Deep Breath In: a podcast for GPs
Tackling primary care’s everyday challenges
Life in primary care can be complex. Deep Breath In explores the highs and lows of being a GP, offering a space to reflect on the grey areas of general practice.

Deep Breath In

As Ramadan draws near, clinicians may be approached by their Muslim patients to discuss managing their health conditions during the month of fasting. How should someone with a chronic condition, such as diabetes or epilepsy, time their medications during this period? Can a person who’s pregnant or breastfeeding partake in fasting? What alternative options are available to someone whose health needs make participating fully in fasting too risky? 

In this week’s episode, we discuss the many questions doctors and patients may have around this topic with Ammad Mahmood and Sahira Dar, authors of a recently published article in The BMJ on advising patients with existing conditions about fasting during Ramadan, and talk about the importance of individualised advice and shared decision making.

Our guests:
Ammad Mahmood is a neurological trainee, currently undertaking a PHD in stroke imaging at the University of Glasgow.
Sahira Dar is a GP, practising in Glasgow, with special interests in lifestyle medicine and mental health issues.

Further reading:
‘Advising patients with existing conditions about fasting during Ramadan’ by Ammad Mahmood, Sahira Dar et al. https://www.bmj.com/content/376/bmj-2020-063613

Ramadan with Ammad Mahmood and Sahira Dar

Diagnosis is a complex categorisation task driven by mental models  that reside in long term memory. Through education and experience, clinicians form scripts that encapsulate their knowledge of specific conditions and develop diagnostic schemas that structure their approach to a specific health problem. 

This cognitive process also intersects with systems, teamwork, and social factors that can enhance or reduce diagnostic accuracy.

In this podcast, we hear about five techniques that can help with the accuracy of those mental models, and mitigate against some of the external factors which may reduce diagnostic accuracy.

Our guests;

Hardeep Singh trained as a GP before moving to becoming a general internist and professor of patient safety research at Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston.

Denise Connor is an associate professor of medicine at University of California San Francisco and a practicing internist at San Francisco Veterans Affairs Medical Center.

Gurpreet Dhaliwal is a general internist at the San Francisco Veterans Affairs Medical Center, and a clinician educator.

Diagnostic excellence with Hardeep Singh, Denise Connor, and Gurpreet Dhaliwal

We see patients all the time who ,more than any drug or cure, just want an explanation for their symptoms, to understand why they feel the way they do.

But giving an explanation isn't necessarily straightforward, we're unsure  of the diagnosis, we might worry about how the explanation might be received, or a 10 minute appointment just isn't time to go into all the details.

In today's episode, we've enlisted the help of consultation skills expert, Roger Neighbour, and hear how important a great explanation is from The BMJ patient editor Amy Price.

Our guests:

Roger Neighbour is a retired GP and a former president of the Royal College of GPs. He has written the books on consultations skills, and teaches courses on how to put those skills into practice.

Amy Price is a patient, a researcher editor for The BMJ's patient and public partnership, and a senior research scientist at Stanford School of Medicine.

Great Explanations

With the focus on covid, and the pressure on hospitals, it may be easy to overlook what’s happening in general practice in the UK - but changes are afoot. Our new health secretary Sajid Javid doesn’t seem to like our long standing GP practice arrangement, NHS England has imposed new weekend working arrangements on the already stretched service, and the workforce pressures continue.

In this episode of Deep Breath In, our GP panel of Tom Nolan, Navjoyt Ladher, and Jenny Rasanathan are joined by Gareth Iacobucci, The BMJ’s assistant news editor, to give them the lowdown on what’s happening around primary care, who some of the key players are, and what his predictions for 2022.

What's in store for general practice in the UK

Parosmia – a distorted sense of smell, and a delayed post-covid symptom – affects approximately 50% of people who experienced loss of smell during their initial covid infection, and it is currently attracting a lot of media attention. We hear from Emily Woodroofe, a third year medical student, about what it’s like to have parosmia, before we speak to Professor Claire Hopkins about what GPs need to know about it, and how they can best support their patients who are experiencing what can be a distressing symptom.


Our guests:

Emily Woodroofe is a third year medical student at Barts and The London School of Medicine and Dentistry.

Claire Hopkins is an ENT consultant, and professor of Rhinology at Guy’s and St. Thomas’ NHS foundation Trust.


