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Ciclos de Conferências MGF XXI
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Ciclos de Conferências MGF XXI
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Introdução Fórum / Conferências
Contactos / Contacts of MGFXXI Conference Cycle
Luís Filipe Cavadas
luisfilipemcavadas@g
Tiago Villanueva
tiago.villanueva@gma
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2º Ciclo de Conferências MGF XXI
"Our clinical records: for patients and health care"
by Professor Mike Pringle
12 a 30 de Outubro de 2009
Mike Pringle é Médico de Família e professor de MGF da Universidade de Nottingham no RU. Antigo presidente do Royal College of GP's. É considerado um "peso pesado" da MGF Britânica e Mundial. Director do projecto inovador PRIMIS+ (http://www.primis.nhs.uk/index.php/about-us). Biografia http://www.nottingham.ac.uk/cps/index.php?page=2.0.0.2 http://www.primis.nhs.uk/conference_2008/popups/biog.asp?s=6
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Perguntas de Luís Filipe Cavadas
Dear Prof. Mike Pringle, Welcome to MGF XXI Conference Cycle! It is a great honour to welcome you in our group during these three weeks. Let’s start the Conference…
1- In this group there are Family Medicine Residents and Family Physicians that are interested to know - Who is Mike Pringle? Can you briefly describe your educational and professional background? I am a general practitioner by background. I was always interested in research and a fortuitous research grant early in my career (it was to study the effect of the computer on the consultation) established my academic career and earned me a doctorate. While climbing the academic ladder – lecturer, senior lecturer, professor, head of division, head of school – through research and teaching I was developing a “political career. At first this took the form of leadership in quality assurance (I am the father of “Significant Event Auditing”) but then as Chairman of the Royal College of General Practitioners (1998-2001). I’ve been national clinical lead for NHS Connecting for Health (the programme to computerise health records for three years and now I’m leading on revalidation. Although this may sound smug, I regard myself as been very fortunate and to have had a very satisfying career with a large measure of control. I’ve got a wonderful family which gives me great pleasure. [Mike Pringle] 2 - Why did you choose the title "Our clinical records: for patients and health care" for this Conference? [Mike Pringle] A key challenge for Portugal family practice will be the development of high quality comprehensive computerised clinical records. All the technology and techniques are established; the major challenge is the implementation. If you are to achieve this you need to be clear of the reasons for doing it and the benefits you’ll achieve. 3 - Is this title the reflex of your PRIMIS+ project? Can you tell more about it? [Mike Pringle] PRIMIS+ is funded by the NHS to improve the quality of GP records. It does this by training and supporting local facilitators; and by feeding back to practices on how their data quality compares with others. 4- My final question in this first round is: What do you know and what do you think about the Portuguese Family Medicine and about our National Health Service? [Mike Pringle] I’m afraid I’m shamefully ignorant of Portugal and its health system. I’ve visited your country several times for conferences and meetings and Portugal was a partner in eHID (a European project that I led and which is referred to in the presentation). I hope to learn more over the next few days.
5- Like you said “I was always interested in research…”; besides health informatics what kind of other topics do you research? 6- Frequently it is discussed that many of the health research are not really directed to the real patient in Primary Care, these studies do not take into account the socioeconomic status of patient, They eliminate many important variables to make the study easier, making them into something very artificial and not applied to the daily lives of our clinical practice. It can be dangerous when applied in our real practice. What you think about it? What you think about the pragmatic trials? 7 - Recently I was in the EGPRN meeting, and your name was cited sometimes in this conference by the excellence of your work. If possible can you share some of your works with us and its main results? 8- What do you think about the actual “state of art” in Primary Care research?
