A General Practitioner Has A Duty To Know About Current Knowledge Of The Diagnosis And Management Of Hypothyroidism

[NBob]

The preamble to Good Medical Practice

gmc-uk.org/guidance/good_me... ,

states that a doctor must (i.e. the doctor has an overriding duty to):

Provide a good standard of practice and care

- Keep his/her professional knowledge and skills up to date

- Recognise and work within the limits of his/her competence

- Work with colleagues in the ways that best serve patients’ interests

At paragraph 3 Good Medical Practice states that a doctor must (i.e. the doctor has an overriding duty) recognise and work within the limits of his/her competence.

A General Practitioner has to have hypothyroidism within the limits of his/her competence. Why? Because the General Medical Services Contract, the Quality Outcomes Framework and the General Medical Council itself together with the Royal College of General Practitioners say so.

General Medical Services Contract

The General Medical Services Global Sum Formula distributes the core funding, or the Global Sum, to general practices to cover the cost of providing routine primary care services to its registered list of patients.

Payments are made to practices according to the needs of their patients and the costs of providing primary care services, and are calculated using the Carr-Hill formula. These services are defined as “essential” and “additional” services in the contract and are listed below:

Practices are required to provide essential services. These cover the:

• management of patients who are ill or believe themselves to be ill with conditions from which recovery is generally expected

• general management of patients who are terminally ill

• management of chronic disease

nhsemployers.org/PayAndCont...

Quality and Outcomes Framework

Hypothyroidism is mainly dealt with in Primary Care (i.e. by a GP). This is specifically confirmed by the Quality and Outcomes Framework of the General Medical Services contract.

nhsemployers.org/Aboutus/Pu...

The Quality and Outcomes Framework (QOF) rewards practices for the provision of 'quality care' and helps to standardise improvements in the delivery of clinical care. Practice participation in QOF is voluntary but most practices on General Medical Services (GMS) contracts, as well as many on Personal Medical Services (PMS) contracts, take part in QOF. It was introduced as part of the new GMS contract in 2004.

nhsemployers.org/Aboutus/Pu...

Hypothyroidism is a Clinical Domain in QOF. The QOF states in the rationale that monitoring of hypothyroidism is almost entirely undertaken in primary care. Under the QOF a GP practice receives a payment if the practice reports the number of patients on its hypothyroidism disease register and the number of patients on its hypothyroidism disease register as a proportion of total list size. The practice receives a further payment The practice reports the percentage of patients on its hypothyroid register who have had a TSH or T4 undertaken in the preceding 15 months.

Within the Clinical Domain, the baseline £127.26 (2011/12) per point is adjusted up or down for each practice according to the prevalence of each clinical condition for that practice’s patients. With 7 points available, a general practice can be paid up to £763.56 for having a hypothyroid register and carrying out thyroid function testing of at least 90% and recording those thyroid function tests. QOF doesn’t state what thyroid function testing is.

QOF also states that there is a clear consensus on how hypothyroidism should be treated, but does not state what or where that consensus is. NICE operates an online facility which allows stakeholders to comment on current QOF indicators. Comments will be used to review existing QOF indicators against set criteria which include:

• evidence of unintended consequences

• significant changes to the evidence base

• changes in current practice

Comments are fed into a rolling programme of reviews and considered by the Advisory Committee. The recommendations of the Committee will then be fed into negotiations between NHS Employers and the GPC. The online facility is available on the NICE website:

nice.org.uk/aboutnice/qof/c....

GMC and Royal College of General Practitioners

The GMC regulates all stages of doctors' training and professional development in the UK. We promote high standards and ensure that medical education and training reflects the needs of patients, the service, students and trainees.( gmc-uk.org/education/index....

In April 2010, the Postgraduate Medical Education and Training Board (PMETB) was

merged with the General Medical Council (GMC). The Medical Act 1983 requires the GMC to set the standards for training and the end-point to be achieved and demonstrated in order for a doctor to enter the GMC’s Specialist Register or General Practitioner Register. The GMC includes the curriculum produced by the Royal College of General Practitioners (RCGP) which defines the learning outcomes for the discipline of general practice in its List Of Approved Speciality And SubSpeciality Curricula Systems.

gmc-uk.org/education/approv...

