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Author: Antony Willman

  • My Iraq experiences

    Not really educational but a reflection.  With the Chilcott enquiry published today, I thought about my own experiences of the Iraq War (or the third Iraq war as it was known by the locals).  I remember thinking ‘this isn’t a good idea’ when it kicked off and worrying about my military colleagues who deployed on Op Telic 1 (the war fighting phase although it was all a bit hairy).  On my tours there and to Afghanistan, I used to write newsletters which were meant to be a bit of light hearted look at the British Army machine and how it worked and interacted (or not) with the locals.  I’ve just re-read them & smiled to myself as we were already wondering ‘what on earth was going on’ and ‘what are we meant to be doing’ in 2004/5, let alone some 11 years later.

     

    I’m going to hopefully share them now.  I think they still read okay.  They are when I deployed on Op Telic 5 in 2004/5.  This was after I had deployed on Op Telic 2 in 2003, just after the war fighting had supposedly finished.

    SAAH1

    SAAH2

    SAAH3

    On reflection, a lot of my operational experiences was mundane primary care.  It also involved doing favours and being continually amazed by how the logistical support provided to the US troops was second to none compared to our hand to mouth existence.

  • A Meta-Analysis of Continuing Medical Education Effectiveness (Mansouri and Lockyer 2007)

    Free text from here.

    In trying to justify why I think PBSGL is a good way of learning, I have done a lot of literature searching and reading about how different CME interventions can change what we do as physicians. The more recent research on PBSGL has demonstrated that Small Group Learning (SGL) is associated with several positive outcomes. For example, implementing guidelines into practice, an activity that is often associated with many difficulties (Macvicar, Cunningham et al. 2006). If only patients would do what they’re told, it would be so much easier! Clearly primary care is not about the sapiental ‘all knowing’ doctor. It is about empowering patients to make decisions. This generates uncertainties. Sharing these uncertainties in a SGL group with a trained facilitator frees up the physician to say what they think with reduced fear. I have often wanted to ask questions in a GP update lecture but am embarrassed to ask simple things about chronic disease management, something we are not always good at working for the MOD with a young population.

    I have also found lectures a mixed bag of usefulness. I write furiously in my learning journal, coming up with all sorts of ideas for audits and interventions only to reflect on them (usually just prior to my appraisal) wondering where has all that enthusiasm gone? This is why I have been such an advocate of SGL and what it can do to enhance our learning and improve patient care. Hence my review of this article for both my professional project and for general interest.

    This meta-analysis is not a new article but is a solid piece of work where the authors undertakes a literature review of CME interventions and looks at outcomes. The main type of interventions examined are active (workshops & individual training), passive (conferences and lectures) and mixed (SGL and post-course feedback). Three types of outcomes are looked at: physician knowledge, physician performance and patient outcome. There were 31 studies which actually generated 61 interventions (as some studies had multiple outcomes). The interventions were entered separately into the meta-analysis. All outcomes had positive & significant effect although the size was generally small. The data was also grouped and analysed for various types of CME. No surprises for guessing the results (summarised in table 3). Interactive SGL, case discussions, multi-faceted programmes and longitudinal workshops all had the largest effect.

    What was interesting was the small number of studies looking at patient outcomes. I decided to look in detail at one of these. Gask et al used role playing actors with videotaped consultations to look at consultation behaviour pre- and post educational intervention (Gask, Usherwood et al. 1998). The subject was depression. In what seems to be a nicely constructed but probably expensive study, ratings of the consultations with the role players were carried out in the context of assessment and management of depression. The intervention involved small group work in five 2 hour sessions. It included intensive training, review of videoed consults, role playing etc. In other words, a very intensive package and probably impractical for a busy GP nowadays.

    It would be a fair conclusion to draw that the least effective methods of delivering education (e.g lectures) are probably the most popular as they are cheaper to provide. More intensive training eg with SGL is associated with better outcomes, but with increased number of hours of intervention so the cost of delivery is probably more. I would argue that case based training can be cost effective and in the one relevant study included in this meta-analysis, physician knowledge improved considerably (Doucet, Purdy et al. 1998).

    Two other findings piqued my interest. The first was that when the assessment was done was important.  This is not surprising. If the assessment is performed 52 weeks later, the impact is likely to be less. The other finding was that mixed disciplines fared less well than single group disciplines. Details were patchy but it is something to consider if planning some interdisciplinary education. It may be that with increased specialisation and training of practice nurses, plus delegation of management to them by GPs, this effect will be less in 2016 than it was in 2007. An adjunct to this was that increased participants had a negative correlation although it is not clear if this this was related. One would expect increased numbers at passive interventions so it may be a secondary effect.

