Alex Burrell is a GP in Bristol.
Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature
Impact of workload
Workload continues to be a hot topic in both clinical and academic primary care. This database study randomly selected 50 GP practices in London covering around 600 000 patients to explore the impact of workload on referrals and prescriptions.1 As workload — measured by number of GP appointments per day — increased, the overall number of referrals did not increase, but the proportion of referrals made for assessment and diagnosis rather than treatment increased. The authors conclude this suggests clinicians are ‘more conservative in diagnosis when under pressure’. The probability of prescribing antibiotics also increased with workload. Neither of these findings are particularly surprising, but it’s further evidence showing that when primary care is under strain, it has knock-on effects for individual patients and the wider health system.
Sleep apnoea and dementia
Obstructive sleep apnoea syndrome (OSAS) is a risk factor for a number of adverse outcomes, including cardiovascular disease and stroke. There is emerging evidence that OSAS is associated with subsequent development of cognitive impairment. This large-scale population-based cohort study aimed to investigate the association between OSAS and the incidence of dementia, and whether treatment with continuous positive airway pressure (CPAP) mitigates any possible association.2 Individuals with an incident diagnosis of OSAS had a 12% higher risk of developing all- cause dementia (adjusted hazard ratio [HR] 1.12, 95% confidence interval [CI] = 1.07 to 1.17) compared to their matched counterparts. In those treated with CPAP, this effect disappeared. The relationship between OSAS and dementia subtypes was stronger for vascular dementia (adjusted HR 1.29, 95% CI = 1.19 to 1.41) and weaker for Alzheimer’s (adjusted HR 1.09, 95% CI = 1.01 to 1.18). The suggested pathophysiology behind this relationship is repeated hypoxia during sleep rather than sleep deprivation itself.
Ethics of lateness
Running late in clinic is a common occurrence for many GPs. This article from regular BJGP Life contributor Richard Armitage explores the causes of lateness, potential negative consequences, and the ethical implications.3 Reasons for lateness are broken down into GP related, patient related, and third party related (including IT failures, contacting secondary care, and interruptions by colleagues). The ethical conundrum comes in that regardless of the cause of lateness, its negative consequences are borne by patients. When running late, it is not ethically acceptable for a GP to actively shorten consultations to compensate for lateness due to the detrimental effect on quality and safety of care. So how can lateness be addressed equitably? Armitage considers this by reason for lateness with relevant practical suggestions for GPs and practices, and the full article is well worth a read. With consultations growing increasingly complex and allied health professionals often seeing the simpler cases by which we could passively catch up, lateness is likely to become more common unless there is to be a big shift in the way we schedule and manage appointments.
Registrar professional identity
Professional identity formation has been explored in depth in medical students, understanding the process by which they end up thinking, feeling, and acting like doctors. There is less literature on this process for postgraduate medics becoming specialists in their chosen field. This Dutch focus group study explored GP registrar perspectives on the development of their professional identity.4 Participants felt that being a ‘good GP’ meant ‘being able to negotiate the endlessness of practicing the profession.’ This perceived endlessness was described in four intertwined areas: GP as an accessible healthcare provider; GP as a collaborative spider in the care-web; providing personalised care; and maintaining a work–life balance. Participants reflected that setting boundaries was key to navigating this: ‘You yourself are the most important precondition for the care you can provide for your patients. If you are not functioning, the patient has no family doctor.’
References
1. Pilvar H, Watt T. The effect of workload on primary care doctors on referral rates and prescription patterns: evidence from English NHS. Eur J Health Econ 2024; DOI: 10.1007/s10198-024-01742-7.
2. Wang J, Subramanian A, Cockburn N, et al. Obstructive sleep apnoea syndrome and future risk of dementia among individuals managed in UK general practice. Thorax 2024; DOI: 10.1136/thorax-2024-221810.
3. Armitage RC. On lateness: the ethics of running behind schedule in general practice. J Eval Clin Pract 2024; 31(1): e14293.
4. Al-Sabiry M, Slootweg I, Numans ME, et al. Exploring residents’ perspectives on their professional identity in general practice residency in the Netherlands: a qualitative study. BMJ Open 2024; 14(12): e088097.
