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New skills, fewer scripts and less screen time: Resolutions for 2018

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1. Learn a new skill
Rightly or wrongly, one of my fears is deskilling – at a personal level, but also at a macro level as a profession.
 
As Dr Margaret McCartney wrote in the BMJ, the enterprise to streamline medicine by outsourcing certain tasks to protocol-driven non-doctors runs the risk of deskilling generalist doctors.
 
There are probably other reasons for losing our skills, such as policy changes and the costs of consumables and maintaining skills. But we can’t always blame others for everything, so I have decided to learn at least one new skill every year.
 
2. Change prescribing habits
I have made a conscious effort over the years to reduce unnecessary antibiotic prescriptions. I am doing the same with opioid analgesics for chronic non-cancer pain, in line with new RACGP guidelines.
 
In the case of antibiotic prescribing, I had to overcome a few hurdles, such as the fear of not meeting my patients’ expectations or leaving a serious infection untreated.
 
Talking to colleagues was helpful and I found that – after a careful history, examination and explanation – most patients accept a ‘watch and wait’ approach, with appropriate safety netting.
 
I feel better for practising less defensive, ‘play it safe’ medicine, which in the end may not be as safe as we’d like to think.
 
There are parallels when it comes to prescribing opioids. After last year’s GP17 conference in Sydney, I took the RACGP’s 12-point challenge to GPs (refer to list, below) and found that I am now spending more time talking with patients about the pros and cons of opioids.
 
Yes, it is easy to slip up, especially under time pressure and, say, just before lunch or closing time. However, by perseverance the snail reached the ark.
 
I find every small successful dose reduction or non-pharmacological intervention satisfactory. I hope this will be a drive to continue the conversations with patients in 2018.
 
Reducing opioid prescribing in general practice: 12-point challenge to GPs
For acute pain:

• Know when non-opioid analgesics are preferred for acute pain in general practice. For example, headache, dysmenorrhoea, dental pains, minor musculoskeletal strains/sprains.
• Engage a physiotherapist early in more severe acute musculoskeletal injuries.
• Prioritise non-opioid options for people who have been on long-term low-dose codeine preparations.
• If opioids are necessary for severe acute pain, limit prescription to three days’ supply.
• On discharge from hospital, discuss early tapering of opioids as part of recovery process.

For chronic non-cancer pain:

• Maximise non-opioid therapies and multidisciplinary care in chronic pain.
• Avoid opioids for chronic non-cancer pain in patients with an active or past substance-use disorder or unstable psychiatric disorder.
• Where opioid therapy is necessary, ascertain responsiveness below 50 mg morphine-equivalent dose per day and seek assistance well before 100 mg morphine-equivalent dose per day is reached.
• Reassess opioid-responsiveness regularly and often; have an agreed practice system for the 12-month structured review of opioid therapy.
• Undertake intermittent planned reductions of opioid dosage in chronic non-cancer pain management.
• Avoid fentanyl patches for non-cancer pain.
• Where existing patients are on >100 mg morphine-equivalent dose per day for chronic non-cancer pain, trial tapering this dose to more appropriate levels.

3. Spend less time behind screens
Excessive screen time for children may be linked to several adverse health outcomes, so at home we use an app to limit the recreational time our children spend on their devices. This helps to make sure they have opportunities to learn, create and connect in the digital space.
 
This sounds great but, in reality, it is a never-ending balancing act. It also made me realise that I may not be the best role model here.
 
It turns out most adults spend more time on their digital devices than they think, which was certainly true in my case. Some of the time behind screens, such as in the consulting room, is difficult to cut back, but not all screen time is essential.
 
I took a social media ‘holiday’ during the month of December, and it felt good. So this year I will unplug more often from the social media fire hose. I may even read a book.

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12-point-challenge opioid-prescribing

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