Luis, Thank you. A few funded topics I have researched are: The effect of the computer on the consultation The effect of video-recording on doctor behaviour in the consultation The effects of spouse concordance (the opposite of twins studies: what commonality of diseases are there despite no genetic link) What determines the level of control in diabetes? Significant Event Auditing Determinants of prescribing costs Avoidable medical admissions The recording of ethnicity in general practice Cardiovascular epidemiology in primary care Are low referring GPs also late referrers for cancer? The evaluation of a major educational initiative in London Influences in teenage pregnancy A national audit of stroke care in England Self care in general practice Antibiotic resistance and its association with prescribing of antibiotics (my only current funded project)
I believe that we have a great opportunity to perform “real” general practice. We can generate hypotheses from our daily work – this is very important if researchers are to address questions relevant to our patients. We can do initial hypothesis scoping, looking for evidence including associations. We can mount testing studies including randomised controlled trials. In the UK everybody has a postcode and the census data can be linked to post codes. So in large anonymised databases like QRESEARCH we can link socio-economic data (which you are right is far too often ignored as a source of bias) and co-morbidity etc. You are very kind. I am proud of the research I’ve done but I’m among the last of the self-taught entrepreneurial generation of GP researchers (I’m 59). I’ve had no clear focus (see above) and I’ve researched anything that grabbed my attention/interest. I’ve never mastered clever statistics. My studies are simple in design and focus on very basic questions. I’ve been lucky to win grants and to work with talented colleagues. Compared to the current generation of leading researchers I was merely their bag carrier. In the UK general practice research is getting better and better. In Nottingham we now have five professors in the Division of Primary Care and we attract millions of pounds in research grants every year. In the last Research Assessment Exercise we were scored higher than any of the hospital-based clinical disciplines. Many researchers in other areas seek us as collaborators.... In Europe general practice research is making slow but steady progress. But we are getting there, especially in Holland and Germany. If anybody wants to see my CV I can circulate it. Mike I completely agree with you. Our research must be performed to the real general practice. Your research topics are an excellent example of that Reality. And in my opinion you are right saying that “My studies are simple in design and focus on very basic questions” because I feel that is in the simplicity that born the biggest ideas with the most repercussions to our practice. I think that in Portugal general practice research is getting better and better too, an example of that are the excellent research works presented in the Second Virtual Congress of General Practice and Family Medicine http://www.virtualcongressgpfm.com/ “In Europe general practice research is making slow but steady progress. But we are getting there, especially in Holland and Germany.” I strongly believe that very soon you will say: "But we are getting there, especially in Portugal, Holland and Germany.” ;)) Best Regards Tiago Villanueva And I thought you would be asking answerable questions!! I could do whole essays for each questions, but I’ll just make a few points: 1 - In your opinion, what are the main strengths and weaknesses of UK General Practice? Strengths – registered patient list; longitudinal record; key role in delivery of health care (and orchestrating other sectors); location for all major public health interventions (health promotion, early detection, chronic disease management); widely valued and supported; good GP income Weaknesses – GPs themselves are always expressing dissatisfaction; political interventions (pay freeze announced last week); recruitment (but OK at present); workload high (but so is autonomy) 2 - Would you suggest any recommended reading concerning best practices in the use of electronic health records in GP? The RCGP commissioned Alan Hassey (and colleagues) to write a guide. I’ll try to find a copy. 3 - What piece of advice would you give a GP trainee that just started his/her vocational training program? I am an enormous supporter of general practice. It has given me a wonderful career. If you want to make a difference to patient care and be valued then it’s a good career choice; but it also offers great flexibility and autonomy. 4 - Imagine you have to interview ten candidates tomorrow for a single GP trainee placement in your Primary Care Trust. What criteria would you use to help you select the most suitable candidates? Beyond qualifications etc: Commitment to patient care Commitment to general practice as a discipline Inter-personal skills Communication skills Vision 5 - Do you think your research background has helped you in your political career? How? How about the opposite? Has your political career helped you carry out your research projects in any sort of way? The two most valuable skills I possess are, I think: 1. The ability to express myself clearly on paper. This is something I learnt from research. 2. The ability to “sell an idea”, to win an audience – used to be called oratory. Travelling around the country explaining the results and implications of my research was invaluable The cusp between “politics” and “research” might be defined as the value driven areas of medicine – quality of care and organisation of care. I’ve researched these and been involved in developing them (politically). Being credible in both areas helps enormously. 