"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

BackgroundMuch of a General Practitioner&rsquo;s (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees&rsquo; clinical and educational experiences of managing people presenting with MUS.MethodA mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.ResultsEighty questionnaires out of 120 (67 %) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.ConclusionManaging MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.<br /

The experiences of general practitioner partners living with distress::An interpretative phenomenological analysis

Doctors, including general practitioners, experience higher levels of mental illness than the general population. General practitioners who are partners in their practices may face heightened stress. In total, 10 general practitioner partners living with work-related distress were interviewed, and transcripts were analysed using interpretative phenomenological analysis. Three major themes arose: (1) extreme distress, (2) conflicted doctor identity and (3) toxic versus supportive workplace relationships. Participants detailed symptoms of depression, anxiety and burnout; reported conflicted identities; and discussed the impact of bullying partnerships. We recommend that organisational interventions tackling issues such as bullying be implemented and opportunities to debrief be offered as protected time activities to general practitioner partners

Improving teaching about medically unexplained symptoms for newly-qualified doctors in the UK: findings from a questionnaire survey and expert workshop

Objectives Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. Design Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. Setting Nineteen foundation schools in England, Wales and Northern Ireland Participants Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. Results The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2–3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor–patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients’ symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. Conclusions There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum

Arabidopsis SWI/SNF chromatin remodeling complex binds both promoters and terminators to regulate gene expression

ATP-dependent chromatin remodeling complexes are important regulators of gene expression in Eukaryotes. In plants, SWI/SNF-type complexes have been shown critical for transcriptional control of key developmental processes, growth and stress responses. To gain insight into mechanisms underlying these roles, we performed whole genome mapping of the SWI/SNF catalytic subunit BRM in Arabidopsis thaliana, combined with transcript profiling experiments. Our data showthatBRM occupies thousands of sites in Arabidopsis genome, most of which located within or close to genes. Among identified direct BRM transcriptional targets almost equal numbers were up- and downregulated upon BRM depletion, suggesting that BRM can act as both activator and repressor of gene expression. Interestingly, in addition to genes showing canonical pattern of BRM enrichment near transcription start site, many other genes showed a transcription termination sitecentred BRM occupancy profile. We found that BRMbound 3� gene regions have promoter-like features, including presence of TATA boxes and high H3K4me3 levels, and possess high antisense transcriptional activity which is subjected to both activation and repression by SWI/SNF complex. Our data suggest that binding to gene terminators and controlling transcription of non-coding RNAs is another way through which SWI/SNF complex regulates expression of its targets

Medium-chain-length polyprenol (C45–C55) formation in chloroplasts of Arabidopsis is brassinosteroid-dependent

Brassinosteroids are important plant hormones influencing, among other processes, chloroplast development, the electron transport chain during light reactions of photosynthesis, and the Calvin-Benson cycle. Medium-chainlength polyprenols built of 9–11 isoprenoid units (C45–C55 carbons) are a class of isoprenoid compounds present in abundance in thylakoid membranes. They are synthetized in chloroplast by CPT7 gene from Calvin cycle derived precursors on MEP methylerythritol 4-phosphate) isoprenoid biosynthesis pathway. C45–C55 polyprenols affect thylakoid membrane ultra-structure and hence influence photosynthetic apparatus performance in plants such as Arabidopsis and tomato. So far nothing is known about the hormonal or environmental regulation of CPT7 gene expression. The aim of our study was to find out if medium-chain-length polyprenol biosynthesis in plants may be regulated by hormonal cues.We found that the CPT7 gene in Arabidopsis has a BZR1 binding element (brassinosteroid dependent) in its promoter. Brassinosteroid signaling mutants in Arabidopsis accumulate a lower amount of medium-chain-length C45–C55 polyprenols than control plants. At the same time carotenoid and chlorophyll content is increased, and the amount of PsbD1A protein coming from photosystem II does not undergo a significant change. On contrary, treatment of WT plants with epi-brassinolide increases C45–C55 polyprenols content. We also report decreased transcription of MEP enzymes (besides C45–C55 polyprenols, precursors of numerous isoprenoids, e.g. phytol, carotenoids are derived from this pathway) and genes encoding biosynthesis of medium-chain-length polyprenol enzymes in brassinosteroid perception mutant bri1-116. Taken together, we document that brassinosteroids affect biosynthetic pathway of C45–C55 polyprenols

