The BJGP publishes videos and multimedia to highlight research findings, clinical impact, and top 10 articles. Here's a selection of BJGP videos. See BJGP YouTube playlist on RCGP's YouTube for more videos and updates. Also see BJGP's new YouTube channel. Accompanying podcasts are available at BJGP Audio. 

 

Remote consultations and dementia during COVID-19

New research from University College London shows that remote healthcare consultations with patients with dementia are easier for issues like medicines, but new issues and physical signs are more difficult when remote. Remote consultations that were described as feasible were mostly by telephone and managed by the carer. Practitioners engaging with people living with dementia and their carers should make extra effort to ensure the efficacy of remote healthcare consultations, addressing difficulties by encouraging use of prompts to remember problems, assessing new emerging issues, rescheduling/missed calls, and inclusion of the person with dementia’s voice. Listen to the podcast interview with Remco Tuijt.

 

Trans men and non-binary UK cervical screening

Dr Alison May Berner discusses new research on cervical screening for trans men and non-binary people. She explains that trans men and non-binary people assigned female at birth (TMNB) experience barriers to accessing adequate cervical screening at personal, interpersonal, and institutional levels, and are less likely to engage in screening than cisgender women. Findings show that many trans men and non-binary people don’t have hysterectomies, 10% clearly do not want a hysterectomy, and 35% are not sure. Unfortunately, current NHS recording of sex/gender as only male or female misses trans men from the screening register. Cervical screening uptake could be increased with improved training for providers, more inclusive clinical environments, and by embracing new testing methods such as self-taken swabs. More information is available from Jo's Cervical Cancer Trust.

 

Which patients miss appointments?  

New research reveals how many primary care appointments are missed, reasons given for this, and what characteristics are commonly associated with missed appointments. Main points discussed in the video:
– In this systematic review 3–48% of appointments were missed 
– Family and work commitments were common reasons 
– Weather, transport, and feeling better were other reasons 
– Doctor–patient relationship and miscommunication were relevant 
– Monday appointments were likely to be missed  

Those from minority ethnicity, low socio-demographic status, and younger patients were more likely to miss appointments. This research is important in addressing the estimated 15 million missed appointments annually in England, costing NHS England £216 million per year. 

 

CKD: inappropriate prescribing 

Potentially inappropriate prescribing in primary care is common in chronic kidney disease and existing prescribing recommendations are often non-specific and relatively unhelpful to clinicians. In this video, Dr Clare MacRae explains that: BNF renal impairment warnings are heterogeneous in terminology; almost 4% of patients were prescribed a drug with a clear ‘contraindicated’ warning; and ‘potentially high risk’ drugs were prescribed in almost 1/4 of patients. High risk prescribing in CKD contributes to adverse drug reactions, unintended harmful events attributed to the use of medicines, and drug-related acute kidney injury (AKI). People with CKD have poorest health outcomes after drug-related AKI, specifically being most likely to have additional loss of kidney function, require dialysis, and die. Adjustment of medications according to kidney function, and avoiding medications that increase the risk of kidney damage, can slow progression of kidney disease and reduce rates of illness.

 

Discontinuing long-term antidepressant use

Discontinuation of long-term antidepressants is more than a simple deprescribing decision. New research shows a repeat prescription should not be considered as ‘just a script’ consultation. Deprescribing begins with considering a patient's social and relational context, and is a journey involving careful preparation, tailored care and regular review. This study suggests GPs need clinical time to do the complex contextual and relational decision-making around diagnosis, prescribing and discontinuing antidepressants. A request for a repeat prescription should always come with a review of whether this medication is still required. Deprescribing is an important consideration, particularly as long-term antidepressant use is on the rise, most antidepressant prescribing takes place in general practice, and about one-third of long-term users have no clear reason for continued use. Listen to the podcast with Associate Prof. Riitta Partanen.