6 - Revalidation of doctors is a sort of "taboo topic" here in Portugal. Why is it important, and could you please briefly explain how it works in the UK for GP's? Revalidation (regular re-accreditation of all doctors) comes in in the UK in 2011. It has been 10 years in the planning and resulted directly from the cardio-thoracic surgery case in Bristol but has been spurred on by a loss of confidence that “poor” doctors were known and were being dealt with. Over time, this assurance of minimum standards has been largely superseded by the aspiration that revalidation will promote better standards of care generally, encouraging reflection, change and improvement. If you want to see our precise proposals, please go to www.rcgp.org.uk/revalidation and upload the Guide to the Revalidation of General Practitioners. For GPs they will continue to have their annual appraisal (do you have those?) and will start uploading evidence for revalidation after each appraisal. Over five years they will accumulate the evidence needed. This will then be seen by their local medical director and, after a quality assurance process, the medical director will recommend them for revalidation. They are then certificated for another five years provided they take part in annual appraisals.... Mike Dear Mike, I am posting my final questions to you below. Many thanks. Tiago 1. I've heard you will chair a session about revalidation in the upcoming conference of the Royal College of General Practitioners. What will your main messages will be, if you can tell us, that is? 2.Around here, health care professionals are very split concerning their opinion towards receiving the swine flu vaccination or not. What does the GP community in the UK, and particularly the Royal College of GP's, think about the swine flu vaccine? 3. If Gordon Brown appointed you tomorrow as the UK's health minister, what would you try to change in the UK's National Health Service? What are you not particularly proud of in your National Health System that should be substantially improved? 4. In what ways do you think electronic clinical records in the UK will evolve over the next 10 years and why? 1. I will be explaining our proposals for revalidation and particularly concentrating on the timetable and roll-out. Since many members of the audience will be appraisers, I'll concentrate some time of enhancing appraisals. 2. We are recommending it to our vulnerable patients. It is too early to know just how safe it is, but my view is that it is better for health professionals to have it in order to protect their patients. However I would not be recommending it for other groups. 3. The greatest problem is variation in standards of care. In general practice this means some GPs and some practices being unacceptably poor. In hospitals, some have long waits and deliver poor care. While I would concentrate on getting clinical standards improved for all, I would also emphasise behaviour. Some doctors are very rude and uncaring. 4. I think that in ten years time we will regard them as just one more part of normal health care, wondering how we ever managed without them. They will have high quality (complete, accurate) content and be available to enable care for a patient wherever and whenever they are seen. Decision support and error trapping will improve patient safety, Patients will have access to their records and will contribute comments and recordings. The anonymised records will be used for audit and quality assurance, clinical governance, research, commissioning and planning. All this is happening somewhere in the UK at present. It'll just become generalised. Mike Mónica Granja Dear Mike, I am sorry the question I would like you to answer is not yet about records, but about appraisal and revalidation. By the way, we do not have either. All we have is a 2 step walk up that adds a title (something like "graduate" and "chief") to our PD and some more money on our wage, but if one prefers not to do so, one can stay just PD all your life. As Tiago mentioned, revalidation is a taboo among Portuguese medical organizations. Yet, I believe it is strongly necessary and still hope someday we will get there. My question is how do you in England arrived to revalidation? When did it start? Who wanted it? How did common physicians react? Thank you very much. Monica (and others), In the mid-1990s two surgeons and the medical director in Bristol (a port in the West of England) were changed with professional misconduct by the General Medical Council (the GMC). Their “crime” was this: for years the paediatric cardiac surgery unit in Bristol had had a much higher death rate than other such units. The surgeons and the medical director knew this. They had done nothing about it. One surgeon (the junior one) was probably just not very competent. One (the senior one) was very obsessional and therefore very slow – it was the length of the anaesthetics that killed his babies. The medical director was found not to have responded to the evidence of the problem and so to have failed in his duty to his patients. I describe this in detail because it totally changed the landscape. It was the first time that such a case had been bought; it was the warning call that poor outcomes were not just “part of life”; and it redefined the agreement between patients and health professionals. After “Bristol” there was a decision (in 1996) by the GMC to bring in regular