What are the sources of stress and distress for general practitioners working in England? A qualitative study

OBJECTIVES: This paper reports the sources of stress and distress experienced by general practitioners (GP) as part of a wider study exploring the barriers and facilitators to help-seeking for mental illness and burnout among this medical population. DESIGN: Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING: England. PARTICIPANTS: A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face-to-face or over the telephone. RESULTS: The key sources of stress/distress related to: (1) emotion work-the work invested and required in managing and responding to the psychosocial component of GPs' work, and dealing with abusive or confrontational patients; (2) practice culture-practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands-fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries. CONCLUSION: In addition to addressing escalating workloads through the provision of increased resources, addressing unhealthy practice cultures is paramount. Collegial support, a willingness to talk about vulnerability and illness, and having open channels of communication enable GPs to feel less isolated and better able to cope with the emotional and clinical demands of their work. Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures-culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well

The acceptability of primary care or community-based behavioural interventions for persistent physical symptoms: Qualitative systematic review.

PURPOSE: Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs. METHODS: A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty-eight full papers were screened against the inclusion criteria. Nine studies were included and quality-assessed. A qualitative evidence synthesis was conducted using thematic synthesis. RESULTS: Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties. CONCLUSIONS: Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow-up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS

Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study

Background People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. Methods We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. Findings We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47–2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10–8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5–49·9, p<0·0001), and medication reviews (2·23, 1·68–2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41–26·9, p=0·0156) and secondary care referrals (1·47, 1·05–2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09–6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03–3·65, p=0·0390), and obesity (2·49, 1·76–3·53, p<0·0001). Interpretation Targeted annual health checks for people with ID in primary care could reduce health inequities

Increasing awareness of gynaecological cancer symptoms: a GP perspective.

In the UK there has been an effort, through the National Awareness and Early Diagnosis Initiative (NAEDI), to increase early stage diagnoses and ultimately cancer survival. Encouraging early symptom presentation through awareness-raising activities in primary care is one method to achieve this goal. Understanding GPs' views about this type of activity, however, is crucial prior to implementation

A Cross-Sectional Study of the Health of Emerging Young Adults in England Following a COVID-19 Infection

PURPOSE: This study describes long COVID symptomatology in a national sample of 18- to 20-year-olds with Polymerase Chain Reaction (PCR)-confirmed Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) and matched test-negative controls in England. Symptoms in 18- to 20-year-olds were compared to symptoms in younger adolescents (aged 11-17 years) and all adults (18+). METHODS: A national database was used to identify SARS-CoV-2 PCR-positive 18- to 20-year-olds and test-negative controls matched by time of test, age, gender, and geographical region. Participants were invited to complete a questionnaire about their health retrospectively at time of test and also when completing the questionnaire. Comparison cohorts included children and young people with long COVID and REal-time Assessment of Community Transmission studies. RESULTS: Of 14,986 people invited, 1,001 were included in the analysis (562 test-positive; 440 test-negative). At testing, 46.5% of test-positives and 16.4% of test-negatives reported at least one symptom. At the time of questionnaire completion (median 7 months post-testing), 61.5% of test-positives and 47.5% of test-negatives reported one or more symptoms. The most common symptoms were similar amongst test-positives and test-negatives and included tiredness (44.0%; 35.7%), shortness of breath (28.8%; 16.3%), and headaches (13.7%; 12.0%). Prevalence rates were similar to those reported by 11-17-year-olds (66.5%) and higher than those reported in all adults (37.7%). For 18- to 20-year-olds, there was no significant difference in health-related quality of life and well-being (p > .05). However, test-positives reported being significantly more tired than test-negatives (p = .04). DISCUSSION: Seven months after PCR test, a high proportion of test-positive and test-negative 18- to 20-year-olds reported similar symptoms to each other and to those experienced by younger and older counterparts