    Doucet, M., et al. (1998). “Comparison of problem-based learning and lecture format in continuing medical education on headache diagnosis and management.” MEDICAL EDUCATION-OXFORD- 32: 590-596.

    Gask, L., et al. (1998). “Evaluation of a training package in the assessment and management of depression in primary care.” Medical Education 32(2): 190-198.

    Macvicar, R., et al. (2006). “Applying evidence in practice through small group learning: a Scottish pilot of a Canadian programme.” Education for Primary Care 17(5): 465-472.

    Mansouri, M. and J. Lockyer (2007). “A meta‐analysis of continuing medical education effectiveness.” Journal of continuing education in the health professions 27(1): 6-15.

  • Hall, Pippa, and Lynda Weaver. “Interdisciplinary education and teamwork: a long and winding road.” Medical education 35.9 (2001): 867-875

    This article looks at education in an interdiscplinary team.  Most people have heard of a multi-disciplinary team where a team of specialists (in their own right) discuss cases.  Think of the MDT approach to hospital based disciplines and particualr complex cancer care.  At the other end of the spectrum is transdisciplinary where there is role blurring within the team members.  This is increasingly the case in primary care with practice nurses taking on more chronic disease management and the use of physician assistants.  Interdisciplinary is probably a more traditional primary care model however where there are distinct roles yet the team works together with a common focus being the patient.  That is not to say this isn’t the case with a MDT but there is more role blurring with interdiscliplinary teams as well as some professional overlap.  It’s what often happens when we discuss patients in primary care as a team looking at all outcomes for a patient.  These could be physical, social or psychological.  The question this article attempts to answer is how do we address the educational needs of that team?

    My professional project is a service evaluation of PBSGL.  This method of CME has been evluated before with generally favourable findings.  My ‘unique selling point’ so to speak is how having a mixed skillset group can enable peer support.  For example, having GPSTs, First5 GPs as well as more experienced GPs.  Whilst this doesn’t fit in with the definitons above, there are some transferable findings.  The article talks about System Issues and Content Issues.  Both are relevant.  Three areas discussed I think are important.

    1. Non-traditional teaching methods such as Problem Based Learning helps focus the team on ‘idea dominance’. This puts teamwork at the fore, with the patient as the focus. This is an important aspect of PBSGL.
    2. Faculty development – who does the education within the team & how do they as educators develop? This role is extremely important in the early days of initiating a programme and it would be easy to become disillusioned if there is apathy towards interdisciplinary education.
    3. Leadership skills – a hugely important yet often overlooked. We probably are demonstrating good leadership in primary care already but may be need to qualify it to allow development. This article pre-dates it but the NHS Academy Medical Leadership Competency Framework is a good start with a self assessment toolkit for those responsible for faculty development and who are facilitators.

    Whilst an older article, it does raise important aspects of how we assure and develop education within the Primary Care Team.  This is perhaps more of an imperative due to the changing roles of the different Primary Care Team members since the article was written and further ‘role blurring’.

  • Hall, Pippa, and Lynda Weaver. “Interdisciplinary education and teamwork: a long and winding road.” Medical education 35.9 (2001): 867-875.

    This article looks at education in an interdiscplinary team.  Most people have heard of a multi-disciplinary team where a team of specialists (in their own right) discuss cases.  Think of the MDT approach to hospital based disciplines and particualr complex cancer care.  At the other end of the spectrum is transdisciplinary where there is role blurring within the team members.  This is increasingly the case in primary care with practice nurses taking on more chronic disease management and the use of physician assistants.  Interdisciplinary is probably a more traditional primary care model however where there are distinct roles yet the team works together with a common focus being the patient.  That is not to say this isn’t the case with a MDT but there is more role blurring with interdiscliplinary teams as well as some professional overlap.  It’s what often happens when we discuss patients in primary care as a team looking at all outcomes for a patient.  These could be physical, social or psychological.  The question this article attempts to answer is how do we address the educational needs of that team?

    My professional project is a service evaluation of PBSGL.  This method of CME has been evluated before with generally favourable findings.  My ‘unique selling point’ so to speak is how having a mixed skillset group can enable peer support.  For example, having GPSTs, First5 GPs as well as more experienced GPs.  Whilst this doesn’t fit in with the definitons above, there are some transferable findings.  The article talks about System Issues and Content Issues.  Both are relevant.  Three areas discussed I think are important.

    1. Non-traditional teaching methods such as Problem Based Learning helps focus the team on ‘idea dominance’. This puts teamwork at the fore, with the patient as the focus. This is an important aspect of PBSGL.
    2. Faculty development – who does the education within the team & how do they as educators develop? This role is extremely important in the early days of initiating a programme and it would be easy to become disillusioned if there is apathy towards interdisciplinary education.
    3. Leadership skills – a hugely important yet often overlooked. We probably are demonstrating good leadership in primary care already but may be need to qualify it to allow development. This article pre-dates it but the NHS Academy Medical Leadership Competency Framework is a good start with a self assessment toolkit for those responsible for faculty development and who are facilitators.

