Peering into my Johari window
The Johari window was first developed by Joseph Luft and Harry Ingham and it is now often quoted in medical education when considering learning needs. Most GPs live in fear of the unknown unknowns it describes in that bottom right corner. I know the areas I am weak on and I have learned to live with them – I refer to wiser colleagues or scuttle off to the books (or Google). I can book myself on a course, do an e-module or read a paper. It’s the stuff that I am completely, blindly, blithely unaware that’ll keep me awake at night. That’s the stuff that will trip me up and damage a patient; maybe even finish my career. It’s an unpleasant feeling to find any unknown unknown – like walking into school and discovering there is an exam happening you didn’t know about. You know the feeling – the dry-mouthed sinking in the pit of your stomach, the little thump in your heart and the pressure in your bladder.
I had no clue there was a new medication for emergency contraception until I had a chance chat with a colleague a couple of weeks ago. I can remember using Schering PC4 a few years ago – it made a lot of women sick and they often had to be re-dosed but it was a good remedy for women with the crushing morning-after regret and anxiety of unprotected sex. To be fair almost no one admitted to this; it was almost always ‘a split condom’. They took two tablets 12 hrs apart within 72 hours of unprotected intercourse. Then along came levonorgestrel and it got a bit easier – a single tablet and no sickness. Now comes ulipristal. As luck would have it there was a paper in the Lancet just days after my stomach dropping realisation of what I thought was a glaring gap in my knowledge.
The paper was set up as a non-inferiority study but it also included a meta-analysis element. In the past, if you had wanted some post-coital contraception after 3 days your only option would have been to get a copper coil fitted. This option still exists but it’s simply not appropriate in many cases and in young women who haven’t yet had babies barely an option at all. Overall, in the meta-analysis there were 22 (1.4%) pregnancies in 1617 women in the ulipristal group and 35 (2.2%) in 1625 women in the levonorgestrel group. It’s certainly non-inferior and it may even be a little better. The interesting thing about ulipristal is that it seems to show an effect for up to 120 hours. The ‘morning-after’ pill has been stretched to 5 days. It’s an important paper – one likely to change my practice. For most GPs any single paper that will change your practice is a rare and notable beast. I may well prescribe ulipristal the next time I see a woman requesting post-coital contraception.
When I was a medical student I learned all the drugs, I learned their ‘proper’ names, their mechanism of action, their indications, their contra-indications and I committed them all to memory. As I get older I realise I really don’t have the same depth of understanding of some the drugs now used. Apparently ulipristal is a selective progesterone receptor modulator (SPRM). I’ve not heard of that before either.
In this case, I was relieved to discover that ulipristal hasn’t even made it into the BNF yet but the Scottish Medicines Consortium released a statement last month and it has now been accepted for use in NHS Scotland. But it is a sign of the times and one of the alarming professional aspects of ageing is the constant swimming against the tide of medical advances. Many GPs undoubtedly feel they are not waving but drowning. It felt easy for a few years but I graduated in 1997 and I can already feel the chill blowing in through the widening gap in my Johari window.
Glasier, A., Cameron, S., Fine, P., Logan, S., Casale, W., Van Horn, J., Sogor, L., Blithe, D., Scherrer, B., & Mathe, H. (2010). Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis The Lancet, 375 (9714), 555-562 DOI: 10.1016/S0140-6736(10)60101-8
