practice members, who can then ignore the results of the audit. There is no guarantee that audit will improve outcomes. \200 It may limit our horizons \200\224from the consideration of the vast imponderables of our patients \200\231 lives in a world of death, decay, and rebirth \200\224to a preoccu- pation with attaining tiny, spec i \201 c, and very limited goals. Some doctors fear that in espousing audit they risk transforming them- selves from approach able but rather bumbling carers and curers who per- haps don \200\231t know exactly where t hey are going, into minor administrative prophets, with too much of a gleam in their eyes a nd zeal in their hearts. 507 New ways of extending primary care: two models As we move away from providing care in expen sive high-technology hospi- tals, more is expected of primary care, with implications for c apital expendi- ture, acquiring new skills, and local access to procedures needing expensiv e equipment, eg endoscopy or ultrasound. Whole specialisms such as derma- tology and day-ca se surgery may move out of the secondary sphere, as the distinction between primary and sec ondary care becomes redundant. Antico- agulant clinics are another example of a hospital se rvice which \200\230might as well be done in the community \200\231. How are these develop ments to be structured (taking the NHS as an example)? What are the dangers and opportuniti es? Market-led models Well-capitalized companies take over running general practices, after winning provider contracts from primary care trusts. Such companies create free-standing p olyclinics (eg the Riverside Medical Center1). Alternatively, large supermarkets/pharmacies create in-store health centers. In both, GPs become salaried employees of the company prov iding services. Federated GP-led models General practices club together to purchase equipme nt and consolidate the new skills required. This is the model favored by the Royal College of General Practitioners (Roadmap) \200\224as providing the most \202 exible model which can rapidly adapt to local priorities 32 \200\224and cause the least disruption to existing services \200\224and maintain continuity of care. 163 Under this model GPs develop special interests and \200\230portfolio careers \200\231 play- ing to their strengths in both the clinical and administrative spheres in an increasingly complex health environment \200\224 in which they both commission and provide care. e r a c y r a m i r P Various kinds of federated GP models exist, from informal alliances to lim- ited companies owned and run by GPs, who hold shares in the company. 164 One thing held in common is that they are part of the NHS family, and share core NHS values of inclusivity, fairness and dis tributive justice. The primary motive for their creation is to maintain general-practice-ba sed primary care \200\224and the system whereby patients can see the doctor of their choice near where they live who stands a good chance of having known them for years. Pros and con s The RCGP cautions against developing polyclinics that focus on diseases and technical car e \200\224but it commend the value of co-location of services to reduce fragmentation. What ever models are adopted, the cardi- nal values of general practice such as interpersonal ca re and continuity of care based on de \201 ned populations must be given full weight. Support for registration of patients at multiple primary care outlets \200\224or even regis tration at A&E clinics or urgent care centers is occasionally fa- voured by some NHS and ot her governmental bodies. This may be desirable for some patients working away from their pr actice based location \200\224but such arrangements are bound to lead to expensive and frag mented care (this is why it is not RCGP policy). Also, registering patients with a single g eneral practice allows longitudinal care, lifelong medical records, con \201 dentiality, a nd team-based care to feed into a viable gate-keeping role. This gate-keeping role keeps co sts down and protects patients from over-medicalization. Quality control2 If a service such as INR testing is taken out of the lab and fragmented to a number of smaller community-bas ed clinics, quality control becomes problematic. Ditto for the validation of GPs with speci al interests. Con \202 icts of interest If a GP federation is a for-pro \201 t organizati on (with funds \202 owing from the NHS) and if the doctors are sitting on boards deciding on which services are to be commissioned, there is a con \202 ict of interest. The NHS is establishing procedures to minimize risk from this possibility \200\224but nev- ertheless, probity is a vital issue, for doctors as well as other NHS staff . 1 Clinics may share wit h \200\230sister surgeries \200\231 and provide on-site gynae, mental health, surgical, an d other clinics. 