This is a re-written version of a blogpost that I put up on northerndoctor.com back in 2008. The death of Jack Klugman seems an appropriate time to post a small tribute.

Kick back and enjoy the classic opening theme for a minute. It’s a proper little earworm – I’ll be humming it for days now. Doo doo-doodoo doo dooo!

One of my resolutions when teaching medical students is to stop making cultural references that are likely to be met with blank looks.  Partly because it baffles the students – most of them were not born when Quincy was in his pomp – but mainly because it is mildly depressing for me.

Quincy, M.E. is the reason I am a doctor.

With no doctors in my family, and in the pre-internet universe (how did we cope?), my view of the medical profession was limited to 1980s television. That really didn’t extend much beyond Quincy, early Casualty and that programme, Doctors to Be, that followed some St Mary’s medical students through their course. That really was it. Exposure to Quincy at such an impressionable age meant that I initially assumed I would go on to be a forensic pathologist. The postmortem scenes may look tepid by today’s maggot-ridden standards but at the time they were thrillingly morbid. However, when I arrived at medical school in 1992 I was very quickly disillusioned after about 5 minutes into our first histology lesson. Squinting down microscopes at pinkish-purplish blobs with my defective colour vision meant pathology quickly lost any glamorous associations with Quincy.

Klugman was magnificent as the character and Quincy remains a great, albeit fictional, role model. He was phenomenally tenacious with exemplary clinical skills. Most importantly, he had a moral compass second to none. All of this was allied to an ability to sniff out a corporate murder from the other side of the county. He was also a bit of a one for the ladies and he enjoyed a good rant at stifling bureaucracy. What a legend.

This is my 20th Clinical Update – you can access them all here. Or jump to the bottom to learn about SMMGP.

The papers covered this time are:

A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 1996-2006. Merrall ELC, Bird SM, Hutchinson SJ. Addiction 2012. Published online ahead of print. 

This study showed that there is an increased risk of death in folk who have recently been in hospital and are also registered with substance misuse services in Scotland. Even those who hadn’t stayed overnight showed an increased risk of death.

Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Benningfield MM, Dietrich MS, Jones HE, et al. Addiction 2012;107 Suppl 1:74–82

This was a secondary analysis from the excellent MOTHER study. Women who had just anxiety were more likely to drop out. Women who were just depressed were less likely to leave treatment.

Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012;107 Suppl 1:5–27.

This was a huge review that lays out all the most recent evidence for buprenorphine treatment.

‘Subutex is safe’: Perceptions of risk in using illicit drugs during pregnancy. Leppo A. Int J Drug Policy 2012;23:365–73.

This qualitative study highlights some of the wider issues in women who use during pregnancy: far too often health care professionals get stuck in the ‘biomedical discourse’ without considering other areas.

Heroin users’ experiences of depression: a qualitative study. Cornford CS, Umeh K, Manshani N. Fam Pract 2012;29:586–92.

Another qualitative study from the remarkable Fulcrum Medical Practice in Middlesborough.

Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Grattan A, Sullivan MD, Saunders KW, et al. Ann Fam Med 2012;10:304–11.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Minozzi S, Amato L, Davoli M. Addiction 2012. Published online ahead of print. 

These two papers look at different aspects around the problems of prescription opioid misuse.

The challenges of reducing tobacco use among prisoners. Richmond RL, Butler TG, Indig D, et al. Drug Alcohol Rev 2012;31:625–30.

‘Do more, smoke less!’ Harm reduction in action for smokers with mental health/substance use problems who cannot or will not quit. Baker AL, Callister R, Kelly PJ, et al. Drug Alcohol Rev 2012;31:714–7.

These two papers draw together papers on smoking cessation in some very challenging groups who have high rates of smoking.

Widening access to treatment for alcohol misuse: description and formative evaluation of an innovative web-based service in one primary care trust. Murray E, Linke S, Harwood E, et al. Alcohol Alcohol 2012;47:697–701.

A web-based service that helps address alcohol may seem like a good wheeze but, in practice, there are many problems and barriers to overcome.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. MacArthur GJ, Minozzi S, Martin N, et al. BMJ 2012;345:e5945–5.

A solid BMJ systematic review that makes it clear that opiate substitution therapy remains a key intervention to prevent HIV transmission. Yet, globally, only around 6-12% of people who inject drugs will receive it.

