February 2021

Skin condition appointments are common in GP surgeries 

Skin conditions are one of the most common reasons for patients to present to their General Practitioner (GP). Reports show that there are around 13 million primary care consultations for skin disease each year¹, yet this is one specialty that historically gets overlooked whist at medical school and in training. This can lead to some doctors lacking confidence in diagnosing and managing skin conditions, only made harder by the fact that GPs are often limited to 10 minutes per consultation. In this time, GPs often have to deal with multiple patient concerns and thus not being able to give the time needed to discuss in-depth management of long-term skin complaints, such as eczema.

GP with an extended role (GPwER) in Dermatology

Referrals into secondary care for long term skin conditions, as well as cancer, are forever on the up and thereby the waiting time for non-cancerous referrals is increasing. In 2000, the NHS proposed a new role: GP with a Special Interest (GPwSI) ² now known as GP with an extended role (GPwER). It was expected that the GPwER would work as part of locally integrated services providing intermediate care and relieve the pressure on consultants. Dermatology has been at the forefront of the development and implementation of such service.

I wasn’t looking to become a GPwER when I entered GP training and fell into this path accidently, however I have not looked back since. My journey started with my first day at a new practice as a final year GP registrar. I had a fully-booked clinic and my first patient was a young lady with an ‘on-going rash’. My heart sank as I tried to recall what I had learnt during the 2 weeks at a Dermatology outpatient clinic in medical school. All I could remember was ‘if in doubt trial a steroid’.

The patient was a very pleasant 21-year-old who had a longstanding history of eczema (a condition I was comfortable in managing) with multiple flares. As a trainee, I was fortunate enough to have an extra 5 minutes for my appointments. She spent majority of the time explaining to me the impact that her eczema had on her everyday life and how it had affected her confidence. We went through her medication which consisted of emollients and steroids. It became evident very quickly that her understanding of how to use the creams was limited, as there was no structure to her day-to-day regime. I decided to revisit her management plan. We discussed how to use them, the amounts to use and how to apply. She was surprised at how important each of these steps were. I was also lucky to have a GP in the practice that had a specialist interest in Dermatology, so I asked her to step in to review the patient and my management plan. She was happy with everything we discussed and impressed at how I had taken the time to go through it in such detail. She reassured the patient and booked her a follow-up in the Dermatology clinic that she ran at the practice, and kindly invited me to shadow her.

Dr Ravi Brar

I spent the next year sitting in on these skin clinics, whenever I had the opportunity. I was in awe of how she was able to unpick the diagnosis and how grateful the patients were. Even my eczema patient seemed like a new person – you could see the confidence that she had now that her skin had improved. This sparked my interest in Dermatology.

Completing my special interest was one of the best things I have done. It gives me a varied week in two specialties that I have a great passion for. I am able to carry out my day-to-day GP work that includes being the Clinical Lead for our practice development, but I also hold Dermatology Specialist clinics in the Community in addition to working alongside consultants in secondary care. On top of that, I have a minor surgery list at the hospital where I perform biopsies as well excisions, including non-melanoma skin cancers. Working alongside consultants really does provide invaluable experience, which I can then implement in the community.

My experience has also allowed me start my own skin clinic (sk:INSPIRE), where our main goal is to help educate patients about their skin, promote skin health and help treat various medical skin conditions.

My key tips for anyone interested in GPwER Dermatology

Before discussing my key tips, I feel that I need to stress that I achieved this before COVID-19 changed the world. Keeping this in mind, there is light end of the tunnel and as the situation eases (fingers crossed); there is no harm in planning your future. 

Dermatology is one of the specialities that has a very good framework for GPs as NHS England and the Royal College of General Practitioners (RCGP) have published guidance regarding the accreditation process. This is the best place to start. The framework for Dermatology and Skin Surgery was produced in collaboration with the British Association of Dermatologists (BAD) and the Primary Care Dermatology Society (PCDS). The framework outlines the curriculum and assessment tools to support the accreditation.

You will be required to complete practical clinical work, and this may be the hardest part of the process – finding a department that is willing to take on a GP. Understandably, during the current pandemic, this will be more challenging, but I am positive that as the situation improves, more departments will be amenable to this. This placement is key; since the accreditation requires case discussions, case reflections, learning logs and clinical supervisor observation. More importantly, it is vital to see as many different skin presentations and feel confident in managing them. There are few opportunities seeing patients with a dermatology consultant down the same corridor to discuss with and learn from.

I ended up sending out numerous emails to different hospitals and with the help of my GP practice, I was able to secure a clinical fellow place. Sometimes, certain GP training programmes run ‘retaining schemes’ in order to keep GPs within specific regions so they can help to develop specialist interests. It is therefore, really important that you research all the different avenues.

Once I had secured my clinical role, I enrolled for the Clinical Dermatology diploma at Queen Mary Hospital. This is a 1-year course, with a mixture of distant learning and weekly online assessments, as well as clinical days at the university, and subsequently, two end of year exam papers. Doing the diploma alongside my clinical work was amazing. It allowed me to implement the theory and the clinical aspect helped me to retain the theory. My advice would be to consider doing the diploma only if it can be paired with seeing cases, as otherwise, in my opinion, you cannot get the best out of both.

It was a great year. You have to immerse yourself to get the best out of it and have a plan as to what you would like to do post-accreditation, but I could not recommend this pathway highly enough for any GP looking to develop a special interest. Don’t forget, this is just for Dermatology – there is a drive to develop many other specialities, such as cardiology. This is one of the beauties of being a GP – you get to dictate which way to steer your career and enjoy it to the max!

Dr Ravi Brar

Find Dr Brar on Instagram here.

Donate    Mental health and skin disease report 2020

By donating to skin disease research you are helping us to find treatments and cures for common conditions like eczema, acne and psoriasis through to potential killers like melanoma skin cancer. Thank you.

Useful Links:

1. https://www.rcgp.org.uk/training-exams/practice/general-practitioners-with-extended-roles.aspx
2. http://www.pcds.org.uk

Reference:

1. https://www.bad.org.uk/library-media/documents/consultant%20physicians%20working%20with%20patients%202013.pdf
2. http://www.pcds.org.uk/p/the-primary-care-dermatology-society