2 If a batch of reagents is faulty, the lab will be onto this at once, but who would know in the communi- ty if a batch of INR test strips was faulty? Perhaps only a fter a series of bloody deaths was investigated. Appraisal, assessment, and revalidation \200\207Appraisal isn \200\231t the same as assess ment. For NHS doctors (yearly appraisal is required) peer appraisal is moving beyond a chat about one \200\231s professional development. 5 areas to address (with data) are: How do I know my clinical care is good? Do I keep up to date? How do I come across to my colleagues and patients? Am I in dialog with my peers to ensure good use of resources (eg prescribing ; referrals)? What have I done about what I have learned? What form does UK appraisal take for GPs? There are 2 administrative forms (Forms 1& 2); then there is Form 3, needing thoug ht and data gather- ing (in protected time) \200\224with a commentary on your work, an acco unt of how it has developed since last year, your view of your developmental needs, and cat aloging of factors that constrain you in achieving your aims, eg: \200 What are the main strengths and weaknesses of your clinical practice? \200 How has the clinical care you pr ovide improved since your last appraisal? \200 What do you think are the clinical care de velopment needs for the future? \200 What factors constrain you in achieving your aims fo r your clinical work? \200 What steps have you taken to improve your knowledge and skills ? \200 What have you found successful or otherwise about these steps? \200 What profess ional or personal factors constrain your skills and knowledge? \200 How do you see your j ob and career developing over the next few years? \200 What are your main strengths and w eaknesses in your relationships with patients? How have these improved? What would you like to do better? What factors in the workplace (or more widely) constrain this? 508 e r a c y r a m i r P What are your main strengths and weaknesses in your relationships with colleagues? How have these improved? What would you like to do better? What factors in the workplace or more wi dely constrain this? Do you have any health-related issues which might put patients at risk? Other areas: Teachi ng; \201 nancial probity; research; management activities. During the appraisal Form 4 is completed and signed by both parties. Form 4 feeds through to Clinical Governance Leads, w ho identify trends and make re- ports to the Trust \200\231s chief executive. Form 5 is a n on-obligatory form containing background ideas supporting Form 4 which may be used to infor m other ap- praisals. Finally there is supportive follow-up (eg a further visit or phone ca ll). Appraisal is a supportive developmental process, a constructive dialog, to re \202 ect on our work, to consider developmental needs, to assess our career, and to consider how we mig ht gain more job satisfaction. \200\230By giving feedback on performance it provides the o pportunity to identify any factors that ad- versely aff ect performance, and to consider ho w to minimize or eliminate their eff ects. It is an important building block in a clinical governance culture that ensures high standards and the best possible patient care. \200\231 Chief Medical 165 Offi cer There is a big question-mark over \200\230ensures \200\231, above. The eff ect of appraisa l on patient care is unknown \200\224but appraisal, it is hoped (and it only is a hope), ca n off er opportunities for interdependent support, self-education, self-moti- vation, and c areer development in the wider medical world. It may also be a catalyst for change and even a tonic against complacency. 166 One criticism is that if appraisals are all about \200\230me \200\231 not \200\230us \200 \231, opportunities for team-building are lost. 167 They may also destabilize by raising un realizable hopes. Appraisal assumes GPs aim to be professional, life-long learners (the \200\230move- &-grow \200\231 aspect of challenging appraisals). If this is not the case, t he less cozy revalidation, performance management, assessment, and mediation will bite. Rev alidation (4 \200\2235yrly) aims to guarantee public safety. Appraisals feed into this. Its 2 core components are 5-yrly relicensure (a function of Royal Col- leges to ensure objecti ve assurance of continuing \201 tness to practice) and spe- cialist recerti \201 cation (affi rmation of maintenance of particular standards patient.co.uk/showdoc/40000773. that a pply to a specialty, eg general practice). 