• Musculoskeletal (MSK) pain and osteoarthritis are clinically common in general practice, but with the new draft NICE guideline on osteoarthritis (published in April 2022) recommending a move away from pharmacological treatments and instead promoting self-management, some GPs have been left wondering how best to manage MSK pain going forwards . In this week’s episode, Dr. Imran Sajid talks to us about the importance of educating patients on what arthritis really is – moving away from the term “wear and tear” – and of taking a thorough history of a patient’s pain journey in consultations. He also gives practical advice on how we might approach non-pharmacological management of MSK pain with our patients. Our guest:Imran Sajid is a GP with a special interest in MSK medicine. He is the clinical lead in MSK & Diagnostics for NHS North West London, an adjunct lecturer in Health Policy at the University of Global Health Equity, as well as being a qualified personal trainer.Further reading:‘Osteoarthritis: assessment and management, draft for consultation, April 2022’. NICE. 2022. https://www.nice.org.uk/guidance/gid-ng10127/documents/draft-guideline

    ‘The tear, flare, and repair model of osteoarthritis’. BMJ 2022;377:o1028. https://www.bmj.com/content/377/bmj.o1028

  • Despite the Conservation party manifesto for the 2019 general election promising to deliver 6,000 additional full-time equivalent GPs, worryingly, the NHS lost 717 FTE GPs between March 2019 and March 2022, and the Health and Social Care Committee’s July 2022 report on workforce was scathing about the Government’s failure to act decisively on the chronic staff shortages across healthcare in the UK. This week, we speak to more colleagues from the RCGP conference: first, we talk to Pamela Curtis about the challenges of returning to general practice after a break; secondly, we speak to a group of GP trainees about their innovative platform, The Big GP Consultation, and hear their thoughts on shaping the future of general practice.Our guests:Pamela Curtis is a salaried GP working at NHS Bristol, North Somerset and South Gloucestershire ICB.Veena Aggarwal, Devina Maru, Liam Loftus and Rachel Weaver are all GP trainees, and are part of the team for The Big GP Consultation.Further reading:House of Commons Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care. 2022. https://committees.parliament.uk/publications/23246/documents/169640/default/

    The Big GP Consultation. https://thebiggpconsultation.co.uk/

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  • In this week’s episode, we share our experiences of attending the recent RCGP Annual Conference, and our thoughts on the topics that were covered in the talks at this year’s event. We talk to RCGP Chair, Martin Marshall, about continuity of care, which he states is one of the defining features of general practice. Evidence has shown that continuity of care is associated with better health outcomes for patients, but how can doctors convince politicians and policymakers of the benefits of it? We also speak to Emma Gladwinfield, a GP in Rossendale, about how connecting with schools, churches and community centres is helping to build relationships with patients and deliver care in her local community.Our guests: Martin Marshall is the Chair of the RCGP, a GP in Newham, East London, and Professor of Healthcare Improvement at UCL.Emma Gladwinfield is a GP in Rossendale, East Lancashire.Further reading:

    ‘Tackling the crisis in primary care’. doi:10.1136/bmj.o1485. https://www.bmj.com/content/377/bmj.o1485

  • As more and more pharmaceutical products come onto the market, there are so many potential drug interactions, and adverse reactions, to bear in mind during a consultation in primary care. In this week’s episode, we speak to Anders Holt, the author of a recent research paper looking at co-prescribing nitrates and sildenafil, which is surprisingly common, and adverse events associated with this. We also discuss the neuropsychiatric side effects of montelukast with Corine Ekhart, and talk about the challenges of striking the right balance between highlighting a rare but important side effect and causing the patient anxiety about taking the medication.Our guests:Anders Holt is a PhD candidate at Copenhagen University Hospital, Denmark.Corine Ekhart is a pharmacist at the Netherlands Pharmacovigilance Centre Lareb in 's-Hertogenbosch, the Netherlands.Further reading:‘Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study’. doi:10.7326/M21-3445 https://www.acpjournals.org/doi/10.7326/M21-3445‘Neuropsychiatric reactions with the use of montelukast’. doi:10.1136/bmj-2021-067554