Further reading:

‘Parosmia—a common consequence of covid-19’ https://www.bmj.com/content/377/bmj-2021-069860

Parosmia with Emily Woodroofe and Claire Hopkins

Consultations about suspected cow’s milk protein allergies are quite common in primary care, but these allergies can be a challenge to diagnose, particularly as symptoms can manifest in many different ways, and testing can be complicated. We talk to Dr. Nicola Brathwaite about the diagnosis and management of cow’s milk protein allergies in infants, and our discussion includes how to navigate consultations with parents who may be distressed and fraught with anxiety over their baby’s symptoms, and how best to manage the reintroduction of milk back into the diet.


Our guest:

Nicola Brathwaite is a paediatric allergy consultant at King's College Hospital, London. She completed her specialist training in Paediatrics and Paediatric Allergy in Cape Town, South Africa.

Milk allergies with Nicola Brathwaite

A recent investigation, by The BMJ, showed a worrying increase in incidence of violence, directed to wards GPs, and reported to the police. In this episode of Deep Breath in, Tom and Jenny are joined by Gareth Iacobucci, assistant news editor for The BMJ who broke the story.

They'll hear from a GP affected, and get some advice on preventing violence, and deescalation, from two mental health experts, who deal with the most agitated patients. 

Our guests:
Adam Janjua, a GP in Fleetwood, Lancashire.
Marcela Schilderman, a consultant psychiatrist at South London and the Maudsley NHS Foundation Trust 
and Anita Bignell, a mental health nurse, at South London and the Maudsley NHS Foundation Trust

Reading list
Violent incidents at GP surgeries double in five years, BMJ investigation finds
https://www.bmj.com/content/377/bmj.o1333

Violence against GPs  with Adam Janjua, Marcela Schilderman, and Anita Bignell

As more and more pharmaceutical products come onto the market, there are so many potential drug interactions, and adverse reactions, to bear in mind during a consultation in primary care. In this week’s episode, we speak to Anders Holt, the author of a recent research paper looking at co-prescribing nitrates and sildenafil, which is surprisingly common, and adverse events associated with this. We also discuss the neuropsychiatric side effects of montelukast with Corine Ekhart, and talk about the challenges of striking the right balance between highlighting a rare but important side effect and causing the patient anxiety about taking the medication.


Our guests:

Anders Holt is a PhD candidate at Copenhagen University Hospital, Denmark.

Corine Ekhart is a pharmacist at the Netherlands Pharmacovigilance Centre Lareb in 's-Hertogenbosch, the Netherlands.


Further reading:

‘Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study’. doi:10.7326/M21-3445 https://www.acpjournals.org/doi/10.7326/M21-3445

‘Neuropsychiatric reactions with the use of montelukast’. doi:10.1136/bmj-2021-067554 

https://www.bmj.com/content/376/bmj-2021-067554

deep breath in

Adverse drug reactions with Anders Holt and Corine Ekhart

In this week’s episode, we share our experiences of attending the recent RCGP Annual Conference, and our thoughts on the topics that were covered in the talks at this year’s event. We talk to RCGP Chair, Martin Marshall, about continuity of care, which he states is one of the defining features of general practice. Evidence has shown that continuity of care is associated with better health outcomes for patients, but how can doctors convince politicians and policymakers of the benefits of it? We also speak to Emma Gladwinfield, a GP in Rossendale, about how connecting with schools, churches and community centres is helping to build relationships with patients and deliver care in her local community.


Our guests: 

Martin Marshall is the Chair of the RCGP, a GP in Newham, East London, and Professor of Healthcare Improvement at UCL.

Emma Gladwinfield is a GP in Rossendale, East Lancashire.


Further reading:

‘Tackling the crisis in primary care’. doi:10.1136/bmj.o1485. https://www.bmj.com/content/377/bmj.o1485

Continuity with Martin Marshall and Emma Gladwinfield

Despite the Conservation party manifesto for the 2019 general election promising to deliver 6,000 additional full-time equivalent GPs, worryingly, the NHS lost 717 FTE GPs between March 2019 and March 2022, and the Health and Social Care Committee’s July 2022 report on workforce was scathing about the Government’s failure to act decisively on the chronic staff shortages across healthcare in the UK. This week, we speak to more colleagues from the RCGP conference: first, we talk to Pamela Curtis about the challenges of returning to general practice after a break; secondly, we speak to a group of GP trainees about their innovative platform, The Big GP Consultation, and hear their thoughts on shaping the future of general practice.


Our guests:

Pamela Curtis is a salaried GP working at NHS Bristol, North Somerset and South Gloucestershire ICB.

Veena Aggarwal, Devina Maru, Liam Loftus and Rachel Weaver are all GP trainees, and are part of the team for The Big GP Consultation.