509 Under- and over-performing doctors It would be nice for the public and the \200\230leaders \200\231 of our profession if there were a small number of under-performing doctors who co uld be retrained or struck off . Things are rarely so simple, and we may have to accept tha t, for many rea- sons, including chance, training, and resilience, the performance of all d octors will, at times, be, or appear to be, suboptimal. If all doctors were the same, and t here was a valid yardstick for measuring quality (a big \200\230if \200\231), then there w ould be, by chance, a large under-performing group, with a corresponding apparently \200 \230over-performing \200\231 group. Anyone assessing performance data needs to take into ac count these questions. What counts as data? Usually only what can be quanti \201 ed; quali ty diff ers. Are the data strati \201 ed for risk? Doctors \200\231 case-mixes can vary ma rkedly. Is our personal data \200\231s accuracy validated? Data entry is often unreliable. Has the accuracy of the data we are being compared to been validated? Could the differences between our data and others have arisen by chance? This is the most revealing question. Im agine a thought-experiment in which 4 equal doctors use diff erent strategies for predictin g whether a tossed coin will land heads or tails. One always chooses heads, one always choo ses tails, and the other two alternate their choices out of synchrony with each other. When I did this experiment for a pre-decided 14 throws each (56 throws in total), the best doct or only had 2 errors, whereas the worst had 7 errors \200\224over 3 times the rate for post -operative deaths (or whatever). The public would demand that this doctor be retrained or s truck off , and the General Medical Council might feel obliged to comply, simply to keep pu blic con \201 dence (it is under great pressure to \200\230do something \200\231). So mus t we all be prepared to be sac- ri \201 cial lambs? The answer is Yes, but there are certa in steps that can be taken to mitigate our own and our patients \200\231 risk exposure. \200 When we encounter doctors who are clearly underperforming (eg due to ad- e r a c y r a m i r P dictions) we must speak out. This will encourage belief in the system. For statistical reasons any series with <16 failures might be best ignored. Such series simply do not have enough power to detect real eff ects. We must strive to be both kind and honest with our patients. The best re- sponse to \200 \234I \200\231d like a home-delivery \200\235 might be to say \200\234I haven \200\231t do ne one for 5 years \200\224and that one went wrong: are you sure you want my services? \200 \235 \200\224 rather than \200\234The UK perinatal death-rate is the same for home and hos pital \200\235. \200 It might be the case that, contrary to the GMC, we should not always be on the look-out for colleagues who might be under-performing so that we can report them to the proper authorities: rather we should be encouraging an atmosphere of mutual support and trust \200\224the sort of environment in which doctors feel safe to say \200\234All m y cases of X seem to be going wrong \200\224can anyone think why? \200\235 To stop this tru st turning into cronyism we must be pre- pared to engage in, or be subjected to, audit (p50 6). The alternative is for clinicians to develop into secret police, informers, and counter -informers. No one would bene \201 t from this. We note that malicious informing is not an iso- lated occurrence in the UK; 80% of those suspended for presumed underper- formance ar e exonerated, but few return to their previous job owing to the stresses enquiries always e ngender. Typical areas in which doctors are seen to be under-performing Local Medical Committees (LM Cs), complaints bodies, and NHS commissioners have all been systematically questioned about doctors whose performance they are reviewing. In the case of LMCs, for example, clinical s kills were the chief worry, followed, in order, by communication problems, management prob- lems, prescribing problems, and record-keeping problems. NHS Trusts have more concern over referral patterns. Patient satisfaction Satisfaction is one of the few measures of outcome (not process) which is measurable. What patients mostly want is a personal service from a sympa- thetic doctor or nurse who is nearby and easy to get to see. A 13 million NHS GP survey in 2007 showed that 86% were satis \201 ed on such measures as open- ing hours etc. 168 The following qu estionnaire1 further quanti \201 es satisfaction. 169 510 1 I am totally satis \201 ed with my visit to this doctor. 2 Some things about my visit to the doctor could have been better. 3 I am not completely satis \201 ed with my visit to t he doctor. 4 Professional care: This doctor examined me very thoroughly. \200 This doctor told me everything about my trea tment. \200 I thought this doctor took notice of me as a person. \200 I will follow the d octor \200\231s advice because I think he/she is right. \200 I understand my illness much better after seeing this doctor. 