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Abbreviations used inthe text

Evidence- basedsuperscripts

N NICE guideline G Guideline from a major guideline- producing body C Cochrane review S Systematic review or meta- analysis published in a major peer-

R Randomized controlled trial published in a major peer-

Referraltimes

E Emergency admission U Urgent referral S Soon referral R Routine referral

Handbooksymbols

" Note

• Warning

E OHGP cross reference M Web link F Telephone number

♀ Female ♂ Male

 Controversy

3 Don’t dawdle

1° Primary 2° Secondary

i Increased/ increasing d Decreased/ decreasing l Leading to/ resulting in

~ Approximately

8 Approximately equal ± With or without

reviewed journal

https://t.me/med1917

Standard abbreviations

AAA abdominal aortic aneurysm ABPI ankle– brachial pressure index ABPM ambulatory blood pressure monitoring ACE angiotensin- converting enzyme ACS acute coronary syndrome ACTH adrenocorticotrophic hormone ADH antidiuretic hormone ADHD attention decit hyperactivity disorder AED automated external debrillator AF atrial brillation AFP alpha fetoprotein AIDS acquired immune deciency syndrome Alk phos alkaline phosphatase ALT alanine aminotransferase ANF antinuclear factor APH antepartum haemorrhage APMS Alternative Provider Medical Services ARB angiotensin receptor blocker ASD atrial septal defect ASO antistreptolysin O AST aspartate aminotransferase AV arteriovenous AXR abdominal X- ray BASHH British Association for Sexual Health and HIV BCG Bacille Calmette– Guérin bd twice daily BMA British Medical Association

BMJ British Medical Journal BNF British National Formulary

BP blood pressure bpm beats per minute

calcium

CABG coronary artery bypass graft CCF congestive cardiac failure CCG Clinical Commissioning Group CF cystic brosis CHC combined hormonal contraception

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STANDARD ABBREVIATIONS

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xii

CHD coronary heart disease CIN cervical intraepithelial neoplasia CMV cytomegalovirus CNS central nervous system COC combined oral contraceptive COPD chronic obstructive airways disease Cr creatinine CRP C- reactive protein CT computed tomography CVA cerebrovascular accident CVD cardiovascular disease CXR chest X- ray d day(s) DDH developmental dysplasia of the hip DES Directed Enhanced Service DH Department of Health and Social Care DIPJ distal interphalangeal joint DLA Disability Living Allowance DI diabetes insipidus DM diabetes mellitus DN district nurse DOAC direct- acting oral anticoagulant DRE digital rectal examination DVLA Driving and Vehicle Licensing Authority DVT deep vein thrombosis EBV Epstein– Barr virus ECG electrocardiogram Echo echocardiogram EEG electroencephalogram ENT ear, nose, and throat EPAU early pregnancy assessment unit ESR erythrocyte sedimentation rate ESRD end- stage renal disease FBC full blood count FBG fasting blood glucose

FEV

forced expiratory volume in 1 second

FH family history FSH follicle- stimulating hormone FSRH Faculty of Sexual and Reproductive Healthcare FVC forced vital capacity g grams

STANDARD ABBREVIATIONS

https://t.me/med1917

GA general anaesthetic GI gastrointestinal GGT gamma glutamyl transferase GMC General Medical Council GMS General Medical Services GP general practitioner GPC General Practitioner Committee GTN glyceryl trinitrate GTT glucose tolerance test GU genitourinary GUM genitourinary medicine h hours Hb haemoglobin HbA1c glycosylated haemoglobin HBPM home blood pressure monitoring HBsAg hepatitis B surface antigen hCG human chorionic gonadotropin HDL high- density lipoprotein Hib Haemophilus inuenzae type b HIV human immunodeciency virus HOCM hypertrophic obstructive cardiomyopathy HPV human papilloma virus HRT hormone replacement therapy HSV herpes simplex virus HV health visitor HVS high vaginal swab ICP intracranial pressure Ig immunoglobulin IHD ischaemic heart disease IM intramuscular INR international normalized ratio IT information technology IU international units IUCD copper intrauterine device IUD intrauterine device IUS progestogen- containing intrauterine system IV intravenous IVP intravenous pyelogram JVP jugular venous pressure