    Whilst an older article, it does raise important aspects of how we assure and develop education within the Primary Care Team.  This is perhaps more of an imperative due to the changing roles of the different Primary Care Team members since the article was written and further ‘role blurring’.

  • OSELTAMIVIR TREATMENT FOR INFLUENZA IN ADULTS: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS (Dobson et al., 2015)

    I was interested to read about a new drug NICE have approved for HUS which by all accounts is massively expensive.  All sorts of harrumphing followed in the press as well as the medical press about funding of expensive drugs and QALYs.  Personally I think NICE have an important yet unforgiving job to do.  I also do get a little cynical at yet another expensive breast cancer drug coming out which, accompanied by a powerful patient interest lobby, is guaranteed to net the drug company a good return.  I remember reading the first papers on the initial Herceptin trials which were sponsored by big Pharma & thinking ‘this actually isn’t that great’.  The study sample was small, the mortality pretty unchanged though admittedly the disease free interval was extended.  I suppose if you have any cancer, these are small positives.  My mother is currently in the terminal stages of bowel cancer and I know how awful it can be.

    The other side is a drug which may benefit millions of us in the event of a pandemic.  This brings us to Tamiflu, or oseltamivir.  Not so long ago, a meta-analysis published in the BMJ reported that neuraminidase inhibitors at best had a modest effect (Jefferson et al., 2009).  This was something I had always suspected.  The patients I treated seemed to have more side effects than benefit in my admittedly small sample.  I assumed powerful lobbying by Pharma alongside failure to disclose unpublished trial data had won the day.

    It was the other day therefore whilst reading the Torygraph that this article piqued my interest.  I won’t go into massive detail as one needs access to full text to assess it.  Suffice to say it seems a well constructed systematic review with lots of blobograms (Forest plots) and actually is quite easy to read.  The statistics seem sound too.  When I see something that is too good to be true, it usually is.  Not wanting to be unfair on the authors, there are one or two concerns.  Firstly 2 of the 4 authors have been paid by Roche.  Secondly, whilst they had no part in the analysis, Roche funded the study under the guise of the MUGAS foundation.  The authors acknowledge this and make valid comment.  The interesting thing about this study is that it used unpublished data.  I don’t know which studies were unpublished but I could probably have a good guess.  Of the 9 studies included, a sizeable minority have confidence intervals that cross the line of no effect.  This includes the 2nd largest.  Clearly when doing a systematic review, one includes all the studies but it is interesting to see all the data.

    Probably the biggest issue and the one that that relates to primary care I the UK is the different analyses that were carried out.  The intention-to-treat-infected population showed far greater effectiveness than the intention-to-treat population.  This is essentially saying that when the nasal swabs were analysed & the results broken down into those who had influenza & those who didn’t, the former group gained far more benefit from oseltamivir.  Patients included in the studies presented with symptoms of influenza had their treatment started within 36hr of onset. In other words no time to obtain a lab result to confirm influenza.  This means the only population relevant to us in primary care is the intention-to-treat population where the effect is much less.  Indeed one of the headlines is reduction of  hospital admissions which in the intention-to-treat group was not significant.  What we really need is a rapid near test to enable a more accurate diagnosis so the drug is used more effectively.

    There are several references to Jefferson’s earlier work and indeed for anyone interested, I would read both studies together.  It is a good example of a systematic review and actually one of the easiest to read I have come across in a while.  It also will give some justification to the Government for the millions of pounds spent on stockpiling drugs in the event of an influenza pandemic.

    DOBSON, J., WHITLEY, R. J., POCOCK, S. & MONTO, A. S. 2015. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. The Lancet.

    JEFFERSON, T., JONES, M., DOSHI, P. & DEL MAR, C. 2009. Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. Bmj, 339.

  • Introduction

    Dear All

    If you are coming to this for the first time, do not be alarmed by the content.  I had to start with something so I imported the Salisbury Plain site into this site.  My aim is to combine PBSGL, the Salisbury Plain Trainers Group and DMS Trainers into one as much of the education that goes on is applicable to all three.  I simply don’t have the time to post to all of them as well!

    The first thing I would ask you to do is to go to twitter.com and get an account.  It’s free and fairly simple to do.  Once done, search for dmstrainers and follow.  I will accept & follow you back.  That’s it!  As we mature as an on-line group, so we can fine tune how we interact with each other and share best practice, in clinical, leadership and educational domains.