5 Relationships: This doctor knows all about me. \200 I felt this doctor really knew what I was thinking. \200 I felt able to tell this doctor about very personal things. e r a c 6 Perceived time: The time I was allowed with the doctor was not long enough to deal with everything I wanted . \200 I wish I could have spent a bit longer with the doctor. y r a m i r P Why do patients change their doctor? The most common reasons are that either the patient ha s moved, or the doctor has retired or is perceived to be too far away. Additional reasons a re described in the table. 170 Patient needs One doctor for all the family Wants woman GP 4 % Rude receptionist Wants alterna- tive medicine Obstetric needs Organizational problems Problems with doctor 5% Long waits 13% Lost con \201 dence in 6% Uninterested/rude 6% Prescriptions criticized 1% Doctor too hurried 1% Visits problematic 1% Communication poor 21% 20% 5% 4% 4% 4% No continuity of care Wants appointments 2% Wants open surgeries 1% Other staff rude A USA study found that a participatory decision-making style leads to pa- tient satisfactio n. Participation was found to depend, in part, on the degree of autonomy perceived to be en joyed by the GP, and on the volume of work. 171 Another approach to gaining satisfaction is to agree and publish standards of care patients can expect, with performance \201 gures for how well these stand- ards are met in practice. This is the philosophy behind the UK go vernment-led Patient \200\231s Charter/British Standards Kitemark BS5750, which aims to: \200 Set standards, eg by agreement with patient participation groups (p496). \200 Monit or progress towards these standards, and publish progress locally. \200 Provide informati on about how services are organized. Maximize choice. \200 Let users know who is in charg e of what, and what their roles are. \200 Explain to users what is done when things go wr ong, and how services are improved, and what the complaints procedure is. Show that taxpayers \200\231 money is being used effi ciently. \200 Demonstrate customer satisfaction. This culture has proved alien to some GPs, perhaps due to a very necessary pr eoccupation with illness and curing, rather than service and its glori \201 cation. 1 The only merit of this questionnaire is its brevity: validity is not assured. The best va lidated is EURO- PEP. 172 The UK QoF system has relied on less well validated Improving Pra ctices Questionnaire (IPQ) or the GP Assessment Questionnaire \200\224GPAQ. It asks about t he practice (eg 48h access) and staff (respect, con \201 dentiality) as well as individual doctors. Formal evaluation (2007) shows they are unreliable. 173 511 Expert patients: plagues, time-wasters, or inspiration? The term expert patient was coined to denote a well-informed patient in full possession of the facts about his or her case, an d contributing to decisions in a valid way. Doctors often fear the expert patient, as so mu ch time has to be spent investigating whether their viewpoints really are valid. This may l ead to lack of harmony in the consulting room. The inherent contradictions and strengths in the idea of expert patients are revealed throu gh reductio ad absurdum (a logical technique beloved of Socrates). 174 Imagine a urologist consulting his GP about whether to have a radical prostatectomy or radiotherapy for his new ly diagnosed prostate cancer. The GP might say to himself: \200\234Why on earth is he cons ulting me? He knows far more about the options than I do. \200\235 But let us imagine that his GP is, in fact, Socrates, who proceeds to ask various questions to reveal his in- ner f ears (incontinence, erectile problems), and what he hopes to achieve by the various treatme nts on off er (to live long enough to see his disabled son through school). Socrates-the-GP is not adding any new facts. He is twisting the kaleidoscope, so that new patterns come in to view. When a coherent pat- tern emerges he shows the urologist the door \200\224saying \200\234Let me know what you decide \200\235. The urologist sincerely thanks him. The man w ho leaves such a consultation is not the same as the one who entered. \200\207The expert p atient has met a different sort of expert. e r a c y r a m i r P A 6-week course in self-management, eg in arthritis self-care 1 Course overview; acute and chronic conditions compared; cognitive symptom management; better breathing; intro- duction to action plans. 