Yonder: Earache, personality disorder, pain scores, and vulvodynia

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Earache

Given the drive to reduce antibiotic prescribing and the fact that parents tend to be cautious about administering analgesia because of a lack of clear instructions, the management of earache in acute otitis media (AOM) is currently of interest in academic primary care. The PIM-POM trial is a Dutch primary care-based study that tested a multifaceted educational intervention to optimise pain management in children with GP-confirmed AOM. In a linked qualitative study, researchers found that parents struggle to recognise earache and other AOM symptoms.¹ Parents valued the GP’s advice on pain management and were happy to accept pain medication as a standalone therapy, provided that the GP explained why antibiotics would not be needed. The authors conclude that GPs should recognise parents’ lack of understanding of the role of pain medication in managing AOM, and that they should try to address this during the consultation.

Personality disorder

The treatment of people with personality disorder (PD) remains one of the most challenging areas in mental health, primarily because individuals manifest their main problems when interacting with others, including clinicians. Although I have anecdotally heard many GPs talk about the challenges of managing patients with PD, the experiences of GPs have actually received little attention in the academic literature. In a recent Bristol study, 15 GPs of varying age and experience were interviewed about PD.² They described experiencing difficulty with monitoring their patient’s mental health, as well as having little knowledge about the efficacy or availability of treatments for PD. They were aware that this patient population often experienced poor mental health and reported a propensity for them to fall into the gap between primary and secondary mental health services, leaving GPs with little choice but to improvise their own management plans. Better guidance and more responsive patient pathways are most definitely needed.

Pain scores

Commensuration — the transformation of different qualities into a common metric — is a fundamental feature of modern society, as evidenced by the proliferation of rankings, cost–benefit analyses, and standardised tests across a range of institutional settings. Anyone who has examined medical student OSCEs in recent years will know that asking patients to score their pain on a scale from 0 to 10 is now taught as an essential part of medical history taking and is a clear example of commensuration in medical practice. A recent Norwegian study examined the practice of pain score rating in the emergency medical setting, finding that scores were generated as much by clinicians’ own (apparently objective) assessments as they were on self-report.³ This was because they considered patients to be prone to knowingly or unknowingly distorting their pain score, which meant that a reliance on self-report would reduce the consistency and precision of their assessment. The authors conclude that clinicians and others should think carefully about the implications of trying to ‘transform the world through the production of numbers’.

Vulvodynia

Vulvodynia is the commonest cause of vulvar pain. It is chronic in nature, of unknown aetiology, and associated with conditions such as fibromyalgia, sleep and mood disorders, and irritable bowel syndrome. There are typically no abnormalities on examination, and a high chance of it being misdiagnosed as vulvovaginal candidiasis. In order to help understand how patient pathways and outcomes in vulvodynia can be improved, a Dutch research team recently explored the care experiences of a group of affected patients.⁴ They found that women are reluctant to start a discussion about sexuality, and therefore expect a proactive attitude from their GP in this. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP. Promising news for us male GPs.