1. GP 4001 Lecture Series 2007-2008 1. Introduction

2. What I plan to cover today Learning outcomes for the courseLearning outcomes for the course Evaluation and assessment of this courseEvaluation and assessment of this course How general practice differs from hospital medicineHow general practice differs from hospital medicine Nature and scope of general practiceNature and scope of general practice

3. Learning Outcomes for this course - I Develop a rapport with patients such that patients are at ease in discussing their health problem(s) (comm)Develop a rapport with patients such that patients are at ease in discussing their health problem(s) (comm) Gather appropriate information on the patient’s health problem(s) including information on the patient’s own perspective on the problem(s). (udp, comm)Gather appropriate information on the patient’s health problem(s) including information on the patient’s own perspective on the problem(s). (udp, comm) Generate a reasonable range of diagnostic possibilities for undifferentiated medical problems presented by patients (udp)Generate a reasonable range of diagnostic possibilities for undifferentiated medical problems presented by patients (udp) Investigate these diagnostic possibilities using appropriately focused history taking and selective physical examination (udp, comm)Investigate these diagnostic possibilities using appropriately focused history taking and selective physical examination (udp, comm)

4. Learning Outcomes for this course - II Construct a general model for the safe and effective management of patients with multiple and long term health problems (cdm)Construct a general model for the safe and effective management of patients with multiple and long term health problems (cdm) Adapt this model to the long term health problems commonly encountered by doctors (cdm)Adapt this model to the long term health problems commonly encountered by doctors (cdm) Construct an appropriate and feasible management plan to deal with the physical, psychological and social aspects of patient’s problem(s) (udp, cdm)Construct an appropriate and feasible management plan to deal with the physical, psychological and social aspects of patient’s problem(s) (udp, cdm) Negotiate this plan with the patient. (comm)Negotiate this plan with the patient. (comm)

5. Learning Outcomes – three principal domains Dealing with undifferentiated problems presented by patients (udp)Dealing with undifferentiated problems presented by patients (udp) Management of chronic ill health (cdm)Management of chronic ill health (cdm) Communication (comm)Communication (comm)

9. Assessment and Evaluation AssessmentAssessment End of year exam – MEQ formatEnd of year exam – MEQ format GP attachment assessment by GP tutorGP attachment assessment by GP tutor Diagnostic thinkingDiagnostic thinking Patient managementPatient management Attitudes to patients and staffAttitudes to patients and staff Responsiveness to teaching and enthusiasm for learningResponsiveness to teaching and enthusiasm for learning EvaluationEvaluation Will be asked to complete an on-line evaluation by MarkClassWill be asked to complete an on-line evaluation by MarkClass In class evaluation exercises throughout the yearIn class evaluation exercises throughout the year

10. How general practice differs from hospital medicine I - the nature of illness seen General PracticeGeneral Practice non-illness & disorganised illnessnon-illness & disorganised illness acute self-limitingacute self-limiting chronic stablechronic stable all age groupsall age groups mixed physical, psychological and socialmixed physical, psychological and social HospitalHospital nearly all clear cut disease acute life threatening acute-on-chronic categorised by age physical and psychologial divided - virtually no social

11. GP v Hospital morbidity by selected ICD categories I

12. GP v Hospital morbidity by selected ICD categories II

13. Spectrum of morbidity in General Practice

14. Bio-psycho-social diagnosis (a.k.a. ‘tri-axial diagnosis’) Diagnosis inDiagnosis in physicalphysical psychologicalpsychological and social termsand social terms Note - not either/ or but degrees of eachNote - not either/ or but degrees of each A manifestation of ‘holistic’ medicine - non-reductionistA manifestation of ‘holistic’ medicine - non-reductionist Philosophically breaking down Cartesian dualism - the ‘mind-body split’Philosophically breaking down Cartesian dualism - the ‘mind-body split’

15. Common problems seen in general practice - Physical Respiratory tract - colds, flu, asthma, bronchitisRespiratory tract - colds, flu, asthma, bronchitis Gastro-intestinal tract - D&V, gastroenteritis, peptic ulcer, irritable bowelGastro-intestinal tract - D&V, gastroenteritis, peptic ulcer, irritable bowel Cardiovascular - IHD, hypertensionCardiovascular - IHD, hypertension Musculoskeletal - backache, OA, soft tissueMusculoskeletal - backache, OA, soft tissue Endocrine - diabetes, thyroid diseaseEndocrine - diabetes, thyroid disease Genito-urinary - cystitis, STDsGenito-urinary - cystitis, STDs

16. Common problems seen in general practice - Psychological Adjustment reactions e.g. grief reactionAdjustment reactions e.g. grief reaction AnxietyAnxiety DepressionDepression Mixed anxiety-depressionMixed anxiety-depression Drug and alcohol problemsDrug and alcohol problems Chronic stable schizophreniaChronic stable schizophrenia Post-traumatic stress disorderPost-traumatic stress disorder

17. Common problems seen in general practice -Social Relationship difficultiesRelationship difficulties Job dissatisfactionJob dissatisfaction Effects of poor housingEffects of poor housing Effects of unemployment/ social deprivationEffects of unemployment/ social deprivation Lack of educationLack of education

18. How general practice differs from hospital medicine II - Organisation General PracticeGeneral Practice small units, non- institutionalsmall units, non- institutional non-hierarchical teamsnon-hierarchical teams low techlow tech easily accessibleeasily accessible HospitalHospital large institutional units highly hierarchical teams high tech filtered access

19. Levels of care Regional Hospital General hospital General practitioner Self care 1,000,000 20,000 2,000 5 People looked after location of care

20. The illness ice-berg HEALTH PRE-SYMPTOMATIC DISEASE SELF-CARE MINOR ILLNESS MAJOR ILLNESS

21. The ‘gate-keeper function’ Controls access to more expensive secondary care resourcesControls access to more expensive secondary care resources Necessary (essential) for cost- containmentNecessary (essential) for cost- containment Appropriate specialist selected for patients who need oneAppropriate specialist selected for patients who need one Avoidance of hazards of specialist care for patients who don’t need itAvoidance of hazards of specialist care for patients who don’t need it Maintenance of skills of specialistsMaintenance of skills of specialists

22. The ‘amoeba’ that is general practice (after Metcalfe, David) HOSPITAL PRIMARY CARE SOCIETY Capital intensive Labour intentsive Hierarchical Low capital Lean manpower Non- hierarchical ageing increasing chronic morbidity declining family ties changing attitudes to professionals polico-economic change ecological change Stiff interface Fluid interface

23. Recommended Textbooks Pocket Essentials of General Practice by Colin Bradley Saunders/ ElsevierPocket Essentials of General Practice by Colin Bradley Saunders/ Elsevier ISBN 13-978-0-7020-2648-5 A Textbook of Family Medicine by Ian R. McWhinney Pub Oxford MedicalA Textbook of Family Medicine by Ian R. McWhinney Pub Oxford Medical ISBN 0-19-515518-X General Practice by John Murtagh McGraw-Hill EducationGeneral Practice by John Murtagh McGraw-Hill Education ISBN: 0074711776