2 Feedback; dealing with Greater patient involvement in health issues and in the decisions relating to patients \200 \231 own illnesses may lead to greater satisfaction, and better health. The more the patien t knows about his or her own set of diseases, the better he or she will be able to decide w hat treatments to opt for. This is the rationale behind the expert patient programs (BOX). These are congruent with Bandura \200\231s social-cognitive theory of behav- iour, which sa ys that the main predictors of suc- cessful behavior change are con \201 dence (self- effi cacy) in the ability to execute an action and expectation that a speci \201 c goal will b e achieved (outcome expectancy). Expert patients (who are con \201 dent and assertive) are said to live longer, be healthier, and have a better quality of life, 175 and are exemplar s of what health is all about (in chronic disease, health is not the absence of de- cay but an optimum, dynamic adaptation to it, p472). anger, fear & frustration; introduction to exercise; making an action plan. 3 Feedback; dis traction; muscle relaxation; fatigue management; monitoring exercise; action plans. 4 Feedback; actio n plans; healthy eating; communi- cation; problem-solving. 5 Feedback; making an action plan; use of drugs; depression management; self-talk; treatment deci- sions; guided imagery. 6 Feedback; informing the health care team; working with your health care professi onal; looking forward. Nonetheless, there is a group of expert patients who tend to be middle-class know-alls who con- sult at great length about various maladies, ar- riving with sheaves of Internet print outs about treatments you have never heard of. Don \200\231t reject these patients out of h and. And don \200\231t assume any sort of superiority or inferiority. Just give your advice as best you can. You may get better re- sults than Socrates \200\224whose last attempt at reductio ad absurdum (during his famous trial) ended fatally when he was forced to drink he mlock. He was right \200\224but it didn \200\231t do him much good. And so with you: you do n \200\231t always have to be right. And by not insisting on this you may live to consult a nother day. NICE 176 Stopping smoking tobacco NHS targets aim to decrease smoking from 26% to <21% by 2 010 and to <15% by 2018: rate of progress was only 0.3%/yr, 177 until the smoking in publi c plac- es ban in England in 2007. This has helped \200\206400,000 people quit. 178 512 Epidemiologists say that 50% of smokers will die of smoking if they don \200\231t quit, lo sing 25 years. Stopping smoking diminishes excess risk from tobacco, so that after 10 \200 \22315yrs the risk of lung cancer approaches that of lifelong non- smokers (but a few genes involved in DNA repair may never return to normal functioning). 179 A similar but quicker decrease of excess risk (halved in 1st year) is found for deaths from coronary disease and, to a lesser extent, risk of stroke. 180 \200\20760% of smokers want to give up, and givin g help achieves more QALYs/ than any other intervention ( 221 \200\223 9515/QALY). \200 181 ,182 Annual UK health costs of smoking \200 GP prescriptions: > 52 million Adva ntages of stopping smoking Saving of life (110,000/yr in UK). \200 Larger babies (smokers \200\231 babies weigh on average 250g less than expected, GP consultations: > 89 million \200 Hospital episodes: > 470 million and their physical and mental development may be less than optimal). Less bronchitis (accounts for millions of lost working days). \200 Less risk from the Pil l: cardiovascular risk \200\200 \211\21020 if uses >30 cigarettes/day. \200 Less risk fr om passive smoking (cot deaths, bronchitis, lung cancers). \200 Return of the sense of ta ste and smell \200\224and relative wealth. To quit (AAMAA=ask, advise, motivate, assist, ar range follow-up.)183 1 Ask about smoking in all consultations (not just where relevant; be subtle; patients won \200\231t listen if agendas clash). Greet any success with enthusiasm! e r a c y r a m i r P 2 Advise according to need. Ensure that advice is congruent with beliefs. 3 Motivate patien ts by getting them to list the advantages of quitting. 4 Assist in practical ways, eg negot iate a commitment to a \200\230quit date \200\231 when there will be few stresses; agree o n jettisoning all smoking junk (cigarettes, ash trays, lighters, matches) in advance. Infor m friends of new change. \200 Nicotine gum, chewed intermittently: \211 ten 2mg sticks ma y be needed/day. Transdermal nicotine patches may be easier. Written advice off ers no adde d bene \201 t to advice from nurses/GPs. Review at 2 weeks; people sense (and act on) your commitment. Only re-prescribe if abstinent. 184 \200 Varenicline is a selective nicotine receptor partial agonist, which NICE rec- ommends as an adjunct to behavioral modi \201 ca tion. Start 1 week before target stop date: initially 0.5mg/24h PO for 3 days, then 0.5mg/1 2h for 4 days, then 1mg/12h for 11 weeks ( \200\201 to 0.5mg/12h if not tolerated). SE: ap- petite change; dry mouth; taste odd; headache; drowsiness; dizziness; sleep disorders; odd dreams; panic; dysarthria; acne; dysuria. Advise to stop if agitated, depressed or suicida l. Bupropion: see BNF. 5 Arrange follow up \200\224until that date consider texting patients (get consent) to send messages of encouragement (can \200\200quitting from 13 to 28%). 