Two of the Key Messages of part 3.17 “Care of People with Metabolic Problems”

gmc-uk.org/education/gp.asp

in The Clinical Examples of the core curriculum, are

• As a general practitioner (GP) you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present. You must also be aware of rarer and important disorders such as Addison’s disease, which can be potentially life-threatening if missed

• Biochemical tests can be diagnostic and often necessary for monitoring metabolic and endocrine diseases, so it is important for GPs to know which tests are useful in a primary care setting and how to interpret these tests and understand their limitations

The RCGP curriculum states that, as a Learning Outcome, a GP should, with regard to hypothyroidism:

1.1 Manage appropriately primary contact with patients who have a metabolic problem

1.3 Know the indications for referral to an endocrinologist, metabolic medicine specialist or nephrologist for investigation of suspected endocrine disease, management of complex metabolic problems, or diabetic renal complications respectively

1.4 Understand the systems of care for metabolic conditions including the roles of primary and secondary care, shared-care arrangements, multidisciplinary teams and patient involvement

1.6 Understand the use and main limitations of tests commonly used in primary care to investigate and monitor metabolic or endocrine disease, e.g. fasting blood glucose, HbA1c, urinalysis for glucose and protein, urine albumin: creatinine ratio, ‘near patient testing’ (point of care testing) for capillary glucose, lipid profile and thyroid function tests, and uric acid tests

2.1 Be aware that non-concordance is common for chronic metabolic conditions, e.g. diabetes, and respect the patient’s autonomy when negotiating management

2.6 Recognise the potential for abuse of thyroxine and propose strategies to reduce dosage

3.2 Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations

3.3 Demonstrate a logical, incremental approach to investigation and diagnosis of metabolic problems

6.3 Empower patients to self-manage their condition, as far as is practicable

The curriculum states that an Essential Feature of a GP is

EF1.1 Recognising your central role as a primary care physician in managing diabetes mellitus and hypothyroidism

Of 16 example texts given in the curriculum, none are thyroid (let alone hypothyroid) specific. Eight are diabetes specific, 2 are about obesity, 1 is the British National Formulary, 1 is about Motivational Interviewing and 1 is about Primary Care. Only 2 refer to endocrine disorders and they include diabetes in the title.

Of the Web Resources, 11 are diabetes related, one is about better testing, two are about obesity, one is the DVLA guidelines for doctors regarding driving licences for patients with medical disorders and one is Institute of Chiropodists and Podiatrists.

[helvella Administrator]

What a biased set of statements!

2.6 Recognise the potential for abuse of thyroxine and propose strategies to reduce dosage

This reads as if in all cases dose should be reduced, reduced and reduced again. Is this the cause of the wave of dose reductions we have seen recently?

The dose should damn well be right and there should be no strategy to reduce it if it is right.

[NBob in reply to helvella]

the point is that GPs SHOULD know about hypothyroidism.

However, what they are being taught is out of date and needs revising.

I picked up on part 2.6 of the syllabus. I am not sure what they mean by "abuse". Thyroxine has been abused in some weight loss circles. I hope it means that where abuse is detected, the dose is reduced, rather than a)recognise abuse and b) propose strategies to reduce dosage.

Martyn Hooper of the Pernicious Anaemia Society had members reporting that their GPs were reducing doses of Vit B12. He wrote to the NHS Chief Medical Officer (with evidence) who in turn wrote to every GP warning them not to reduce Vit B12 doses.

Can TUK do the same? I tried searching the blog posts for "reduce" to get some evidence but got no results. Any body at TUK who can search or collate posts about GPs who want to reduce dosage?

[shaws Administrator in reply to NBob]

The point is the neither GP/many endocrinologist no very little about the function of the thyroid gland. This is the Royal College of Physicians' stance. As stated by Dr John Lowe they and the BTA make False Statements.

british-thyroid-association...

[NBob in reply to shaws]

Hi Shaws,

Establishing that GPs shouls know about hypothyroidism is a first step in dealing with GPs.

Good Medical Practice says that a docotor msut work within his/her area of competence. Hypothyroidism therefore is in a GPs area of competence. Not knowing about hypothyroidism is contrary to Good Medical Practice and could be negligent.

Thanks for that . I have that statement and note that it is endorsed by the Royal College of General Practitioners.

According to the RCGPs own syllabus, a GP should leave their training knowing about hypothyroidism. The syllabus states that

"GPs should Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations"

in other words, GPs should recognise signs and symptoms of hypothyroidism and then arrange appropriate investigations.

So then we look at the RCP STATEMENT which says

"It is therefore essential that thyroid function is tested biochemically alongside a careful clinical assessment of the individual patient."

The statement states that clinical features are essential.

If a GP follows his/her training and reads the RCP statement they should know that clinical presentation and signs and symptoms are important.

Where GPs should know better and need some Continuous Professional Development is:

1) the statement is full of errors and misleading statements, is not backed up by evidence or even references.

