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PRIMARY CARE: Paul Little, Martina Dorward, Greg Warner, Katharine Stephens, Jane Senior, and Michael Moore Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study BMJ 2004; 328: 444 [Abstract] [Full text]

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Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study

Moyez Jiwa, David Gelipter, Liz Woods, Sue Nutbrown and Damian Bragg   (3 March 2004)

Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study 3 March 2004
Moyez Jiwa, Lead Research Fellow University of Sheffield, David Gelipter, Liz Woods, Sue Nutbrown and Damian Bragg Send response to journal: Re: Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study	We welcome the stimulating report on a nested observational study by Little et al(1). It was encouraging to see medical students listed among the authors. Since the implementation of research governance framework delays resulting from the approval process make it impractical to include students as participants on a research team who then earn the right to authorship. Professor Little and colleagues deserve credit for their success on this and other recently published work(2). Their study may help shed light on reports that non-cancer patients are occasionally channeled onto fast track pathways(3). In particular the observation in this paper that more than one in five patients were referred despite the doctor's perception of limited medical need. It would have been helpful to validate these perceptions with the diagnosis at discharge from the specialist clinic. We suspect these data are not available. We draw attention to work from our region suggesting that GPs enter relatively few details on referral letters(4). Some argue that this is because significant signs and symptoms are uncommon even where pathology is present. Two alternative views can now be taken; either that practitioners do not elicit these features or alternatively as per this paper that such features are absent and practitioners are referring patients anyway. We suspect that the truth lies somewhere among these extreme views. What this does raise however is possibility to improve care by focusing on a fundamental aspect of performance namely communication skills. The skill of eliciting information, negotiating management and finally relaying that consultation to others. On behalf of the Journal club Mosborough health centre, Sheffield. UK 1. Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 2004; 328:444-6. 2. Little P, Dorward M, Gralton S, Hammerton L, Pillinger J, White P, Moore M, McKenna J, Payne S. A randomized controlled trial of three pragmatic approaches to initiate increased physical activity in sedentary patients with risk factors for cardiovascular disease. BJGP, 2004, 54, 189 -195. 3. Jones R, Rubin G and Hungin P. Is the two week rule for cancer referrals working? BMJ 2001;322: 1555-6. 4.Jiwa M, Walters S, Cooper C. Quality of referrals to gynaecologists: towards consensus. J Clin Gov 2002;10: 177-181 Competing interests: None declared