185 N=1705 For those who do not want to give up Give them a health education lea \202 et, record this fact in the record, and try again later. \200\20725% of school leavers smoke regularly. T he Health Education Council has a smoking education project for schools. It has been commen ted that smok- ing rates may not be rising too fast in children owing to cost, and to mobil e phones, which are cheaper, and just as good a fashion accessory. Every health \200\230ou tlet \200\231 should have a policy on promoting non-smoking and off ering practical advice: primary health care teams; hospitals; midwives; pharmacies \200\224and also, perhaps, scho ols and employers. Health commissioners also need to promote knowledge and training in this area. 186 Reducing alcohol intake UK alcohol death rate: >20,000/yr 187 The problem isn \200\231t alc ohol, it \200\231s life \200\224lives in which sobriety poses insuperable problems: conscio usness of futility, debt, responsibility, and social inhibitions. Alcohol obliterates all t hese, and will continue to do so, until other methods are more attractive. Cheap alcohol an d peer pressure matter too ( \200\234if I don \200\231t get pissed every Saturday and play sex games, I \200\231d seem like a freak \200\235). 188 513 With the toll that excess alcohol takes in terms of personal misery and the national purse (> 1.6 billion/yr UK), the need to reduce alcohol use and its root causes intake should be almost top of government \200\231s social policy goals. But a powerful industry ensures th at alcohol is cheaper (relatively) and more readi- ly available than ever before \200\224so that its use on an individually moderate scale arouses no comment. It is assumed to be saf e, provided one is not actually an alcoholic. It is more helpful to view alcohol risks and bene \201 ts as a spectrum (see OHCM p236 for the bene \201 ts of alcohol). Problems are listed on p363. \200\207A strategy to reduce bad eff ects of alcohol in your patients migh t comprise: \200 If a symptom could be alcohol-related, ask in detail about consumption. \200 Question any patient with \200\230alerting factors \200\231 \200\224accidents, driv ing off ences, child neglect, assault, attempted suicide, depression, obesity. Question oth - ers as they register, consult, or attend for any health check. Helping people to cut down \200\207Time interventions for when motivation is maximal, eg as (or before) pregnancy st arts. Small reductions do matter. 189 \200 Take more non-alcoholic drinks; reduce the sip frequency, eg by shadowing a slow drinker in the group. Don \200\231t pick up your glass u ntil he does (and don \200\231t hold your glass for long: put it down to avoid unconscious sipping). e r a c y r a m i r P Limit opening hours; don \200\231t drink alone or with habitual drinkers; sip, don \200\231 t gulp. \200 Don \200\231t buy yourself a drink when it is your turn to buy a drinks \200 \231 round. \200 Go out to the pub later (but some pubs now open all night). \200 Take \200\230days of rest \200\231 when no alcohol is used. Try \200\234No more for me please, I expect I \200\231ll have to drive Jack home \200\235 or \200\234I \200\231m seeing what it \200\231s like to cut down \200\235. Agree goals to maintaining \200\201drinking An al cohol diary helps get facts right. \200 Teach him to estimate his alcohol intake (U/week, see below). \200 Consider an \200\230Alcohol Card \200\231 which the patient can bring to each visit to show: units/week; pattern of drinking; reasons for misuse; each alcohol-re lated problem (and whether a solution has been agreed and action implemented); job record; family events; biochemical markers (GGT, MCV); weight. \200 Give feedback about how he is doing \200\224eg if GGT ( \200 -glutamyl transpeptidase) falls are discussed at feedback, there is much lower mortality, morbidity and hospitalization compared with randomized contr ol subjects. \200 Enlist family support; agree a system of \200\230rewards \200\231 for sobriety. \200 Group therapy, self-help groups, disul \201 ram, local councils on alcoho l, com- munity alcohol teams and treatment units may also help (p363). Setting limits for low-risk drinking eg \211 20U/week if \200 ; \211 14U/week if \200 \200\224 there are no absolu tes: risk is a continuum. NB: higher limits are proposed, on scant evidence (eg 4U/day; 3U for women). One unit is 9g ethanol, ie 1 measure of spirits, 1 glass of wine, or half a pin t of ordinary-strength beer. 190 \200\207Primary care is a good setting for prevention: in tervention leads to less alcohol con- sumption by 15%, reducing the proportion of heavy dr inkers by 20% \200\224at one-twentieth the cost of specialist services. 