  • A recent investigation, by The BMJ, showed a worrying increase in incidence of violence, directed to wards GPs, and reported to the police. In this episode of Deep Breath in, Tom and Jenny are joined by Gareth Iacobucci, assistant news editor for The BMJ who broke the story.They'll hear from a GP affected, and get some advice on preventing violence, and deescalation, from two mental health experts, who deal with the most agitated patients. Our guests:Adam Janjua, a GP in Fleetwood, Lancashire.Marcela Schilderman, a consultant psychiatrist at South London and the Maudsley NHS Foundation Trust and Anita Bignell, a mental health nurse, at South London and the Maudsley NHS Foundation TrustReading listViolent incidents at GP surgeries double in five years, BMJ investigation finds


  • Consultations about suspected cow’s milk protein allergies are quite common in primary care, but these allergies can be a challenge to diagnose, particularly as symptoms can manifest in many different ways, and testing can be complicated. We talk to Dr. Nicola Brathwaite about the diagnosis and management of cow’s milk protein allergies in infants, and our discussion includes how to navigate consultations with parents who may be distressed and fraught with anxiety over their baby’s symptoms, and how best to manage the reintroduction of milk back into the diet.Our guest:

    Nicola Brathwaite is a paediatric allergy consultant at King's College Hospital, London. She completed her specialist training in Paediatrics and Paediatric Allergy in Cape Town, South Africa.

  • Parosmia – a distorted sense of smell, and a delayed post-covid symptom – affects approximately 50% of people who experienced loss of smell during their initial covid infection, and it is currently attracting a lot of media attention. We hear from Emily Woodroofe, a third year medical student, about what it’s like to have parosmia, before we speak to Professor Claire Hopkins about what GPs need to know about it, and how they can best support their patients who are experiencing what can be a distressing symptom.Our guests:Emily Woodroofe is a third year medical student at Barts and The London School of Medicine and Dentistry.Claire Hopkins is an ENT consultant, and professor of Rhinology at Guy’s and St. Thomas’ NHS foundation Trust.Further reading:

    ‘Parosmia—a common consequence of covid-19’ https://www.bmj.com/content/377/bmj-2021-069860

  • With the focus on covid, and the pressure on hospitals, it may be easy to overlook what’s happening in general practice in the UK - but changes are afoot. Our new health secretary Sajid Javid doesn’t seem to like our long standing GP practice arrangement, NHS England has imposed new weekend working arrangements on the already stretched service, and the workforce pressures continue.

    In this episode of Deep Breath In, our GP panel of Tom Nolan, Navjoyt Ladher, and Jenny Rasanathan are joined by Gareth Iacobucci, The BMJ’s assistant news editor, to give them the lowdown on what’s happening around primary care, who some of the key players are, and what his predictions for 2022.

  • We see patients all the time who ,more than any drug or cure, just want an explanation for their symptoms, to understand why they feel the way they do.But giving an explanation isn't necessarily straightforward, we're unsure of the diagnosis, we might worry about how the explanation might be received, or a 10 minute appointment just isn't time to go into all the details.In today's episode, we've enlisted the help of consultation skills expert, Roger Neighbour, and hear how important a great explanation is from The BMJ patient editor Amy Price.Our guests:Roger Neighbour is a retired GP and a former president of the Royal College of GPs. He has written the books on consultations skills, and teaches courses on how to put those skills into practice.

    Amy Price is a patient, a researcher editor for The BMJ's patient and public partnership, and a senior research scientist at Stanford School of Medicine.

  • Diagnosis is a complex categorisation task driven by mental models that reside in long term memory. Through education and experience, clinicians form scripts that encapsulate their knowledge of specific conditions and develop diagnostic schemas that structure their approach to a specific health problem. This cognitive process also intersects with systems, teamwork, and social factors that can enhance or reduce diagnostic accuracy.In this podcast, we hear about five techniques that can help with the accuracy of those mental models, and mitigate against some of the external factors which may reduce diagnostic accuracy.Our guests;Hardeep Singh trained as a GP before moving to becoming a general internist and professor of patient safety research at Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston.Denise Connor is an associate professor of medicine at University of California San Francisco and a practicing internist at San Francisco Veterans Affairs Medical Center.

    Gurpreet Dhaliwal is a general internist at the San Francisco Veterans Affairs Medical Center, and a clinician educator.