potassium

kg kilograms

xiii

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STANDARD ABBREVIATIONS

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xiv

KUB kidney, ureters, and bladder X- ray L litres LA local anaesthetic LBBB left bundle branch block LFT liver function test LH luteinizing hormone LIF left iliac fossa LMP last menstrual period LMWH low- molecular- weight heparin LN lymph node LRTI lower respiratory tract infection LTOT long- term oxygen therapy LUQ left upper quadrant LVF left ventricular failure LVH left ventricular hypertrophy m metres MAOI monoamine oxidase inhibitor M,C&S microscopy, culture, and sensitivity MCP metacarpophalangeal MCV mean cell volume MDI metered dose inhaler mg milligrams MHRA Medicines and Healthcare products Regulatory Agency MI myocardial infarction min minutes mL millilitres MMR measles, mumps, and rubella MND motor neurone disease mmHg millimetres of mercury mo months MRI magnetic resonance imaging MS multiple sclerosis MSU midstream urine

sodium

NAAT nucleic acid amplication test NHS National Health Service NI National Insurance NICE National Institute for Health and Care Excellence nocte at night NSAID non- steroidal anti- inammatory drug NSTEMI non- ST elevation myocardial infarction

STANDARD ABBREVIATIONS

https://t.me/med1917

oxygen

OA osteoarthritis OCD obsessive– compulsive disorder od once daily OOH out- of- hours OT occupational therapy OTC over- the- counter PAN polyarteritis nodosa PCI percutaneous coronary intervention PCO primary care organization PCOS polycystic ovarian syndrome PD Parkinson’s disease PE pulmonary embolus PEFR peak expiratory ow rate PET pre- eclamptic toxaemia PHCT primary healthcare team PIP Personal Independence Payment PIPJ proximal interphalangeal joint PMH past medical history PMS Personal Medical Services PN practice nurse po oral

3–

phosphate

POP progesterone- only pill PPE personal protective equipment PPH post- partum haemorrhage PR per rectum prn as needed qds four times daily QOF Quality and Outcomes Framework RA rheumatoid arthritis RBBB right bundle branch block RCGP Royal College of General Practitioners RCOG Royal College of Obstetricians and Gynaecologists RhD rhesus factor RIF right iliac fossa RPOCT rapid point-of-care test RR relative risk RTA road trac accident RUQ right upper quadrant s seconds

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STANDARD ABBREVIATIONS

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xvi

sc subcutaneous SH sexual health SLE systemic lupus erythematosus SOL space- occupying lesion SNRI serotonin and noradrenaline reuptake inhibitor SSRI selective serotonin reuptake inhibitor stat immediately

SpO

peripheral oxygen saturation

STEMI ST elevation myocardial infarction STI sexually transmitted infection SVC superior vena cava TB tuberculosis TCA tricyclic antidepressant tds three times daily TFT thyroid function tests TIA transient ischaemic attack u units U&E urea and electrolytes UC ulcerative colitis URTI upper respiratory tract infection US(S) ultrasound (scan) UTI urinary tract infection VF ventricular brillation VSD ventriculoseptal defect VT ventricular tachycardia WCC white cell count wk weeks y years

" All other abbreviations are dened in the text on the page in which they appear.

Elderly care and child health ags:conditions peculiar to children or elderly people, or in which management varies for these groups, are agged as follows:

Child health

Elderly care

https://t.me/med1917

Chapter

What is general practice?

What is general practice? 2 General practice in the UK 4 Becoming a GP in the UK 6 Education in primary care 8 Appraisal and revalidation 10 GP working arrangements 12 Career options for GPs 14 Good medical practice for GPs 16 The primary healthcare team 18 Foundation doctors in primary care 20 Stress in general practice 22 Organizations important to general practice 24 Practice in other countries 26

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CHAPTER What is general practice?

What is general practice?

‘Generalism describes a philosophy of practice which is person, not disease, centred; continuous, not episodic; integrates biotechnical and biographical perspectives; and views health as a resource for living and not an end in itself.’