191 There is no evi dence that GP intervention has to include more time-consuming advice such as compressed cog nitive/behavioral strategies. 192 Simple advice works \201 ne as judged by fall- ing GGT levels, at least for men. After interventions, women may report drink- ing less, but this i s not re \202 ected in a falling GTT. 192 Does education work? Rarely: as medical students , we do drink less in the \201 nal year, compared with year 2; but, overall, 27% are prob lem drinkers. 193 Should we all write and implement a personal alcohol policy? \200\207 \200\231No doctor should practice after even 1 glass of wine. \200\231194 Domestic and intimate partner violence This is common but often unreported. It includes phy sical, sexual, emotional, and psychological abuse. It is rarely isolated, and often escalat es in severity and frequency and involves children in 50 \200\22370%. 195 \200\207Ask dire ctly about this, eg in antenatal clinics (risk is \200\200 during pregnancy, and the life of the mother and baby are more at risk). 196 Distinguish between generalized aggressors, f ami- ly-only aggressors, and non-family-only aggressors. Once violent always vio- lent? Thi s unfair generalization is less likely to be true for family-only aggres- sors. 197 This an important, as with each subsequent act of violence, guilt is less, at least when women are perpetrators 198 (violence is not male only, and same-sex partnerships are equally or more violence-prone). 199 \200\230To respond to violence only as a crime of a single party is a near guarantee of failure to re- duce future violence. Violence can be reduced only by tr eating each incident as an opportunity for all parties \200 to explore their own involvemen t in and re- sponsibilities for violence. Arbitrary \200\230punishment \200\231 of individ uals for collective violence is, like most punishment, itself a form of violence. Arbitrary assign- ment of blame is an evasion of responsibility on the part of the blamer \200 Most strategies are primarily focused on blame and criminalization, are thus inher- ently counte r-productive, resulting in the observed high rates of recidivism. \200\231 200 A model of v iolence? Think of a 3-stranded noose: past patterns of mutual violence twisting in and out of known family and personal psycho pathology, shot through by the central problem of power imbalance. 201 What tightens this noose (and around whose neck) depends on random dyadic e vents and loosened inhibitions, related to drugs, alcohol, or sexual jealousy. How to un- t ie this knot? There is only one way: dialog (humor, honesty, and hope). Epidemiology 35% wo men experience domestic violence at some time; 1 : 10 in the last year. 30% of domestic vi olence starts in pregnancy. 202 Police record >1 million incidents of domestic violence/yr (1 in 4 of UK assaults). Of women murdered, 40% are killed by a current or ex-partner. Thos e who are abused are: Likely to get PTSD ( \200\20642 \200\22327%; p347); 203 5 \200\2239 \211\210 more likely to abuse alcohol/ drugs; 3 \211\210 more likely to be psychotic/depre ssed; 5 \211\210 more likely to commit suicide; and 15 \211\210 more likely to miscarry t han non-abused women. Their part- ners are more likely to have many sexual partners without using condoms, \200\200risk of HIV; 204 fear of violence may inhibit disclosing serology to partners. 205 The abused may attend frequently with trivial or non-existent complaints. They may minimize signs of violence; be evasive or reluctant to speak in front of partners, and partners tend to be ever-present, so that it is diffi cult to talk to the client alone . This can be most diffi cult if the partner is needed for translation purposes ( \201 nd another translator who is not from the family). Social Services can help women disclose vio lence (eg after unexplained in- jury etc). Ask about abuse in antenatal clinics so that iss ues can be addressed before injury. Involve social services if children are involved (p146) . Refuge The Women \200\231s Aid Federation (0345 023468uk) can provide legal advice, emoti onal support, refuge, and police liaison. Court orders are obtainable quickly, and may be t he only way to stop men going near previous victims. 206 They may also require someone to l eave home, or let the victim return home. They are not long-term solutions, but can save li fe. In the UK, Law Centers give access to legal protection: to \201 nd the nearest, phone 0207 387 8570 \200\224or the patient \200\231s solicitor may be available. The police may also need calling. Prevention Lack of full-time employment is a leading predictor of who is going to get abused, 207 but simply saying \200\234Go out and get a job \200\235 rarely h elps. See also Child abuse, p146. Parent \200\223child interaction therapy (PCIT)1 is one v alidated way of reducing family violence. 