2)The statement is not NICE guidance. There is a lot of case law to state that guidance is just that - guidance. it is not legally enforceable.

NICE says this about guidance

"Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian/carer."

NICE go on to say In particular, guidance that does not recommend a treatment or procedure, or that recommends its use only in defined circumstances, is not the same as a ban on that treatment or procedure being provided by the NHS. If, having considered the guidance, a health professional considers that the treatment or

procedure would be the appropriate option in a given case, there is no legal bar on the professional recommending the treatment or on the NHS funding it.

Even if the RCP statement were some form of guidance, GPs can deviate from guidance if they have a good reason to do so. Such as...patients getting better with no risk of osteoporosis.

3) GPs also have a duty to keep up to date according to Good Medical Practice and Revalidation checks GPs Continuing Professional Development. As Rod's diligent work in bringing new research to the forum shows, there is a lot of new evidence out there to show that TUK and Drs S, P and M approach is logical and evidence based. So a GP SHOULD know about the developments in managing thyroid problems.

4) not to practice defensive medicine. Fear of being reported to the GMC makes many GPs practice defensive medicine by sticking to the " your blood tests are in range - you are OK, computer says no" approach. However, negative defensive medicine is contrary to Good Medical Practice and is in itself negligent.

The GMC have conducted an internal review of Dr M's last Fitness to Practice hearing and concluded that they cannot say that NO responsible body of opinion would behave in the way that Dr M did in the relation to the suggestion of using thyroxine,and then the GMC brought Dr M's case to an end.

If we can publicise this, more doctors will be free of the fear of GMC hearings for treating patients with blood results in the BTA reference range. and use the knowledge that they should have.

Phew, not bad for a Sunday morning. Now to take the dogs out for a long walk.

[shaws Administrator in reply to NBob]

I can see you've recovered from your upset the other day. I hope it's not too cold for your walk.

When you read what the medical profession say but don't know it us furious. How many patients have continuing ill-health due to 'blindness' , ie cannot recognise one clinical symptom.

[NBob in reply to helvella]

Also of great importance is this

3.2 Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations

this should steer GPs away from the "you're within range" nonsense but they stick to the mantra.

[helvella Administrator]

Have slammed in a complaint about the PDF itself (unsearchable, cannot be viewed by a screen-reader because it is so badly created). And this:

As a general practitioner (GP) you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present. You must also be aware of rarer and important disorders such as Addison’s disease, which can be potentially life-threatening if missed

To me that reads as if thyroid cannot be life-threatening - even if missed.

Rod

[NBob in reply to helvella]

I think that the phrase "such as" is inclusive and Addison's disease is only one example. Addison's disease is more well known than Myxoedema Coma and that should be taught.

Myxoedema Coma is life threatening, as you know. Remember recent posts about patients dying because hypothyroidism was not diagnosed? even when the patient presented hospital resulting in the death of the patient?

[helvella Administrator in reply to NBob]

Yes - I agree about "such as" - but the separate sentence has the effect of divorcing it as if it were one of very few potentially fatal issues.

[puncturedbicycle]

Ironically they do not require clinical evidence to suggest that you're depressed, or rather they will then accept the same kind of 'anecdotal observation' that they reject in the case of hypothyroidism.

[NBob in reply to puncturedbicycle]

DAVID L SACKETT Professor NHS Research and Development Centre for Evidence Based Medicine, WILLIAM C ROSENBERG Clinical tutor in medicine, J A MUIR GRAY Director of research and development, Anglia and Oxford Regional Health Authority,R BRIAN HAYNES Professor of medicine and clinical epidemiology and W SCOTT RICHARDSON, Clinical associate professor of medicine, University of Rochester School of Medicine and Dentistry, wrote in the British Medical Journal in 1996

Evidence based medicine: what it is and what it isn't

It's about integrating individual clinical expertise and the best external evidence

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the

proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice...

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.

Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients...

Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook

approaches to individual patient care...

Doctors practising evidence based medicine will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients;..

Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions...

To find out about the accuracy of a diagnostic test, we need to find proper cross sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow up studies of patients assembled at a uniform, early

point in the clinical course of their disease...

It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false positive

conclusions about efficacy. Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm. However, some questions about therapy do not require randomised

trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external

evidence and work from there.

Good Medical Practice states that a doctor MUST treat a patient as an individual. in other words, not as a sample of a population. Relying on studies and not taking the patient into account is bad science, bad medicine, a breach of Good Medical Practice and can result in harm to patients.

[shaws Administrator]

Yes, you are right -it is diagnosis by blood test alone - they have no knowledge whatsoever of clinical symptoms.