In the early 9th century, when apothecaries, physicians, and surgeons provided medical care, the term ‘general practitioner’ became applied to apothecaries taking the Membership Examination of the Royal College of Surgeons of England. Over the past 60y, general practice has established itself as the cornerstone of most national healthcare systems. In general, the better the primary care provision, the better the health of a population.2 General practitioners (GPs or family physicians) have shown the intellectual framework within which they operate is dierent from, complementary to, but no less demanding than that of specialists.

What is medical generalism? The RCGP denes medical generalism

as:‘An approach to the delivery of health care that routinely applies a broad and holistic perspective to the patient’s problems.’ It involves:

• Seeing the person as a whole and in the context of his/ her family and

wider social environment

• Using this perspective as part of the clinical method and therapeutic

approach to all clinical encounters

• Being able to deal with undierentiated illness and the widest range of

patients and conditions

• In the context of general practice, taking continuity of responsibility

for people’s care across many disease episodes and over time and coordinating care across both health and social care organizations

The role of the GP GPs diagnose illness, treat minor illness in the

community, promote better health, prevent disease, diagnose and certify disease, monitor chronic disease, and refer patients requiring specialist services. General practice is the primary access point to health services.

Although patients have an average of >5.5 consultations with their GP every year in the UK, only  in 20 consultations results in a secondary care referral. To do this, GPs must:

• Have a working knowledge of the whole breadth of medicine

• Maintain ongoing relationships with their patients— they are the only

doctors to remain with their patients through sickness and health

• Focus on patients’ response to illness rather than the illness itself taking

into account personality, family patterns, and the eect of these on the presentation of symptoms

• Be interested in the ecology of health and illness within communities

and in the cultural determinants of health beliefs

• Be able to draw on a wide range of resources including intuition,

medical knowledge, communication skills, business skills, and humanity



Reeve J (200) Protecting generalism— moving on from evidence- based medicine? BJGP 60:52.

Stareld B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health.

Milbank Q 83:457– 502.

https://t.me/med1917

WHAT IS GENERAL PRACTICE?

In addition to day- to- day medical care of their patients, GPs in the UK have a number of additional roles:

• Gatekeeping GPs control access to hospital- based services enabling

cost- eective care

• Navigating GPs work with patients/ carers to guide them eectively and

safely through the healthcare system

• Service redesign and improvement GPs manage service provision within

their own practices, and beyond their practice boundaries

• Research GPs need critical appraisal skills to understand and apply

relevant evidence to inform clinical decision- making. They need to be competent in collecting and analysing data for service improvement, and must collaborate eectively in primary care- based research

• Education GPs can be eective teachers in a wide range of contexts,

educating patients, practice sta, medical students and junior doctors, fellow GPs, and the general public

• Leadership Many GPs have leadership roles— in their own practices,

within their localities, or nationally

What is the dierence between GPs and specialists? Marshall

Marinker contrasted the role of generalists and specialists as follows:

GPs Specialists

Exclude the presence of serious disease Conrm the presence of serious disease

Tolerate uncertainty— managing patients with undierentiated symptoms

Explore probability of seeing patients from a population with a relatively low incidence of serious disease

Marginalize danger— recognizing and acting on danger signs even when diagnosis is not certain

Reduce uncertainty— investigating until a diagnosis is reached

Explore possibility of seeing a preselected population of patients with a relatively high incidence of serious disease

Marginalize error— ensuring accurate diagnosis and treatment

To perform their roles well, GPs must show empathy for their patients; engagement and commitment to involve themselves in every aspect of patient care; appreciation of the limits of their skills and expertise; and professionalism in their dealings with both patients and colleagues.

What is primary care? Primary care services provide the rst point

of contact in a healthcare system. In the UK, general practice is one of the primary care services; others include community pharmacy, dental services, and optometry services.

Further information

Independent Commission on Generalism (20) Guiding patients through complexity: modern medical generalism. M https:// www.health.org.uk/ publications/ guiding- patients- through- complexity- modern- medical- generalism Marinker M (990) General practice and the new contract. In:Bevan G, Marinker M (eds). Greening the White Paper, pp. 8– 7. London:Social Marketing Foundation. RCGP (202) Medical generalism:why expertise in whole person medicine matters. M www.rcgp.org.uk Simon C (2009) From generalism to specialty:a short history of general practice (2009). InnovAiT 2():2– 9.

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