But first: why the hospital doctor who thinks that they have had an inappropriate referral probably has an educational need.
Every day, around the world, there is tutting by hospital
doctors about the inappropriate referrals that they receive from primary
care. If we assume that both clinicians
believe in good patient care and the best use of resources then someone must
have an educational need for this situation to take place. My question is: who has that need?
Let’s take a fictional yet real example: a baby with an
umbilical granuloma. The child has apparently been
sent to the paediatric emergency department by the clinician who saw them in
Primary Care. The emergency department
doctor sees the child, noting the inappropriate use of the ED to filter referrals
from a GP. They complain but accept
their lot and assess the child but then send the child back to the GP.
Imagine that we could get the two clinicians to sit down and
discuss what happened. What the GP trainee
who saw the child would say was that they thought that the child had an
infection of their umbilicus, which they know to be a risk for sepsis in
babies. They tried to refer the child
but they were passed back and forth between the paediatricians on call who said
that this was a lump and therefore surgical, while the surgeons said that
umbilical infections should be referred to the paediatricians. In the end there was confusion and in the
process both teams thought that the other had accepted it and the faxed letter
from the GP never found an owner.
So the ED doctor might have been more sympathetic and less
likely to say that the ‘referral’ was inappropriate when they found out that it
was not a referral. What the GP trainee
might have learned is that umbilical granulomas often have a degree of discharge and look messy but that
doesn’t equal infection. They may have
been interested to know that many clinicians are adopting a ‘leave it alone’
approach to umbilical granulomas since they have a natural tendency to
resolve. (1) Some advocate hypertonic saline (2) as a topical treatment but ultimately if left alone, these unsightly lumps will
go away if you ignore them for long enough.
Most will welcome the move away from the game of ‘hit the moving target
with a silver nitrate stick’ while hoping that there is no accidental
application onto healthy skin.
Lets hope that the joint RCPCH and RCGP document 'Facing the Future Together' with its 11 recommendations will provide an impetus for better communication between primary and secondary care. I am particularly hopeful that point 4 becomes a reality because educational meetings can work both ways.
Facing the Future together: The first four standards-
Lets hope that the joint RCPCH and RCGP document 'Facing the Future Together' with its 11 recommendations will provide an impetus for better communication between primary and secondary care. I am particularly hopeful that point 4 becomes a reality because educational meetings can work both ways.
Facing the Future together: The first four standards-
So whenever something seems ‘inappropriate’, it may be a
misunderstanding or there may be a genuine opportunity to share something
between two professionals. I accept that
there are GPs who don’t care about inconveniencing patients or overloading
their local emergency department but these are a vanishingly rare breed. More often, if I get in touch to clear
something up that is exactly what happens and I am just as likely to be the one
set straight. The important thing is to
talk to each other and not about each other.
That really would be inappropriate.
Edward Snelson
Naturalised Citizen of the People's Republic of South Yorkshire
@sailordoctor #GPpaedsTips
Easter egg - for more on umbilical granuloma follow the links below
Easter egg - for more on umbilical granuloma follow the links below
Umbilical granulomas: a randomised controlled trial J Daniels, F Craig, R Wajed, M Meates
- www.banglajol.info/index.php/BJCH/article/download/10360/7648 BANGLADESH J CHILD HEALTH 2010; VOL 34 (3): 99-102 Therapeutic Effect of Common Salt (Table/ Cooking Salt) on Umbilical Granuloma in Infants AKM ZAHID HOSSAIN, GAZI ZAHIRUL HASAN, KM DIDARUL ISLAM
Disclaimer: All the opinions expressed here are someone else's.