recertification of all doctors and a major national inquiry led by an ethicist called Ian Kennedy. The Bristol Inquiry supported regular recertification. There were then a series of high profile cases of “bad doctors” – in truth there was no real pattern. They varied from a mass murdered (Shipman) who would never have been detected by revalidation to a totally incompetent gynaecologist (Neill) to sexual offenders (Clifford, Aylott and others). The case for revalidation became stronger and stronger; the profession became more and more beleaguered. In the period 1996 to 2001 I worked to design and deliver a system of five yearly recertification, by then known as revalidation, for general practitioners. In 2000 the GMC lost its confidence in the idea and decided that the new system of annual appraisals would solve its problem. The British Medical Association (BMA - the powerful doctors’ trade union) and many Royal Colleges (other than the Royal College of General Practitioners which I led at the time) came out against meaningful revalidation. The GMC therefore decided that “five annual appraisals equals revalidation”. By this time I was on the GMC and argued alone that this was wrong. Fortunately enough powerful people outside the GMC spoke out to persuade the Government to halt revalidation plans and to review the whole area. They did so and by 2005 it was clear that they supported the original plans. Since then the BMA has taken to the sidelines (they are waiting for a good opportunity to attack but cannot do so yet). The Royal Colleges have agreed to revalidation. The Department of Health has become very keen and supportive. And the process of gathering strength. I’ve referred to the core document for GPs on the RCGP website. Our proposals are now with the GMC for approval. We hope to have that by early next year. We are doing four pilots at present with more planned. In the spring of next year we’ll recruit a small number of locations to be “early adopters” (the first to do it for real) and by early 2010 the first genuine recommendations for revalidation will be made to the GMC. Then in April 2010 we start the first of five full years in each of which about 12,000 GPs will be revalidation (there are approximately 60,000 in all). By April 2015 we just start again! What does it entail? Each GP will have their annual appraisal which will be strengthened to include the requirements of revalidation. So at the end of the five years they’ll have five certificates of satisfactory annual appraisal, five personal development plans and five reviews of development plans. They will have evidence that they do at least 50 hours of relevant continuing education a year (the Learning Credits are a bit more complicate but that’s the bottom line); they’ll have evidence of quality improvement (two audits, five significant event audits, reports of all formal complaints); they’ll have done patient and colleague surveys; and they’ll have declared that there are no issues around health or probity. Of course this applies to all doctors but I’m only involved directly in the half that are GPs. So, what do people think about it? Most doctors think it’s taken far too long to happen and just want to get on with it. Some are still fighting it, but their numbers are dwindling. The public thought all doctors were regularly reapproved anyway and think its about time this happened. The government is behind it. The main risks are: The elections next year (will the new government be as supportive?); the BMA which is just waiting for the right issue to oppose it; and support for poorly performing doctors (this has been neglected and underfunded for years). Happy to answer any other questions (on anything!). Mike Thank you very much. Your story gave me some more hope, since we seem to be no more than a dozen years behind you (but in Portugal both trade unions and our RCGP equivalent - the Ordem dos Médicos - strongly fear revalidation). One thing you mentioned also happens here: most patients think revalidation is somehow currently done. They trust the system, but the system lets them down. Some time ago I had the chance to read the Scottish RCGP revalidation toolkit and it seemed to me an extremely defying and pleasant task, something I would really like to be told "do it". Mónica Manuel Rodrigues Pereira About the revalidation scheme in UK, could you describe it in detail, regarding to the concrete criteria evaluated and how it's done? Around the world there are two distinct philosophies about our expertise area. One defending it as simple General Medicine or General Practice, as you call it in the UK. Another one, besides covering General Medicine, also covering Family Dynamics, Child Health, Maternal Health and Preventive Medicine, as we do it in Portugal. What do you think about this two distinct philosophies and how do you imagine the future evolution of our expertise area? Will they evolute separately? Do you think one will be generalized and the other one extinct? About the revalidation program you must admit it can have some pernicious details if you don't carefully study the best way to do it. For example, it surely can't be based on industry biased conference presences. You must know what to value and how to value. Four more questions: 1. In the UK, how is it balanced the public and the private investment concerning the Health Care? 2. In your opinion, what is the general feeling of the British physicians about their working conditions? 