  • As Ramadan draws near, clinicians may be approached by their Muslim patients to discuss managing their health conditions during the month of fasting. How should someone with a chronic condition, such as diabetes or epilepsy, time their medications during this period? Can a person who’s pregnant or breastfeeding partake in fasting? What alternative options are available to someone whose health needs make participating fully in fasting too risky? In this week’s episode, we discuss the many questions doctors and patients may have around this topic with Ammad Mahmood and Sahira Dar, authors of a recently published article in The BMJ on advising patients with existing conditions about fasting during Ramadan, and talk about the importance of individualised advice and shared decision making.Our guests:Ammad Mahmood is a neurological trainee, currently undertaking a PHD in stroke imaging at the University of Glasgow.Sahira Dar is a GP, practising in Glasgow, with special interests in lifestyle medicine and mental health issues.Further reading:

    ‘Advising patients with existing conditions about fasting during Ramadan’ by Ammad Mahmood, Sahira Dar et al. https://www.bmj.com/content/376/bmj-2020-063613

  • There was a proposed vaccine mandate for NHS staff in the UK (now abandoned) but in other countries mandates continue, but are they without harm, and do we have evidence about how effective they are?In this episode, we'll be discussing how a proposed vaccine mandate would have affected GP practices in the UK, particularly when it comes to the demographics of staff who have not accepted the vaccine. We'll also be discussing direct and indirect evidence which might have helped us assess the efficacy of a mandate.Our guests;Steve Mowle is a GP in South London, and honorary treasurer, of the Royal College of General Practice.

    Juan Franco is a GP at the Hospital Italiano de Buenos Aires, Argentina, and Vice-Chair of the Research Department at the Instituto Universitario Hospital Italiano (IUHI), where he is also Director of the Cochrane Associate Centre.

  • A recent case against a GP in England has worried the profession - does the fact that a patient, born with a neural tube defect, successfully sued their mother's GP open up the floodgates for litigation? How will that effect the way that you practice?In this episode we're joined by Claire Dyer, The BMJ's legal correspondent, who explains how that case unfolded.We also have a clinical update on childhood constipation, and the authors of a recent article in The BMJ give their tips on getting kids to drink movicol.Show jumper wins case against mother’s GP for “wrongful conception” that resulted in her disabilityhttps://www.bmj.com/content/375/bmj.n2999Childhood constipation


  • With Christmas 2021 only just around the corner, we round off the year by chatting about our ‘Deep Breath In’ highlights, and by sharing some of the great feedback we’ve received from our listeners. We talk to Inga Usher and Aswin Chari, whose study comparing neurosurgeons with aerospace engineers (“It’s not brain surgery” vs. “It’s not rocket science”) was featured in The BMJ’s 2021 Christmas issue. Finally, we end the episode with a quiz on ICU slang (what on earth does ‘closest crocodile to the canoe’ mean?), 2021 NICE guideline updates, and, finally, the Bristol stool chart. Merry Christmas!Our guests:Inga Usher is a final year clinical PhD student at UCL Cancer Institute, studying a rare bone cancer, chordoma, and an aspiring neurosurgeon. Aswin Chari is a neurosurgical trainee at Great Ormond Street Hospital, London.Further reading:SEED Eating Disorder Support Services: https://seed.charity/Mitchell and Webb brain surgeon & rocket scientist sketch: https://www.youtube.com/watch?v=THNPmhBl-8I“It’s not rocket science” and “It’s not brain surgery”—“It’s a walk in the park”: prospective comparative study: https://www.bmj.com/content/375/bmj-2021-067883

    Just a smidge, or a bridge too far? Slang use in the ICU: https://www.bmj.com/content/375/bmj-2021-067900

  • Following the recent COP26 Climate Change Summit, we discuss, in this week’s episode, the announcement that some 50 countries have committed to reach net zero carbon emissions within their healthcare systems by, or before, 2050. We talk about the role that GPs can play in reducing the carbon footprint of their practice, how to tackle climate anxiety, and how integrating greener practices into our healthcare systems aligns with better health benefits for our population as a whole – both now and in the future.Our guests:Richard Smith is the chair of the UK Health Alliance on Climate Change, and former editor of ‘The BMJ’. Aarti Bansal is a GP, working in Sheffield, and the Net-zero NHS GP lead for the Humber, Coast and Vale Health and Care Partnership. She is also the founder of Greener Practice.Further reading:Greener Practice website: https://www.greenerpractice.co.uk/Greener Practice guide to inhaler prescribing: https://www.greenerpractice.co.uk/greener-practice-guide-to-inhaler-prescribinghttps://www.bmj.com/content/375/bmj.n2416