 

GPs’ gut feelings for assessing cancer risk

The use of gut feelings has often been described in primary care, and bodies like NICE are beginning to recognise clinicians' judgement in their guidance. This study shows how, rather than being used in isolation, gut feelings prompt evidence gathering and discussion with colleagues that can benefit patients with symptoms that don't easily fit with clinical guidelines. GPs use their gut feelings to prompt building a case for accessing further investigations, by re-examining the reasons why the patient came to them, how their presentation fits with clinical guidance, and seeking second opinions from their colleagues. Experience was seen as important to the development of reliable gut feelings, but so too was empathy and the GPs' relationships with their patients which allowed them to notice the subtle changes that could make them think: 'Something is not right here and I need to find out what it is'. Read the new qualitative research and the associated quantitative article. 

 

BJGP Webinar on Health Inequalities​ ​

It is 50 years since the ‘Inverse Care Law’ was introduced by Dr Julian Tudor Hart. In recognition of the totemic article, the BJGP hosted a free 1.5-hour webinar on health inequalities, with a video introduction from Prof. Sir Michael Marmot. The webinar focused on recent research and analysis from leading primary care researchers, in the form of short presentations. Visit BJGP Webinars for upcoming events and join the Twitter discussion at: #BJGPwebinar.

Jump to various sections in the video by following the links: 00:00 BJGP Editor, Dr Euan Lawson, opens the webinar. 01:07 Webinar chaired by Dr Carey Lunan, GP, Chair of the Deep End Project, and former Chair of RCGP Scotland; Dr Lunan introduces Prof. Sir Michael Marmot. 03:59 Prof. Sir Michael Marmot speaks on 50 years of the Inverse Care Law. 16:42 Prof. Simon de Lusignan, Professor of Primary Care and Clinical Informatics, University of Oxford: Excess mortality in the first COVID-19 wave. 29:54 Dr Sarah Hillman, GP and Clinical Lecturer in Primary Care, University of Warwick: Socioeconomic status and HRT. 43:55 Prof Paramjit Gill, Professor of Primary Care, University of Warwick; Trustee, South Asian Health Foundation: BME minorities and COVID-19. 01:02:22 Q&A Panel Attendees’ questions. 01:26:11 Close and final comments by Chair: sum up of '3 things we can take back to our practice'.

 

Group consultations in UK general practice ​

New research by Dr Laura Swaithes and colleagues at Keele University suggests group consultations provide an enjoyable interaction between general practice staff and patients. Seeking interviews with general practice staff from a range of disciplines, the research revealed that group consultations may enhance multidisciplinary working, provide the opportunity for more patient-centred care, and reduce workload. With GPs and nurses reporting high levels of stress and burnout, primary care needs to adapt and deliver new models of care to ease workload pressures. Could group consultations be the future?

 

Doctors experiencing domestic abuse

Female doctors face unique barriers to help-seeking and reporting domestic abuse. The work environment is often experienced as unsupportive, victim–survivors often do not feel able to talk about the abuse confidentially, and they fear consequences of reporting. Domestic abuse among doctors needs to be acknowledged by NHS workplaces to ensure suitable policies are in place. Dr Emily Donovan discusses the impact of domestic abuse on doctors experiencing partner violence. Listen to the podcast interview. If you have been affected by the issues raised here, visit Refuge or Women's Aid.

 

Comorbidity in chronic kidney disease

New research has found that almost all people with CKD have coexisting comorbidities, and that extreme comorbidity is over 40 times more common in adults with CKD compared with controls. As increases in medications with more long-term conditions may harm the kidneys, the authors call for guidance to assist clinicians in treating CKD that takes into account other illnesses. This study compared over 1 million people in Scotland, and found that almost all physical and mental health conditions are more common in people with CKD. Investigating this complexity will help identify new ways of treating people while reducing the risks of simultaneous treatments. Dr Clare MacRae discusses this in a podcast.