Benzodiazepine use and risk of dementia: evidence from the Caerphilly Prospective Study (CaPS). Gallacher J, Elwood P, Pickering J, et al. J Epidemiol Community Health 2012;66:869–73

A UK based cohort that shows that there is a clear association between benzos and dementia. Some aspects of the paper seem to rule out reverse causation but there wasn’t a dose-dependent relationship – so whether benzos are causal is not yet clear.

Would it be appropriate for the Royal College of General Practitioners to run an alcohol-based event as a fundraiser for the new building at Euston Square? Apparently so.

Unfortunately, the RCGP website has rather highlighted the tension here. On one hand, it is perfectly reasonable to enjoy alcohol in a social context. On the other hand, alcohol is a massive public health problem with significant costs and harms to individuals and society. It seems the RCGP can cater for all viewpoints.

William Pickles

This month in the BJGP, the editor, Roger Jones, reviews open access publishing. There are lots of issue around open access and these are well summarised in the article. In general, open access is regarded as A Good Thing. I wouldn’t disagree.

Organisations such as the Wellcome Trust, the Research Councils UK, and National Institute for Health Research all have plans, or at least aspirations, to make the research that they fund open access. However, there are clear financial implications for some journals with the risk they could go to the wall if they don’t manage their income. Personally, I’m not sure that’s necessarily a disaster – arguably, there are far too many journals publishing too many papers of dubious quality.

The BJGP have analysed their papers from the past 2½ years. They reckon around 50% would have had APCs (article-processing charges) in their research grants. However, 50% wouldn’t and 38% were from outside the UK. Clearly, there is a risk that this research wouldn’t have made it into publication.

The current range for APCs in medical publishing is around £1000-2500 per article; not a large fraction of a major research grant, but a very significant sum for research that is not externally funded or which has been conducted with no funding at all.

I’ve been recently involved in a piece of ad-hoc research. It’s been through peer review and accepted by an open-access journal and we are now trawling around various departments in the university in a bid to find some funding. It’s a problem.

General practice has a rather proud tradition of research in the community. William Pickles, the first president of the College, came to light for his epidemiological work in Wensleydale. And I admire the work of Doug Jenkinson – a now retired GP who studied hundreds of cases of pertussis in his own practice over a long career. Perhaps there is no room for the amateur (not that I would classify the quality of work as amateur in those cases) in research these days but it would be a shame if an unintended consequence of open access was to close off these avenues. It isn’t necessarily desirable that community and primary care research becomes confined to academic silos.

So, I wonder if some kind of hybrid model may be most appropriate for the BJGP. I’ll watch with interest.

Roger Jones (2012). Open access publishing: a new direction for medical journals BJGP, 62 (603), 514-515 DOI: 10.3399/bjgp12X654830

The MPS continue with their excellent twice yearly edition of Sessional GP. I’m still writing the back page article for them – this time it’s The irony of complaints where I get to muse on the various aspects of complaining and moaning that we all do in the NHS.

Sessional GP is a good idea. There is a very real risk that sessional and locum GPs can feel excluded from many publications that emphasise practice-specific systems and risks. Of course, it’s not like we do radically different jobs to GP principals but there are some subtle and meaningful differences.

It’s all available for free online. If you want to delve into the individual articles you can follow these links:

• In the dark: Risks of telephone consultations

  Dr Tony Males looks at the skill-set required for consulting on the telephone in order to safeguard patients

• Revalidation watch

  Dr Rachel Birch is in the first wave of GPs going through revalidation; she shares her experiences

• Home visits

  Dr Zaid Al-Najjar explains the art of telephone triage

• Don’t miss the signs

  Charlotte Hudson explores all guidance surrounding child protection

• How to create a patient safety culture

  Julie Wilson discusses how to build a patient safety culture in primary care

• From the outside looking in

  Terri Bonnici highlights the locum’s role in the complaints investigation process

• In the hot seat: Dr Susan Stone

  Dr Susan Stone shares her battle plans for getting commissioners to engage with sessional GPs

• Final thought: The irony of complaints

  Blogger and locum GP Dr Euan Lawson [er, that's me] says that when it comes to complaints we should be grateful that thorns have roses

Or you can read an interactive version of the PDF at the link below:

http://www.medicalprotection.org/Default.aspx?DN=e636d167-4a53-4197-b63c-9222315e2c68