208 This off ers practical help in rec- ognizing antecedent events which tend to trigger violence. 1 Through a one-way mirror, the therapist watches parents interact with the child. The parent wears a device in the ear to receive h elp & real-time feedback from the therapist next door. 514 e r a c y r a m i r P 515 Sustainability, and alternative/holistic medicine We need to know about alternative medicin e to understand our patients \200\231 - undeclared distress, which use of these treatments is so often a sign of. We can also advise on the safety of various therapies. We must also learn from therapists about patient-centered care, and the sustainability of healthcare. Th is entails systems of interacting methods to restore and optimize health that have an ecolo gical foundation, that are environmentally, economically and socially viable inde \201 nit ely, and that function harmoniously both with the human body and our wider environment, and that do not result in unfair or disproportionate impact on any ecosystem. Alliance for Nat ural Health www.anh-europe.org Some alternative therapies are the orthodoxies of a diff erent time (eg herb- alism) or pla ce (the Ayurvedic medicine of India), some are mainly diagnostic (iridology), some therapeu tic (aromatherapy). Some doctors are suspicious of unorthodox medicine, and feel that its p ractitioners should not be \200\230let loose \200\231 on patients. But in many places the law is that, however unorthodox a practi- tioner may be, he or she cannot be convicted of u nethical practice in the ab- sence of clear harm. Many people ( 5 million/yr in the UK) con sult alternative practitioners, often as a supplement to orthodox treatment. Some will feel unable to tell their doctor about trips to alternative therapists, unless asked. e r a c y r a m i r P Modern medicine is criticized for sacri \201 cing humanity to technology, and with little bene \201 t for many people. In contrast to the orthodox doctor, alter- native therapists is seen as taking time to listen, laying on hands rather than instruments, and giving medic ines free (not always!) from side eff ects. Acupuncture: Can treat many ailments; increasin gly used in orthodox prac- tice for pain relief, control of nausea and treatment of addicti on. For these, endorphin release provides a scienti \201 c rationale. Homeopathy: is based on the idea that \200\230like cures like \200\231, and that remedies are improved ( \200 \230potentiated \200\231) by increasing dilution. Randomized trials show no greater effi ca cy than placebo, or suggest real (small) bene \201 ts, eg in asthma. Manipulative therapie s (osteopathy; chiropracty) are widely used and may help musculoskeletal and other problems , eg asthma. Yoga: This is an ancient Indian discipline with physical, mental, and spiritua l components which aims to achieve a state of spiritual insight and tranquility. Randomized trials show that yoga can produce worthwhile bene \201 t. 209 Clinical ecology: Starting from the fact that atmospheric pollutants, toxins, and xenobiotic chemicals (from other org anisms) are known to be harmful, a system is built up around techniques (using intradermal injections) for pro- voking and neutralizing symptoms related to foods. Holism: Holism enta ils a broad view: of the patient as a person, of the role of the therapist, of the therapie s used. The patient \200\231s autonomy is encouraged through involvement in decisions, and nurturing of self-reliance. \200\207Specialism doesn \200\231t exclude holism: nephrologis ts can be as holistic as naturopaths. As shown on p478, most models of the GP consultation are based on a patient- centered holistic approach. Compare the sequence \200\230bronchiti s \200\203antibiotic \200\231 with \200\230bronchitis \200\203smoker \200\203stressed \200 \203redundancy-counseling \200\203?antibiotic \200\231. \200\235Doctor, can I use alternat ive therapy for HRT? \200\235 One answer might be: \200\234Ex- tracts from red clover (Tri folium pratense), soybean (Glycine max) and black cohosh (Cimicifuga racemosa; eg 8mg of st andardized extract PO/24h) are of- ten used. Some trials support their use, 210,211 but the se are active agents that might have the same SEs as HRT. Finding out might cost millions . You could try them, and you might well be lucky. \200\207Beware advertising in \202 uen ces. \200\235 212 Integrative medicine: This is a patient-centered, interdisciplinary, non- hierar- chical mix of conventional and complementary solutions to case management of patien ts with complex problems, eg chronic low back or neck pain. 213