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Yonder: Repeat antibiotics, co-located drug services, autism diagnosis, and medical student lockdown motivation

Alex Burrell is an ST4 Academic Clinical Fellow in General Practice based in Bristol.

Repeat antibiotics
Duty lists, especially during winter, can be a seemingly endless stream of respiratory tract infections (RTIs). For patients who re-present, we might be asked or feel the need to prescribe a second or even third course of antibiotics. These within-episode repeat prescriptions were the focus of this study,1 which found that almost 20% of lower RTIs and 10% of upper RTIs treated with antibiotics had at least one more course of antibiotics prescribed. The second course was prescribed a median of 10 days after the first and was the same antibiotic class in almost half of cases. Frequent visits to the GP with RTI and having previously had multiple courses of antibiotics for RTI were associated with repeat antibiotic prescriptions — ‘it needed a couple of weeks last time, doc’. With repeated courses, differentiating natural recovery from effective treatment becomes harder. Managing patient expectations around symptom resolution with the first prescription seems crucial to avoiding potentially unnecessary repeats.

Co-located drug services
Heroin-assisted treatment (HAT) is a relatively new model of care for the 5%–10% of people who use opiates that do not benefit from the standard methadone model. HAT involves prescribing synthetic diamorphine for twice-daily supervised self-administration. This service evaluation in North East England examined HAT co-located in a primary care service.2 They found a significant reduction in unplanned emergency interactions at 3 and 6 months compared to pre- HAT, and an increase in engagement with preventative care particularly around wound management and infection prevention. The authors felt much of the transition from a reactive to proactive relationship with health care in patients using HAT was down to co-location within primary care. While this is a very small study, it offers a useful reminder for other services designed for inclusion health groups: co-location can improve access to primary care through proximity and convenience, but more importantly by reducing real and perceived stigma.

Autism diagnosis
Accessing NHS services that diagnose autism can be extremely difficult and frustrating for patients and GPs alike. Could primary care clinicians diagnosing autism help? This US study3 examined autism diagnosis by primary care providers using caregiver-reported information: from 2004–2019, around one in ten children with autism were diagnosed in primary care and these children were on average 1 year younger than those diagnosed in non-primary care settings (mean age 4.1 years versus 5.3 years). The authors consider a tiered diagnostic model to help with the waiting time crisis: GPs screen for autism, diagnose ‘clear- cut’ cases, and refer more complex cases for specialist assessment and diagnosis. Ten per cent of cases being diagnosed in primary care feels very high: in the UK, GPs are not trained or expected to make this diagnosis so the tiered approach doesn’t feel feasible for staff or good for patients, particularly with a gold standard diagnostic assessment being multidisciplinary and longitudinal.

Medical student lockdown motivation
At the height of the COVID-19 pandemic, lockdowns and social distancing made delivering face-to-face medical education very difficult, and teaching had to rapidly move online at short notice. This mixed- methods study with fourth year students at Hamburg University Medical School explored the effects of online teaching on student motivation.4 Qualitatively, limited interactions with lecturers, patients, and peers led to a lack of role models, a reduction in feelings of competence and autonomy, and a loss of positive social pressure and peer support. The quantitative results are challenging to unpick, with the qualitative quotes offering much greater insight: ‘When I went to bedside teaching, it was always so motivating. I knew why I study medicine and I knew why I want to learn in order to be able to help’. With so much teaching for both under- and postgraduate medics now moving online, it’s worth keeping this in mind.

References
1. Lalmohamed A, Venekamp RP, Bolhuis A, et al. Within-episode repeat antibiotic prescriptions in patients with respiratory tract infections: a population-based cohort study. J Infect 2024; 88(4): 106135.
2. Poulter HL, Moore HJ, Ahmed D, et al. Co-located Heroin Assisted Treatment within primary care: a preliminary analysis of the implications for healthcare access, cost, and treatment delivery in the UK. Int J Drug Policy 2024; 126: 104367.
3. Smith JV, Menezes M, Brunt S, et al. Understanding autism diagnosis in primary care: rates of diagnosis from 2004 to 2019 and child age at diagnosis. Autism 2024; DOI: 10.1177/13623613241236112.
4. Moll-Khosrawi P, Küllmei J, Chindris V, et al. Medical student´s motivational changes during the COVID-19 university lockdown: a mixed-method study. BMC Med Educ 2024; 24(1): 226.

Featured photo by Patrick Tomasso on Unsplash.

The BJGP is the world-leading primary care journal. At BJGP Life we add multi-media comment and opinion for the primary care community.

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