Wednesday, 5 March 2008

Working late

Long time no blog. But I'm still here.

It's been a bit up and down this week. Yesterday I went to an educational session on sexually transmitted diseases which was very helpful. It was well taught, and I ended up a lot clearer in my mind about an area that can be worrying. Today I tried to stay calm and unstressed but this was difficult as the work kept piling up. As I reached 7pm I saw my last patient of the day who was the fifth “emergency” added to the end of the evening session. I dealt with the presenting complaint, a relatively minor infection. She asked me a question about another matter which I could answer quickly, so no problem there. But she then wanted to discuss two other matters; each would have required a full ten-minutes to deal with adequately, and one would have required a vaginal examination. By this stage my nurse had gone home.

And the fact is that I was weary. After ten hours fairly continuous work and with another half hour's paperwork in prospect before I could go home for my tea, I really didn't want to have to think hard about two more problems. And I don't think it would have been in my patient's best interest to be dealt with by a tired grumpy and resentful doctor. So I gently asked her to make a routine appointment to see me again later.

It is at this point, ladies and gentlemen, that the Government wants me to do another ninety minutes of intensive “out-of-hours” consulting. Feel free to insert your own expletive.

On a different subject, it is now increasingly common for consultants to send copies of their clinic letters to the patient as well as to the referring GP. This often works well. Last week I reviewed a man whom I had referred to the lipid clinic with raised triglycerides. He had already received a copy of the consultant's very helpful letter and been able to consider it, so we were able to have an in-depth discussion straight away rather than me having to explain everything from scratch. But in the same day's postbag I came across a letter from a neurologist who had seen a rather nervous young patient with dystonia. It contained the sentence “I have reassured him that there is no more serious disease than dystonia”, and I wonder what the patient thought when he received his copy.

Being a bit old and fuddy-duddy I share my partner's sense of mild outrage that one local consultant, who pioneered sending copies to the patient a few years ago, now addresses his letter to the patient and sends a copy to the GP. Sometimes he adds a postscript “GP please do so-and-so”. We think this is bad manners. As the patient's regular doctor we have referred him or her to a colleague for advice, and gone to some trouble to write a helpful letter of referral. For the consultant not to reply directly to us seems improper. Perhaps we should invite the patient to write their own letter of referral to this consultant? To be honest it's the least of our worries at present, but I do think that it's another straw in the wind.


The Shrink said...

10 hours clinical toil with another half hour's admin and pressure for another 90 minutes?! Jumping ship from GP land to hospital . . . phew . . . there but for the grace of God go I!

As has been pointed out, even those devoted public servants, our laudable MPs, don't work 12 hours days each and every day (and weekends and night cover too).

Letters. I write back to the GP after each referral's seen. I write to my colleagues about things that are relevant when I want them to do something and would copy the GP in out of courtesy, even though the GP isn't having to act on anything then. After any interaction (even writing a script for 2 months of memantine this morning) I write to the GP saying what I've done.

Seldom do I write to patients.

I used to but patient groups and carer groups locally don't care for it. Our Royal College said it's not typically seen as useful in older peoples' mental health services (and can be unhelpful). For 2 years I wrote zealously but, well, everyone was right. Now I just copy patients in or write directly to them when there's a specific purpose in doing so.

Most correspondence is sharing involved or technical clinical detail between one doctor and another. Governance issues preclude dumbing down and obfuscating salient sensitive details. So that's that, then.

Dr Grumble said...

If you are really keen you can write separate letters to the GP and the patient -

Elaine said...

As a patient, I have receeived one copy of the letter to the GP by a Consultant Neurologist. I very much appreciated it. No other consultants have had the courtesy to do so. When I mentioned this to my last GP, he printed off a copy of his letter from the Consultant Cardiologist.

I really was grateful for the opportunity to read and digest his comments and recommendations so I could discuss them with my GP

Anonymous said...

Good to see you back again, Doc Brown

Good decision on the last patient of the day.

As regards the Government plan :-(

I consider consultants writing to patients to be a risky business and it should only be done if it's been discussed as an option at the time of the consultation.

Being a bit old and fuddy-duddy too, I agree that letters should be addressed to the referring doctor :D

Stay well!

Anonymous said...

Good to see you are back, wondered if you had got snowed under again or left the country!

My experience is that patients generally appreciate seeing copies of the reply from their consultant to their GP. Care is needed with letters to avoid misunderstandings eg terms with different lay and medical meanings and to avoid raising unrealisable expectations raised (eg "please arrange an XYZ scan /daily district nurse visits / supply of equipment etc).

It is sad that your hospital colleague has so dismissed the GP from his mind as not to reply to the referral letter. I am sure it is just thoughtlessness and the consultant may well amend his practice if he realises what a demoralising effect it has on the patient's GP.

In these times when doctors are feeling besieged by the press and the government and even occasional patients, doctors rely on the support of their colleagues as well as the appreciation and understanding of their patients to keep going.

For many GPs the extra ninety minutes tagged onto the end of the day and the extension of the week to include Saturday mornings will be the straw that breaks the camel's back. Although in theory it's voluntary, practices will be put under pressure to deliver and there are no new resources to do it, in fact resources are being taken away from daytime care. Those over 50 are considering retirement and the younger ones are looking at Australia and Canada. What a shame for a country which pioneered the development of general practice and family medicine as a speciality.

Dr Andrew Brown said...

Thanks everyone for your comments, which are at least as interesting as the original post. :-)