 

BJGP Top 10 research – articles most read and published in 2020

This collection of Top 10 research most read and published in 2020 brings together high-profile primary care research and clinical innovation. Congratulations to Top 10 authors and all BJGP contributors in 2020!

BJGP Top 10 research: 1. Gut feelings,  2. Chronic kidney disease, 3. Paramedics in primary care, 4. COVID-19 and older adults, 5. GP burnout, 6. Methotrexate safety, 7. Oseltamivir for coronavirus, 8. COVID-19 and ethnicity,  9. Cancer risk, 10. Sepsis referral with NEWS.

 

Targeting treatment for depression with Target-D​

New research examines a self-administered tool for depression. This RCT shows that 'Target-D', a person-centred clinical prediction tool and e-health platform matching management options to prognosis, results in greater improvement in depressive symptoms at 3 months than usual care. Target-D is administered via a set of questions on a tablet in the waiting room. Within minutes patients receive feedback and a suggestion of next steps for treatment. This approach could feasibly be implemented in routine practice to support more efficient and effective depression care without adding to GPs’ workload. Listen to the podcast interview with Prof. Jane Gunn.

 

Psychosis risk

GPs rarely encounter patients with psychosis, but more commonly see patients with psychotic symptoms that do not meet diagnostic criteria for psychotic disorder, such as hearing voices or having paranoid beliefs. One-third of these patients at risk will go on to develop psychosis within 3 years. Findings in this new study show that some GPs were not familiar with the concept of being at-risk of developing psychosis. Also, when patients met criteria for a more common mental health condition, such as depression or anxiety, GPs would not always screen for psychotic symptoms. In the podcast and video, Prof. Stanley Zammit and Daniela Strelchuk explain ways that GPs can screen for psychotic symptoms.

 

Media depictions of remote consulting throughout COVID-19

This new study by Oxford academics, led by Professor Trisha Greenhalgh, looked at newspaper coverage of the shift to remote consultations. It found that media depictions of remote GP consultations in the early months of the pandemic linked GPs with progress, efficiency, and safety; whereas media reports in more recent months have emphasised missed diagnoses, challenges to the therapeutic relationship, and digital inequalities. Perhaps rightly, the press have questioned why a policy originally introduced for infection control was then made permanent. Listen to the podcast interview with Dr Gilly Mroz and Professor Trisha Greenhalgh.

 

Reducing missed appointments

Missed appointments, or DNAs ('did not attends'), come at a great cost to general practice. While most view DNAs as a patient problem, this study, supported by the Health Foundation, highlights the appointment system itself as an integral cause of DNAs. This study shows the impact of quality improvement coaching, including sharing appointment system data, among practices. The findings illustrate how structural change to the appointment system can produce sustained reductions in DNA rates. Listen to the full podcast interview with Dr Tom Margham.

 

Association of non-malignant diseases with thrombocytosis

Previous research shows 11% of people with high platelet count in primary care are diagnosed with cancer in the following year. But what about diagnosing the 89%? A new study from the same team at University of Exeter flags up likely conditions. They found that inflammatory bowel disease, iron-deficiency anaemia, rheumatoid arthritis, COPD, and giant cell arteritis were more likely in patients with thrombocytosis than in those with a normal platelet count.

 

Recognising end of life in older people

Identification of end of life can be challenging for clinicians, particularly in older people living with frailty. In this study, fewer than half of people aged ≥75 years who died had a code in their electronic health record (EHR) to suggest that their death was anticipated by their GP. End-of-life codes in EHRs were entered near to death (median 4 months prior). In the minority of older decedents (aged ≥75 years) for whom end of life was recognised, only a small proportion were on the palliative care register or had their preferences for place of care or death recorded.

 

Mortality in the first COVID-19 pandemic peak

The COVID-19 pandemic has passed its first peak in many countries in Europe. A study from the University of Oxford examined the characteristics associated with excess deaths in the first COVID-19 pandemic peak. Findings were that male sex, population density, black ethnicity, and people with long-term conditions, including learning disability, had higher odds of mortality. Planning for subsequent peaks should take account of these findings. Listen to the podcast interview with Professor Simon de Lusignan.

