Tuesday, 19 May 2015

Why I need GPs to be medical leaders (Easter egg - GORD in babies)

Please Help Me to Change My Practice

In January 2015 NICE published the first of their newly branded ‘CG’s which happened to be Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people.  I don’t know how you decide which NICE guidelines to look at but my filter is based on relevance and the extent to which they might make me cry into my coffee.   This one scored a 10, partly because I see lots of vomiting babies (with accompanying parent – this is usually the one I’m more worried about) and partly because we have known for a long time that the available treatments are inconsistent at best.  In the absence of a guideline it is much easier to work through the various non-pharmacological interventions and then take a stepwise approach to treatment, while hopefully the underlying predisposition to create laundry and sleep deprive your parents gradually resolves in time for me to take all the credit.

The truth is that when I see a child with reflux, things are usually pretty desperate for the family.  They are tired, smell of vomit and feel that every time they see a different doctor or nurse they are told something that contradicts previous advice.  I then find it difficult to admit that the problem with which they present is going to follow a course over which I have little influence.  Certainly I do make a difference where possible.  I explore the way that feeds are being given and often find that the volume of feed is excessive.  Occasionally I discover a previously undiagnosed urinary tract infection and get to feel like a real doctor.  More often there is no easy answer and I reach for my prescription pad to prescribe an alginate. 

The thing is that NICE have now said that the initial treatment should be a feed thickener if the child is formula fed.  That should be a simple thing to change but for me it isn’t.   

From CG1 2015

I remember well how in General Practice I used to do this process change.  One day I would find out something, next I would have a quick chat with my GP colleague and then I would get on and do it.  No major fuss.  How things have changed.  Now that I work in a hospital it takes months to change most things.  Certainly when there is an urgent need we get that turned around much faster.  (I won’t say how long faster is.  It depends.)   However if the change is less urgent it requires consensus, consultation and committees to the Nth degree.
In the interest of balance I should extol the virtues of this more cumbersome approach.  It would be chaos if there was no way of ensuring consistency of practices within the various teams of any hospital.  That consistency only comes if guidelines are agreed and well governed.  Achieving that sometimes feels ungainly but is far better than conflicting practices within the same organisation or changes that are ill thought through and are not universally agreed.

The good news is that in the case of these vomiting children it hasn’t been a problem.  The dilemma that I might have faced was taken away because thankfully the last few children that I have seen with gastro-oesophageal reflux were all being treated with feed thickeners and not an alginate.   Since previously the latter was the norm I can only assume that these GPs have decided to lead the way.  No fuss, no committees and no delay.  How wonderful that GPs are playing to their strengths and getting on with changes that take much longer for Secondary Care to implement.

So thank you for providing some true medical leadership.  For those of us working in hospital, we need you in General Practice to lead the way for us.  I’m sure we’ll catch up eventually.

Edward Snelson
Kiddie Doctor
@sailordoctor #GPpaedsTips

Disclaimer: All disclaimers are nonsense.

  1. http://www.nice.org.uk/guidance/NG1/chapter/1-recommendations

More treats from the Easter egg:

1) NICE doesn't want us diagnosing 'silent reflux' so much

2) Some red flags here suggesting that there may be another diagnosis or that the GORD warrants rapid referral

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