3. In the UK, what is the average workload in a typical week? 4. In the UK, how is calculated a physician salary and how much he earns? Manuel, In the UK a “full time” general practitioner in his or her own practice (working as a partner or principal as we call it) works either four days or four and a half. They can be very long days so 50 hours would be very usual. For this they are paid between £90,000 (I know a very few who are beneath this) and £140,000 per year. The main/only income for most GPs is from the NHS but the variation is explained by the fact that the practice gets paid according to its number of patients (with adjustment to earn more for deprived, the elderly etc); the quality of care it offers (Quality and Outcomes Framework); the services it offers; and reimbursement of some costs. The practice then pays its staff, pays for the building etc and divides the rest among the GP Partners. Some GPs do other things privately (such as occupational health for example) and they either do this in their free time or they reduce their practice commitment (and earnings) in order to do these things. NHS Pensions are good – in general terms half of your pay with index linking through retirement. Many GPs now work as employed doctors, employed by the practice GP Partners to do half days in the practice – many are half time or more; some do single sessions in many practices. Such doctors should earn about £75,000 a year full time. The mood? Well, in all my 35 years in general practice I have never been able to say that the mood is good. My patients who are farmers will never say that it has been a good harvest – its either too wet or too dry; the yield was too low or the price wasn’t good enough. I know how they are doing by the cars they drive and the holidays they take. The same applies to GPs. They earn much, much more than they used to but are always complaining that it isn’t quite enough. They drive BMWs and Mercedes and holiday in the Maldives, but still complain that they are over-worked..... But I guess at present they are about as contented as they will ever be. Manuel, I have attached our Guide to the Revalidation of General Practitioners that will hopefully address your first question. Your second question is interesting. In the UK we agree with your position. Although we are now the “general physicians” of the health service we are far more than that. We are the clinical face of public health (public healthdoctors have retreated into commissioning). Most importantly, as you say, we are the only doctors who see and manage patients holistically as individuals, family members and community members; we manage their physical, social and psychological needs as far as we are able; we have long term relationship and we orchestrate their health care experience; and we are the only ones who live with their friends and families long after they have died. The essential for us family doctors is to define our expertise, be proud of it and ensure that it is valued. Our patients need, from time to time, orthopaedic surgeons and intervention radiologists. But they much more need us and the surgeons and investigators cannot do their job in any effective way (reference USA) without a strong and effective family doctor service. Mike Liliana Laranjo Dear Mike Pringle: Thank you for your active participation in this conference, it's being very interesting. My questions are: 1. What's the state of the art versus what is widely available/used in health information technology around Europe? 2. Are there any studies/articles concerning this matter that you would suggest that we read? 3. What is, in your opinion, the role of information and comunication technologies in the empowerment of the citizen and in health literacy? 4. What's your position concerning the development and implementation of personal health records (microsoft's health vault or google health, for example)? Are they already being used in the UK? Do you think they should be widely available there (NHS funding?)? 1. All general practices have and use clinical GP computer systems. These are very sophisticated and, for example, provide the NHS with information on the quality of care provided in order to pay GPs (a third of GP income comes from the Quality and Outcomes Framework). The use of electronic health records for other purposes is the subject of my lecture in the virtual congress. 2. I posted a report by Dr Alan Hassey done recently for the RCGP. If you want more than that please ask. 3. My view is that health care is a partnership. If I collapse with chest pain, it is a one-sided partnership: I expect decisions to be taken on my behalf with minimal intervention by myself. But if I were to have diabetes I would expect to be the expert on my diabetes and to look after it myself with information, education and support from health professionals. A key way to achieve this is through access to correct and timely information to supplement that given by my health professional. Many of my patients are very internet literate and ensure they know of best practice and the most up-to-date guidance. 4. In the UK we have well developed electronic records in primary care so the pressure for “patient controlled” records is less. However I do believe that it is the patient that owns the record. So I think in time we should move towards a copy of the patient’s record being available to and under the control of that person. If that record is kept by Google then we all need to be sure that they’ll keep it confidential, protect its integrity, record all accesses but facilitate research and secondary uses (see my presentation to the virtual congress). Mike