  • Primary care in the UK is in crisis. General practice was already under huge strain, as a result of the pandemic, high levels of seasonal respiratory viruses, as well as chronic understaffing and underfunding, but recent negative media campaigns against GPs, amidst the health secretary’s plans to publish ‘league tables’ of GP practices, have added to this and have led to increased demoralisation among doctors. In this week’s episode, we discuss the current political climate affecting the NHS, perceptions of our healthcare system, and how this has changed over the last 10-20 years. If GP ‘league tables’ are not the answer, what creative solutions are needed in order to encourage new GPs into primary care, and to retain doctors in the workforce?Our guests:Gareth Iacobucci is the assistant news editor for ‘The BMJ’.

    Lucy Martin is a GP, working in Dudley, as well as the acting medical director for Dudley Integrated Health & Care NHS Trust.

  • Over the past 18 months, eating disorder specialists have seen a huge rise in the number of referrals, and experts have said that the pandemic has created “the perfect storm” for eating disorders, especially among children and young people. As GPs, what do we need to know about eating disorders? What red flags should we look out for, and how do we approach this thorny issue with our young patients? In this week’s episode, we talk to Dr. Simon Chapman about spotting the signs of an eating disorder, and we get advice on management. We also chat to Zoe John and Victoria Adeniji, who are both in recovery from their eating disorders, about their experiences and about how GPs may best support people with a history of eating disorders in their care.Our guests:Simon Chapman is a consultant in paediatrics and adolescent medicine at King's College Hospital, London. He is also the medical lead for the Maudsley Centre for Child and Adolescent Eating Disorders.Zoe John and Victoria Adeniji are ambassadors for Beat, the UK’s eating disorder charity.Further reading:The MARSIPAN guidelines: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr189.pdf?sfvrsn=6c2e7ada_2

    Online resources on the Beat website: https://www.beateatingdisorders.org.uk/get-information-and-support/get-help-for-myself/downloads-resources/

  • Fatigue is one of the most common presenting symptoms GPs see in a consultation, and it feels like, during the pandemic, more of us than ever have been experiencing excessive tiredness. With our guests this week, Sophie West and Robert Koefman, we discuss the new NICE guidelines on obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome, and how sleep apnoea seems to be both under-diagnosed and over-diagnosed in primary care. We talk about the diagnostic challenges of this condition, particularly with the limitations of the available screening tools, the long list of comorbidities that may be linked to OSA, and the difficulties of remote consultations, as well as the huge benefits using a CPAP machine may provide to a patient. Our guests:Sophie West is a respiratory consultant, based in Newcastle upon Tyne. She is also the lead of the Newcastle regional sleep service.

    Robert Koefman is a GP at Binfield Surgery in Berkshire. He has also been involved in ENT and community sleep clinics for over 20 years.

  • A slightly different spread of this episode of Deep Breath In, Navjoyt Tom and Jenny are discussing two separate topics, headaches and team debriefings.Firstly headaches, the team discuss why so many GPs find headaches to cause the most anxiety in their practice, and get some advice on migrainous headaches from Heather Angus-Leppan, consultant neurologist at the Royal Free London NHS Foundation Trust (also discussed vaccinations and CVST in our covid vaccination episode).Secondly, team debriefings - seeking support from colleagues is essential, but the way in which teams discuss problems can be helpful or harmful. Michaela Kolbe, psychologist and director of University Hospital Zurich's simulation centre joins us to give some tips on how to make those team meetings work better.Reading listTeam debriefings in healthcare: aligning intention and impact


  • Doctors are taught from medical school about the benefits of IUD, and are often advocates of them to patients.However, recent media attention on the pain that some women suffer when having their IUD's fitted have started conversations about the need for cervical blocks, and more honest counselling of women about the procedure.

    Rebekah Fenton, adolescent medicine fellow at Lurie Children's Hospital of Chicago joins us to talk about how she councils her patients, and why the most important thing is to make sure women are in charge of their reproductive healthcare decisions.