 

Pregnancy abnormalities from ACE inhibitors and ARBs 

The adverse effects of ACE inhibitors and ARBs for pregnant women and their babies are known, but the recording of pre-pregnancy advice when prescribing these drugs is suboptimal, according to a new study from Queen Mary University of London. The study was conducted across 140 general practices in East London in women aged 15-45 years who were issued a prescription for an ACE inhibitor or ARB. Of over 300,000 women, 2651 were prescribed an ACE inhibitor or an ARB; and of these, 81.4% had no record of contraception prescription. Dr Elizabeth Lovegrove discusses the findings and their clinical relevance in a podcast interview.

 

COVID-19: twice the risk for ethnic minorities

Research by Hull et al. shows patients with south Asian and black ethnicity are at increased risk of suspected COVID-19, even when we take into account multimorbidity, obesity and social deprivation. This study of GP records also shows that GPs were adept at distinguishing symptoms of COVID-19 from common respiratory infections and saw large numbers of suspected cases. Daily counts of suspected cases recorded by GPs can act as an early warning system to detect new outbreaks of disease in the future. Watch the interview with Dr Sally Hull, who emphasises the importance of GPs recording and managing cases in their community.

 

Legacy of grief and COVID-19

Iona Heath, Former President of the RCGP, writes of the many unexpected kinds of grief from COVID-19. She states: ‘It will be very important to resist the temptation to pathologise, label, or precipitately refer on the sequelae of grief’. She emphasises we must acknowledge that some communities, particularly those subject to the structural violence of poverty and racism, have been significantly more exposed to loss of parents, life partners, children, and dear friends. She describes the power of relationship-building as an investment that has the potential to make future care easier for both patient and GP.

 

GPs' gut feelings in cancer diagnosis

A systematic review suggests GPs' gut feelings may have a role in cancer diagnosis. The studies, which used varied conceptualisations of 'gut feelings', showed associations with patients initially being unwell rather than with a suspicion of cancer. Pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded, and became more predictive of cancer as clinical experience and familiarity with the patient increased. This may encourage GPs to acknowledge the diagnostic value of gut feelings and have more confidence in including them in their clinical assessment. Claire Friedemann Smith explains the findings in a video interview.

 

Racism and health​​

Dr Carter Singh is a full time GP partner at Willowbrook Medical Practice, Nottinghamshire. An 'expert-by-lived-experience' in racial inequality, it is this passion that motivates him to challenge discrimination, inequality, and marginalisation in the NHS. The August issue of the BJGP publishes Dr Singh’s letter on Asking questions along with an Editorial on Racism and Health by Paramjit Gill and Virinder Kalra, and an Editor’s briefing on Prejudice Plus Power = Racism. Life & Times looks at BAME excess deaths and chronic stress by Sarah Evans, Conversations about race and abuse in the NHS by Tariq Hussain, COVID-19 and equity by Gemma Ashwell et al, and indigenous health in the COVID-19 torch by Tim Senior. View the full contents of the August BJGP.

 

Unsafe prescribing of methotrexate

GPs in England continue to breach national guidelines on tablet strength designed to avoid accidental methotrexate overdose, according to research on trends in prescribing of methotrexate. High doses of methotrexate increase the risk of toxicity and 21 deaths have been attributed to methotrexate from 1993 to 2017. Doctors are advised to avoid 10mg tablets and prescribe only 2.5mg tablets. Here, Brian MacKenna, Pharmacist Researcher – University of Oxford, from the Evidence-based DataLab discusses the findings. Also watch videos on Practice and OpenPrescribing at BJGP Life.

