That articulated lorry hurtling towards you may be driven by one of your fat beer drinking patients- who just has fallen asleep at the wheel. Sleep apnoea used to be a rather esoteric research field in the backroads of respiratory medicine but is now mainstream or, more alarmingly, main road. Respiratory physicians may joke that if you make your patients wait 45 mins for their appointment, you need only investigate those who doze off in the waiting area. But, if the prevalence is 4% and rising in our increasingly obese population, with links to hypertension and diabetes, perhaps we should take a more active approach. Should we be doing routine pulse oximetry in all our obese patients?
Jon Miles, Chest Physician at North Manchester General Hospital, raised a number of new and challenging issues at the BMJ Masterclass: General Update for GPs, in Manchester and our conversation about sleep apnoea completely changed my perceptions. He made me think again about other aspects of respiratory medicine but I have never heard a speaker so enthusiastic about treating rhinitis. Patients with rhinitis don’t just feel miserable but he showed research pointing out that severe rhinitis may have an impact of on academic performance; there may even be a case for moving academic exams to winter time when hayfever is rare. He advocated specific allergy testing and more aggressive specialist treatment beyond nasal steroids. We may need to think more seriously about runny noses.
The science of symptoms. What? We value the art of medicine and the importance of the clinical history. But we rarely think about quantifying these symptoms. GPs rarely measure breathlessness using the MRC Dyspnoea Scale or New York Heart Association classification (in heart failure). We seldom actually measure the volume of sputum, except in patients with cystic fibrosis, or use sputum colour charts to grade infection. How do you grade the severity of a cough? Jon described a colleague, affectionately known as professor cough, who not only measures cough but can make a specific diagnosis based only on the pattern of the cough. We may not yet have begun to think seriously about the science of symptoms, but we are starting to look at the science of signs. We can already quantify signs to estimate prognosis and, in respiratory medicine the CURB-65 is already well validated. The BMJ is interested in prognosis modelling so, expect to see more about prognostic scales and in the future, I expect to see more research into measuring symptoms.
Do you still use a stethoscope or an ophthalmoscope? So, last century. Traditionally trained clinicians might have come away from the masterclass a little disillusioned: The stethoscope, our traditional garland of honour, may be of little value in respiratory medicine and, possibly in general practice; its sensitivity and specificity is poor. Our ophthalmologist, Dan Nolan, from Pennine Acute Hospital NHS Trust, also questioned our clinical acumen when pointing out that retinoscopy, without pupil dilation, is virtually worthless.
But I did learn some important lessons in contemporary medicine- that in a contact lens wearer, an acute red eye should always be referred to a specialist as lens pressure can harm the corneal micro vessels. And, from Jonathan Bowling, a dermatologist in Oxford, that the allergenic pigment in black hair dye is the same as is used in black henna tattoos, a useful diagnostic test. His dermatology quiz challenged, entertained, and frustrated us. Unsurprisingly, none of the audience could identify Tinea Incognito.
Domhnall MacAuley is primary care editor, BMJ