard treatments following major new studies – e.g. statins and ACE inhibitors – and we started to use medications in new and seemingly counterintuitive ways – e.g. beta blockers in heart failure. There were several well-thumbed, brightly coloured copies of the British National Formulary (BNF) kicking around every ward, often two or three issues out of date. The internet and email were new and unavailable on the wards. Prescribing was guided by a combination of the BNF, senior colleagues and research papers.
The translation of research evidence into practice has evolved, even though much of the final advice remains within those familiar colourful covers of the BNF. In 1999 the National Institute for Clinical Excellence (now National Institute for Health and Care Excellence) was founded, publishing its first clinical guideline in 2002 (schizophrenia) and its first public health guideline in 2006 (smoking brief interventions and referrals). The BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain, in adult and children’s versions since 2005, includes treatment summaries and prescribing advice that are aligned with NICE guidance. These treatment summaries provide information on much more than just medication. The heart failure section for example includes lifestyle advice, practical steps to identifying fluid accumulation and wider considerations ranging from contraception to psychological support and exercise. Most of us now access the BNF via its phone app and many of us will skip straight to the individual drugs rather than spend time with these useful treatment summaries.
The related Clinical Knowledge Summaries (CKS) sit adjacent to the BNF and BNFc tabs on the NICE website. Returning to allergic rhinitis, this is where we find practical advice including details about environmental exposures. There is information that would be well known to a gardener (e.g. trees pollinate in spring, grass in early summer) but perhaps not to a junior doctor. A detailed section on self-management gives advice that is of direct relevance to doctors and patients, also helping to steer clear of unnecessary interventions. The allergen avoidance advice provided is practical and plausible, and provides the rationale and links to the full guidance. BMJ Best Practice provides a similar function, and has a regularly updated phone app. If the practical advice from these resources works then the patient benefits and a prescription is avoided or limited to a specific period or situation.
As clinicians we regularly meet patients with seemingly trivial conditions that we brush over. The patient’s usual antihistamine is dutifully written up on the drug Kardex as they arrive on the ward, without wondering why they are on it. We can all learn from the summaries provided by NICE’s Clinical Knowledge Summaries and BMJ Best Practice. It is satisfying to bring a preventive approach to our work, taking practical steps that complement or avoid medication, thereby reducing side effects and minimising adverse reactions.
Dr Graham Mackenzie, GPST2, Edinburgh, Scotland
12 October 2020
Biography: Graham Mackenzie has been a doctor for 25 years, and is currently retraining as a GP. He has also worked in hospital medicine and was a Consultant in Public Health Medicine in NHS Lothian for 11 years, during which time his remit included women and children’s health and quality improvement.
Featured image of pollen is from Dartmouth College Electron Microscope Facility, via Wikipedia.