Maria Manuel Marques Hi Mike, Thanks for answering our questions, it has been really interesting to read this conversation. I have one question: Do you find important for family physicians to promote the speciality near the community? If so, what do you suggest to do that? Maria, GPs in the UK don’t usually “promote” their discipline. We are the public face of the NHS. We do over 250 million consultations (for a population of 60m) per year. We get public approval ratings in the high 90s per cent. People see what we do and, by and large, appreciate it. The big problems that lead to complaints are: Access – sometimes having to wait for non-urgent appointment (in bad practices for urgent ones too) Continuity – “I never see the same doctor twice” especially out of hours (now provided by organisations outside the practices Time – some people feel rushed. The average appointment length is 10 minutes but that can be insufficient. Late running – the GP or nurse running late causing the patient to wait Others – attitude, clinical competency, not giving patient the prescription or referral they wanted, poor facilities But by and large most people can see what we do and support us in doing it. Mike Lídia Oliveira: Hello Mike! We hope you are enjoying this brainstorm as we are, it is truly interesting to read all these answers! Thank you for your kindness. 1 - Could I ask you to make a description of your schedule? Like...how is your week like in terms of hypertension, diabetes, pregnant, children appointments...how is a GP's agenda organized normally? you spoke about 50 hours... do you manage to have quality free time? I know this is now quite a "scientific" matter but I'm really curious about this... 2 - Do GPs have any hospital activities? Any period of emergency? 3 - What program do you use for clinical records? Does it have a good acceptance among GPs? 4 - How often there are scientific meetings? Is there an opportunity to attend these events in your daily practice? 5 - How many patients you observe in a regular day of work? 6 - What advice would you give to a Portuguese GP who would like to work in the UK? What are the main differences which could affect initial adjustments? Sorry for all the questions... And thank you for reading! Dear Lidia, Thank you for your questions. I am an academic and do very little clinical general practice so I’ll respond as if I were a full time GP. Most GPs get to their surgery premises about 8 am and see their first patients at 8.30 am, consulting at 10 minute intervals through to about 11.30 am. There may be a few urgent patients to see then, a visit or two and paperwork. Then there’s likely to be a lunch time meeting (management, quality assurance etc). Early afternoon will be for special clinics, paperwork etc and then a surgery session will restart about 3 pm going through to 6.30 pm. After that there are the urgent patients and telephone consultations. We hope to leave the building soon after 7 pm. It is up to the GPs whether they work out of hours sessions for the local organisation – if they do they earn extra. My practice has four partners – one male and three female (I’m not a partner any more) – and three practice nurses. The practice nurses do triage (see urgent cases and deal with most of them); chronic disease reviews; contraception etc in addition to traditional nursing roles. They are supported by a health care assistant who takes most of the blood samples. We have a midwife who does all the antenatal care and community nurse who do home nursing. Lots of patients with chronic diseases come to the GPs but their routine checks are often done by nurses. Some GPs work sessions in hospitals as assistants. Perhaps they might develop an expertise in dermatology or gynaecology. Once trained they might offer their skills to the local practices as a direct referral – a scheme called “GPs with a Special Interest”. We all use computers for our clinical records with varying degrees of success. Most GPs are very proficient at creating electronic records. If there isn’t a lunchtime meeting in the practice then there may be a meeting at a local education centre to attend. Most areas have a scheme whereby all the practices close down for one half day a month (covered by the out of hours service) so that all the staff can attend educational meetings. Advice for a Portuguese doctor? Well, I’m not trying to recruit but to describe it as it is. I would suggest that you need to be very confident of your English; be prepared to “start at the bottom” by doing out of hours sessions and working as a locum (doing sessions; and I would ensure you have good social networks to give you support (this is a general point about working abroad). Mike Clara Fonseca Dear Mike, I had the great privilege of meeting you at the EGPRN conference in Bertinoro, where you participated as an extraordinary keynote speaker! Last week I was in Dubrovnik for another EGPRN meeting and some of our friends asked me to send you all their best (Javier from Spain and Pinard from Turkey). We are all in the photo that I send you, as a small token, with this message (for the participants in the CC2: Mike Pringle is the handsome gentleman at the left, just next to Tiago Villanueva, and I'm the second young lady from the right ). Tomorrow I'm going to participate in a conference and the theme of my lecture is "Research teaching in GP vocational training program", which is something I do here in Portugal. One of my key messages is that research must be part of the normal GP skills and that the figure of a practitioner-researcher should be promoted, instead of the practitioner vs researcher culture that we still have. I wonder if you agree with me... What would you say to convince them? Thank you very much for the time