Further reading:

House of Commons Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care. 2022. https://committees.parliament.uk/publications/23246/documents/169640/default/

The Big GP Consultation. https://thebiggpconsultation.co.uk/

Retention with Pamela Curtis and GP trainees

Musculoskeletal (MSK) pain and osteoarthritis are clinically common in general practice, but with the new draft NICE guideline on osteoarthritis (published in April 2022) recommending a move away from pharmacological treatments and instead promoting self-management, some GPs have been left wondering how best to manage MSK pain going forwards . In this week’s episode, Dr. Imran Sajid talks to us about the importance of educating patients on what arthritis really is – moving away from the term “wear and tear” – and of taking a thorough history of a patient’s pain journey in consultations. He also gives practical advice on how we might approach non-pharmacological management of MSK pain with our patients. 


Our guest:

Imran Sajid is a GP with a special interest in MSK medicine. He is the clinical lead in MSK & Diagnostics for NHS North West London, an adjunct lecturer in Health Policy  at the University of Global Health Equity, as well as being a qualified personal trainer.


Further reading:

‘Osteoarthritis: assessment and management, draft for consultation, April 2022’. NICE. 2022. https://www.nice.org.uk/guidance/gid-ng10127/documents/draft-guideline

‘The tear, flare, and repair model of osteoarthritis’. BMJ 2022;377:o1028. https://www.bmj.com/content/377/bmj.o1028

Musculoskeletal pain and osteoarthritis with Imran Sajid

In this episode of Deep Breath In, we'll be considering how a physicians personal experience of illness - either themselves, or as a parent or carer, might affect their approach to management of it in a patient. 

We'll also have an update on the NICE guideline for treatment of Gout - particularly highlighting changes around uses of urate lowering therapy, and how often we should be testing patient's serum urate levels when they're experiencing flare-ups.

Our Guests.

Katherine Hall is the associate dean of medical admissions at the university of Otago, and has researched how physician experience affects their practice.

Alastair Dickson is a GP, and lecturer at Hull York Medical School. He co-authored The BMJ article on management of gout.

Reading
Gout: diagnosis and management—summary of NICE guidance
https://www.bmj.com/content/378/bmj.o1754

Physician experience, and gout with Katherine Hall and Alastair Dickson

The GP crisis with Rebecca Rosen


This week, we discuss the ongoing GP crisis, an ever-topical subject, in light of recent UK governmental changes. In early September, Thérèse Coffey laid out her plans for the NHS in the House of Commons, but, with general practice struggling so much as it is, is she proposing practical and feasible solutions, or will her initiatives be merely papering over the cracks? We’re joined by Rebecca Rosen to discuss whether or not there’s any real substance behind the proposed changes, how to manage patients’ expectations around access to care, and how primary care practitioners might be best supported in order to help ease the strain on them.


Our guest:

Rebecca Rosen is a GP in South East London, and a senior fellow in Health Policy at the Nuffield Trust.

GP Crisis with Rebecca Rosen

This week, we’re joined by Huseyin Naci to discuss the recent press release from Eisai and Biogen announcing the Phase III trial results for lecanemab for use in Alzheimer’s disease, and the FDA’s decision to accept the drug onto its accelerated approval pathway. We talk about the pros and cons of using surrogate endpoints to predict clinical outcomes. How can we strike a better balance in clinical trials between generating high-quality and trustworthy evidence, and the urgent needs of patients with life-limiting conditions and very few available treatment options?


Our guest:

Huseyin Naci is an associate professor of Health Policy at the London School of Economics and Political Science (LSE). He is also an advisor to the Analysis section of The BMJ.

Surrogate endpoints with Huseyin Naci

The possibility that patients will suddenly have access to their notes has caused some anxiety for GPs in England. The department of health's plans to allow patients to prospectively access their medical record lead to fears about increased workloads, misunderstandings, and safety - and the plans have now been pushed back.

In this podcast the Deep Breath In team are joined by the authors of a recent article in The BMJ to explore those fears, hear about the potential benefits, and understand the evidence behind open notes.

Our guests;
Charlotte Blease, and interdisciplinary health researcher at OpenNotes, Beth Israel Deaconess Medical Center/Harvard Medical School.
Brian McMillan, a GP and senior clinical lecturer at the University of Manchester
Gail Davidge, research associate at the University of Manchester

The article they're discussing is a practice pointer on Adapting to transparent medical records: international experience with “open notes”
https://www.bmj.com/content/379/bmj-2021-069861

Patient access to notes with Charlotte Blease, Brian Macmillan and Gail Davidge

In general practice, it can often feel like a lot is changing beyond our grasp. On top of this, the pandemic has left many healthcare professionals self-reflecting on their careers and lives, and trying to work out what they really want going forward. 

