Wednesday, 25 April 2007

Dear Doctor...

A large amount of hospital correspondence flows into our practice every day, and floats around from in-tray to in-tray for a bit, collecting initials before eventually finding its way into the patients' notes. We have not yet implemented scanning and “workflow” of these documents, mainly for technical reasons. It's easy to criticise, but I have identified a number of areas in which the letters can be less than ideal.

They tend to be late. A delay of a month is normal, three months not unusual, and six months not unknown. Apparently secretaries are in short supply due to some very slight problems with funding in hospitals at the moment, but I'm sure our dear Government will have it sorted in a jiffy. Frequently I read about a new diagnosis and recommended treatment in a letter, look on the computer record and find that the patient consulted us, told us the diagnosis and was prescribed the new treatment one month earlier. To be fair this is often because the clinic doctor gave the patient a note to bring to us, in the certain knowledge that the letter would lag far, far behind.

They are not always specific about what the GP is expected to do. This is an area in which our workload has multiplied enormously in recent years. In the “old days” (before the last reorganisation but three) we would refer patients with difficult problems to the hospital, and they would sort them out. Nowadays nearly every third clinic letter mentions some task that needs to be done: starting a drug, changing a dose, checking a blood, arranging some other investigation, making a referral. It is not always clear whether the clinic doctor has done it himself or is asking us to do it, and if the latter then it may not be clear whether the patient has been told. Does she know to come to collect the new prescription or have the blood test? We don't really want to have an extra consultation with our patients after every outpatient appointment.

They sometimes reveal a na├»ve (if flattering) belief in our powers. One of our young men recently attended Casualty with chest pain. The Cas officer added a footnote to his report which I read today, saying “he has not been eating properly for the last two months due to stress, I would be very grateful if you could review this”. We did have some inkling that he was having problems and had been prescribing him antidepressants since before Christmas, although he had been delightfully vague about what his problems actually consisted of. When I last saw him one month ago he looked stressed, told me that he was having nightmares, and added “I've got a lot to say but don't know who to say it to”. Shortly afterwards he was arrested and jailed on remand. He has been in the nick ever since, except when he sallied forth briefly to Casualty with his chest pain. Sadly I am not able to provide tempting and nutritious meals and a congenial stress-free environment inside our local branch of HMP, though I expect that the GMC will include this as one of the Duties of a Doctor in the next revision of their helpful little leaflets.

But I am aware that our referral letters sometimes leave a lot to be desired (I mean, other practices' referral letters, not ours!) and some of my best friends are hospital doctors*, so my criticisms are meant to be both gentle and constructive.

[*] That is to say, I am on speaking terms with at least two.


Dr Michelle Tempest said...

I guess this goes both ways on reading GP letters... but very construcive blog. Thanks.

Dr Andrew Brown said...

I always find psychiatric referral letters difficult to write. The history is often complicated and difficult to encapsulate in a few pithy paragraphs. "Dear Dr Tempest, please see and treat" is so much easier!
Thanks for the compliment.

QUASAR9 said...

It's a two sided coin
or even two edged sword.

Doctors notes (like all notes) are a necessary bureaucracy - so that we have some idea of what is going on - in this case about a patient.

But alas, I think one cannot beat the knowing the patients history personally (not from some file) the knowing the patient from birth to date ...

instead of having to refer to copious notes (or referrals) to be able to recognise the patient on site - and to be able to analyse or address the illness or malady (or symptom) of the day ...

without needing to sift thru paperwork, or historywhich may not help us in any way.

But alas (again), the world is not perfect - or there'd be no sickness or disease or broken bones from the daily play

and the casr would not go wrong, and the washing machine would not play-up, but then how would the doctor, the mechanic and the plumber earn their pay.

Death of a salesmam?
We cannot all run a shop or hope to sell, someone has to be the shopper too. And between the creator or manufacturer and the retailer there's a whole army of paperworkers & bureaucracy along the way.

Thank God, when we want a coffe we are generally 'instantly' presented with one like an espresso

Imagine if we had to read thru the notes of how the coffee bean was grown how it was picked, how it was bagged, how it was roasted & shipped or shipped and roasted, how it was put in a pack or jar, and all the paperwork to get it onto the supermarket shelf or coffee shop and bar.

Mind you the Kenco advert is so concise and so brief, we think there's no more to it than from the machineto the cup ...
and let the aroma the room fill!