you are dedicating to us! I hope we'll meet again sometime. Best regards, Clara You are right in one way and, I’m afraid, I think not right in another. We need all general practitioners to have the skills to read and understand research and to integrate best evidence into their clinical practice. Good primary care research needs input by “ordinary” general practitioners in posing good and relevant questions; advising on the research; cooperating in data gathering (including finding cases and recruiting them); and helping with interpretation. However, research needs to be a professional activity and very few doctors manage to remain full time or near full time and still lead research. Just getting large grants requires massive input into applications. So I think we need both practitioner-researchers and researchers who still do clinical practice.... Mike Xavier Cos Dear all, I'm Xavier Cos. Luis Cavadas and Tiago Villanueva have invited me to join this forum. Unfortunatelly I couldn't be connected till today. My comment is related to the last comments of Mike. I think that it would be desirable that I physician could manage clinics and research properly, but that is only something ( in my opinion) exceptional. Research ,requires great doses of voluntarism, because our Health system don't recognized it as priority. At the same time many of the Europeans countries research in Primary, and primary care in its whole is not represented at the academic level (University). So it's time t begin, to start building a new frame. Pushing our authorities to include research in Primary Care as another point in their agendas. To promote those professionals who wish to leader a project like this. Ok Clara, Clinics+Research together, but we need the structure , the frame and in this frame it's necessary that some opinion leaders would developed the work just for this field. When we already have the frame (the structure) we will be able to enrol those professional in Primary Care, and give them facilities and possibility to network with other. Sometime this professionals would like o work harder and develop a major project, and maybe i that situation will be better to stop doing clinic just to concentrate in one area, research. Congratulaion for this iniciate, Dr. Francesc Xavier Cos Director Sant Marti de Provençals Primary Care Centres. Barcelona. Spain. Vice Chairman Primary Care Diabetes Europe
Xavier, Good to hear from you! And I agree. We need to build the academic capacity in the Universities and medical schools. Juan Gérvas Dear Mike: It is a pleasure to meet you again, now at this virtual conference. I am here because my close contact with the Portuguese colleagues, being a member of their electronic list, and my previous participation in the first conference. As usual, your are direct and honest, so the picture you draw is clear even when refering to grey zones. Thanks for all. One of these grey zones refers to research and general practice. As I see the situation, research is a professional activity when we are speaking about the "process" (data mining, statistics, bureaucracy, and so on), but a free lance activity when refering to "creativity" (generation of hypothesis, interpretation of results, clinical application of the outcomes and so on). The "process" is a very boring activity, a very simple one, in my opinion, as most methods have a routine of work and it is easy to produce the desire "elegance" (to follow the rules). This is the reason why most research has no external or clinical interest, because it is the outcome of methods, no ideas. In my opinion GPs could and must lead research if we want/need research that helps in improving the quality of the clinical work and the quality of our patients lifes. Of course, usually with a professional group which care of the process. I say "usually" because we need also research without statistics as "numbers" are not always essential. Making research, as I see it, implies a starting point (generation of hypothesis), an intermediate process ("the process") and a final interpretation and application of the results. GPs are essential in the beginning and at the end. Professionals are essential in the intermedite process. Of course, some GPs might devote full time to research and cover the whole picture. Best regards from Spain, two months before leaving the clinical work to devote my time to teaching and research activities (I am now 60 years old, seeing patients from the 18) Juan Gérvas Juan, Great to hear from you again. And I too am in the process of finishing patient care! I think we are totally agreeing – you said what I wanted to say so much more eloquently. Mike Bruno Heleno Dear Prof Mike Pringle, Thank you for this e-conference. I'd like to post a few questions: 1) I've read that Conservative party has proposed major changes to patients' access to electronic medical records in the UK. The most significant of which is allowing patients, not only to access their EMR at home, but also to add information they find relevant to their record. What opportunities and threats do you see in this? Will we be seing this in a near future? 