This week, we speak to Claire Kaye about her role as a coach for doctors. Claire talks to us about the benefits of coaching, including helping to get rid of internal & external noise, shaping the mindset, and coping better with change. She also offers advice on the best ways to approach coaching in order to achieve a positive outcome. 

Our guest:
Claire Kaye, formerly a GP, is an executive coach. She specialises in career development. 
Instagram: @drclairekayecoaching 
LinkedIn: @drclairekaye 
Website: www.drclairekaye.com

Coaching with Claire Kaye

Reproductive coercion may feel like something that we don’t see very often in general practice, but a 2022 poll carried out for BBC Radio 4 of 1,060 UK women between the ages of 18 and 44 found that half of them had experienced some form of reproductive coercion. This week, we speak to returning guest Annabel Sowemimo about the various forms that reproductive coercion can take, and who might be at risk of experiencing it. We discuss how we, as GPs, can identify these patients, and, once we’ve done so, how we might be able to help them. Later on, we talk to our BMJ columnist, John Launer, about how narrative medicine approaches can help to reach a better & more satisfying resolution to a consultation “puzzle” for you and for the patient.


Our guests:

Annabel Sowemimo is a community sexual health registrar, based in Leicester. She is also a PhD candidate at King’s College London, and is the co-founder of the charity Reproductive Justice Initiative.

John Launer is a GP educator, working for Health Education England. He is also a freelance educator and writer, as well as being a columnist for ‘The BMJ’.


Further reading:

‘How to recognise and respond to reproductive coercion’. BMJ 2022;378:e069043. https://www.bmj.com/content/378/bmj-2021-069043

‘John Launer: The art of paying attention’. BMJ 2022;378:o2294. https://www.bmj.com/content/378/bmj.o2294

‘Careful, kind care is our compass out of the pandemic fog’. BMJ 2022;379:e073444. https://www.bmj.com/content/379/bmj-2022-073444

Reproductive coercion and narrative medicine with Annabel Sowemimo and John Launer

How long would it take GPs to enact all of the guideline recommendations that they might be expected too? Far more GP hours than exist in any healthcare system, but as medicine has turned its attention to primary prevention, and expanded the populations whose health we seek to improve, those guidelines are taking up more and more time.

A recent analysis in The BMJ has proposed the concept of “Time Needed to Treat” and implores guideline makers to take account consultation time as a precious, finite, resource when thinking about their recommendations.

In this episode of Deep Breath In, we’re joined by Minna Johansson, family doctor and director Global Center for Sustainable Healthcare, who co-authored that analysis to talk about how the concept has gone down, and what it might mean for rethinking what primary care is supposed to do.

Reading list:
Guidelines should consider clinicians’ time needed to treat
https://www.bmj.com/content/380/bmj-2022-072953

Time needed to treat, with Minna Johansson

The theory that depression is caused by serotonin deficiency has become embedded in our practice over the years, and can be a persuasive explanation of the condition for patients considering starting antidepressants. We talk to Tony Kendrick about the evidence (or lack thereof) to support this hypothesis, and what that means for the efficacy of antidepressants, particularly SSRIs. Later on, we speak to Mark Horowitz to discuss how to come off antidepressants safely, and manage withdrawal symptoms, and how to advise and support our patients as they gradually reduce, then stop, their medication. 


Our guests:

Tony Kendrick is a retired GP, and NICE committee member for the 2022 guideline update on depression in adults. He is also a professor of Primary Medical Care at the University of Southampton.

Mark Horowitz is a training psychiatrist, working as a clinical research fellow at North East NHS Trust, and as an honorary clinical research fellow at UCL, he is also the co-founder of outro.com.


Further reading:

‘Antidepressants and the serotonin hypothesis of depression’. BMJ 2022;378:o1993 https://www.bmj.com/content/378/bmj.o1993

‘Stopping antidepressants’. Royal College of Psychiatrists. 2020. https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/stopping-antidepressants

Antidepressant withdrawal with Tony Kendrick and Mark Horowitz

This week, we're going to be returning to a guest we heard from a while ago - Claire Kaye. 

Claire was a GP before deciding to become a coach, and we found her way of thinking through our wants and needs so useful, we decided to invite her back. 

This week we're going to be talking about that holding onto that feeling of excitement you had at the beginning of your career, a feeling that's difficult to hold onto, as the pressures on general practice mount.

Our guest:
Claire Kaye, formerly a GP, is an executive coach. She specialises in career development.
Instagram: @drclairekayecoaching
LinkedIn: @drclairekaye
Website: www.drclairekaye.com

Deep Breath In

BMJ talk medicine