 

Avoid the term ‘morning sickness’

According to new research, ‘morning sickness’ is a misnomer. It can happen at any time in a 24-hour period. In a video interview, author Professor Roger Gadsby explains why GPs should drop the unhelpful name ‘morning sickness’. He states that many pregnant women feel that it trivialises the problem. In an accompanying video interview Caitlin Dean, researcher, nurse specialist, and mother, states: 'Telling her she's got a bit of morning sickness is the most invalidating and upsetting thing you can do’. She asks that GPs talk about it in terms of ‘nausea and vomiting’. Article and videos are all available via ArticlePLUS. 

 

Hospitalisation and homelessness

Homeless people registered at a specialist surgery who had a combination of chronic physical illness, mental illness, plus alcohol and/or drug dependence – known as ‘trimorbidity’ – were four times more likely to have an unplanned hospital admission. The study, conducted in a specialist homeless practice in Brighton, showed that the three significant risk factors were enduring mental health problems and/or personality disorder, gastrointestinal disease and alcohol dependence. Catherine Himsworth discusses the findings in this short video.

 

Paramedics in primary care

The role of paramedics is expanding beyond the ambulance service into general practice. Georgette Eaton, herself a paramedic, and colleagues from Nuffield Department of Primary Care Health Sciences, University of Oxford, explored the role of paramedics in primary care.

 

Professor Martin Marshall at the BJGP Research Conference

BJGP Research Conference Plenary 1: The importance of research in taking the NHS into the next decade. Professor Martin Marshall, 12 March 2020, RCGP London. https://bjgp.org/conference | #BJGPRC

 

Dr Richard Vautrey at the BJGP Research Conference

BJGP Research Conference Plenary 2: The NHS and the current political climate. Dr Richard Vautrey, 12 March 2020, RCGP London. https://bjgp.org/conference | #BJGPRC 

 

Early GP referrals lead to longer surviving cancer patients​

A study analysed data of 1.4 million patients with cancer in England, and found that cancer patients from the highest referring GP practices had a lower mortality rate. The research highlights increases in primary care referrals and access to diagnostic tests which allows more cancers to be diagnosed. This has also led to the number of people diagnosed with cancer following an A&E presentation to drop from 1 in 4 to fewer than 1 in 5. 

 

BJGP Top 10 research

Countdown of top 10 research articles most read and published in 2019 – 10. End-of-life admissions, 9. Online triage, 8. Video consultations, 7. UK newspaper coverage of GPs, 6. Brain tumour diagnosis, 5. Inflammatory marker testing: sensitivity, 4. Hospital admissions of frail older people, 3. Multiple inflammatory marker testing, 2. Medication reviews, 1. Asylum seeker health. 

 

Safety netting to avoid missed diagnoses

The diagnostic strategy of safety-netting is examined by Edwards et al. who found use of safety netting in almost two-thirds of consultations, but actions required by patients were not always documented. In an accompanying paper, Edwards et al. report the development of a coding tool. Formalising safety netting may be particularly important in patients with low risk but not ‘no risk symptoms’ suggestive of cancer.

 

BJGP's impact, readership, and peer review

Find out in 90 seconds why authors publish with us. The BJGP publishes high-quality research and has the highest impact factor of all primary care journals worldwide, reaching 4.43 for 2018; additional journal metrics are the 5-year impact factor 4.187, Immediacy Index 1.380, Eigenfactor 0.00937, and Article Influence Score 1.370. View download statistics and top Altmetric scores, plus time from submission to first and final decisions.

 

BJGP's clinical research impact

The BJGP publishes high-quality research with clinical impact. This video shows the impact of research on: 1. Detecting multiple myeloma, 2. Avoiding unnecessary thyroid tests, 3. Recognising testicular cancer, 4. Detecting atrial fibrillation, 5. Cancer safety netting, 6. Extending prescription length, 7. Investigating weight loss, 8. Responding to maternal non-attendance, 9. Shortening antibiotic treatment for sore throat, 10. Prescribing exercise for postnatal depression, 11. C-reactive protein and acute cough.