2) You've mentioned that in the future, EMR would allow to improve patient safety. How can this be done? How does this "error traping" work? 3) This might be a bit off topic... I've read with great interest the discussion about the role of researchers who still practice and research practicioners. From what I've been seeing during my residency, I believe that a huge leap in portuguese primary care research will be made in a near future. I think, however, that we are still in dire need of PhDs and PhD students in our field. I'd like to ask you how many PhD programmes in general practice / primary care do you know of in the UK? Where can I learn more about application requirements and funding? Is it possible to be enrolled in a PhD programme and have one day in the week to be working in a GP practice? Thanks in advance, Bruno Bruno, Thanks. My answers are: 1. Increasing access to medical records, especially the summary records, is general policy but the Conservatives have endorsed it. HealthSpace allows this and will in time allow comments and data (drug reactions, blood pressure readings etc) to be added by the patients. It is not clear how these comments/entries can get back into the GP record. However, otherwise I am very supportive of the whole idea of the clinical record as being co-produced in a meaningful partnership. 2. EMR and patient safety: When I prescribe on my clinical computer it checks for the drug spelling and offers only correctly spelt drugs (I cannot enter a free text drug name – it reminds if there is a common confusion – penicillin and penicillamine for example). It then offers only recognised regimens and doses. I can create a new regimen but the fact that I am doing so is a warning that I may be wrong. It checks for paediatric and elderly doses. When I press the prescribe button the computer checks for recorded allergies or reactions to that drug, and for interactions with other prescribed drugs. When I prescribe something that can be taken for a period of time I specify a review interval and the patient cannot order the drugs after that date without a first warning and then a block. I could go on. The computer warns me if I try to prescribe a beta blocker in asthma.... 3. PhDs are not rare in UK medicine. Most of my generation have MDs. Such higher degrees are very necessary for those who will DO the research but are less necessary for those who will suggest ideas, support research and contribute to interpretation. In Nottingham we have quite a few PhD students in my school but very few at present are also medical doctors. I hope that helps. Mike Mike Pringle Dear all, First, thank you very much for inviting me into your email group. I'm impressed with the vibrancy of your discourse and the breadth of subjects you cover. In terms of my participation, there have been, I think, four themes: Theme 1: The work and roles of GPs in the UK and Portugal. Although I highlighted some differences, clearly the similarities are much greater. The consultation, the key to primary care, must be essentially the same; health needs will be very similar; and therapies are identical. The main differences, as we discussed, rest on political decisions (contract, investment, assigned roles) and perhaps culture (societal expectations etc). Theme 2: Electronic medical records. This was the subject of my contribution to the virtual congress (not a lot of input there - not sure if that's a great success at present). However, we discussed the role of the EMR in general practice (fully integrated with our work and supporting "patient safety") and the slow moves to use EMRs throughout the health service (slowest in hospitals) and to link them up. Theme 3: Revalidation. This was an early topic and the discussion was interesting for me for the positive view that many of you expressed. I believe that revalidation will inevitably come to all European countries and to all health professions (in the UK the nurses are beginning to consider it). However the system for revalidation in the UK needs to develop and prove itself first. So I think you probably have a decade before it hits you! Theme 4: Primary care research. Your enthusiasm for the research agenda is very gratifying. I think we arrived at a consensus: All GPs need to be able to use research (understand papers and systematic reviews, and to be able to translate that into their practice); some/most need to support research by posing research questions, helping to gather evidence and assisting in interpretation; and a few need to develop the skills to lead research. The later need to be part of traditional research environments such as Universities, but they must retain contact with "real general practice" so that their work remains relevant. It is perhaps this last group that is missing in Portugal. Without "professional researchers" you will not get access to research grants, infrastructure and publications.
This has been a really simulating experience for me. I look forward to meeting one or two of you in Glasgow next week. If I can be of help to any of you in the future. Please ask. Mike Comentários / Comments Se desejar, pode enviar os seus próprios comentários aos temas abordados na conferência. Os memos serão colocados online, nesta página. If you want, you may participate and post your own comments here:
1 comment posted 09/12/2009: Dear Luis and Tiago, what a great idea and initiative you are successfully pursuing with this virtual Conference portal! I enjoyed reading your vivid and very challenging discussions (you have made even witty Mike Pringle sweat sometimes, I could tell, am I right, Mike? ;-) and it was a supreme pleasure to see the names of so many friends in this forum, hi everybody! It is wonderful to follow the success of la jeuness de GP/FM in Europe and I think, you do not only produce the evidence that GP/FM is on an upward trend, I think you are part of this evidence! My favourite topic in this discussion was revalidation, by the way. Thanks to all contributors of this interesting and challenging conference and regards from Istanbul, Pinar
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