  • Potential Research Project: Web 2.0 technologies in Primary Care Education. What is the current level of knowledge and utilisation of Web 2.0 technologies in Primary Care Education.

    Any thoughts?

  • OSELTAMIVIR TREATMENT FOR INFLUENZA IN ADULTS: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS (Dobson et al., 2015)

    I was interested to read about a new drug NICE have approved for HUS which by all accounts is massively expensive. All sorts of harrumphing followed in the press as well as the medical press about funding of expensive drugs and QALYs. Personally I think NICE have an important yet unforgiving job to do. I also do get a little cynical at yet another expensive breast cancer drug coming out which, accompanied by a powerful patient interest lobby, is guaranteed to net the drug company a good return. I remember reading the first papers on the initial Herceptin trials which were sponsored by big Pharma & thinking ‘this actually isn’t that great’. The study sample was small, the mortality pretty unchanged though admittedly the disease free interval was extended. I suppose if you have any cancer, these are small positives. My mother is currently in the terminal stages of bowel cancer and I know how awful it can be.

    The other side is a drug which may benefit millions of us in the event of a pandemic. This brings us to Tamiflu, or oseltamivir. Not so long ago, a meta-analysis published in the BMJ reported that neuraminidase inhibitors at best had a modest effect (Jefferson et al., 2009). This was something I had always suspected. The patients I treated seemed to have more side effects than benefit in my admittedly small sample. I assumed powerful lobbying by Pharma alongside failure to disclose unpublished trial data had won the day.

    It was the other day therefore whilst reading the Torygraph that this article piqued my interest. I won’t go into massive detail as one needs access to full text to assess it. Suffice to say it seems a well constructed systematic review with lots of blobograms (Forest plots) and actually is quite easy to read. The statistics seem sound too. When I see something that is too good to be true, it usually is. Not wanting to be unfair on the authors, there are one or two concerns. Firstly 2 of the 4 authors have been paid by Roche. Secondly, whilst they had no part in the analysis, Roche funded the study under the guise of the MUGAS foundation. The authors acknowledge this and make valid comment. The interesting thing about this study is that it used unpublished data. I don’t know which studies were unpublished but I could probably have a good guess. Of the 9 studies included, a sizeable minority have confidence intervals that cross the line of no effect. This includes the 2nd largest. Clearly when doing a systematic review, one includes all the studies but it is interesting to see all the data.

    Probably the biggest issue and the one that that relates to primary care in the UK is the different analyses that were carried out. The intention-to-treat-infected population showed far greater effectiveness than the intention-to-treat population. This is essentially saying that when the nasal swabs were analysed & the results broken down into those who had influenza & those who didn’t, the former group gained far more benefit from oseltamivir. Patients included in the studies presented with symptoms of influenza had their treatment started within 36hr of onset. In other words no time to obtain a lab result to confirm influenza. This means the only population relevant to us in primary care is the intention-to-treat population where the effect is much less. Indeed one of the headlines is reduction of hospital admissions which in the intention-to-treat group was not significant. What we really need is a rapid near test to enable a more accurate diagnosis so the drug is used more effectively.

    There are several references to Jefferson’s earlier work and indeed for anyone interested, I would read both studies together. It is a good example of a systematic review and actually one of the easiest to read I have come across in a while. It also will give some justification to the Government for the millions of pounds spent on stockpiling drugs in the event of an influenza pandemic.

    DOBSON, J., WHITLEY, R. J., POCOCK, S. & MONTO, A. S. 2015. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. The Lancet.

    JEFFERSON, T., JONES, M., DOSHI, P. & DEL MAR, C. 2009. Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. Bmj, 339.

  • Chronic Pain

    After our 2 sessions on chronic pain, we have performed a couple of audits at Bulford.  My own is here: . Tony Dickinson has also done one here:

    I found both sessions incredibly useful.  I am finding I am being more pragmatic with patients and being realistic with outcomes.  I think the main learning points for me have been

    a. what is feeding the chronic pain cycle?  Catastrophising I think is an excellent term.

    b. recording follow up thoroughly in follow up using the 6A’s.  In particular affect, adverse effects and analgesic effect.

    I think there is probably some more work to do on the occupational aspects of strong analgesia.

  • Chronic Pain

    After our 2 sessions on chronic pain, we have performed a couple of audits at Bulford.  My own is here: 20150121-Opiate audit . Tony (D) has also done one.

    I found both sessions incredibly useful.  I am finding I am being more pragmatic with patients and being realistic with outcomes.  I think the main learning points for me have been

    a. what is feeding the chronic pain cycle?  Catastrophising I think is an excellent term.

    b. recording follow up thoroughly in follow up using the 6A’s.  In particular affect, adverse effects and analgesic effect.

    I think there is probably some more work to do on the occupational aspects of strong analgesia.