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Rapid Responses: Rapid Responses published:
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That'll be me, then
- Maurice Conlon (26 March 2005)
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The lead clinician should have been a nephrologist
- Hugh C Rayner (26 March 2005)
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GP computer as safety net?
- David J Young (27 March 2005)
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It can only get worse
- Bob Bury (29 March 2005)
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The lead clinician is standing up, but is likely to fall over.
- James N hardy (1 April 2005)
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Maurice Conlon, GP Principal Ridgacre House Surgery, South Birmingham PCT. B32 2TJ
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I have the answer - it's the GP. Secondary Care now seems so refined and pigeon-holed that there are no remaining generalists, excepting A&E and Geriatricians, left in hospitals. I have been asked by a cardiologist in the LVF clinic to refer a patient to the general cardiology clinic because the ECHO is fine but the patient might have angina. I recognise Craig Gannon's scenario and could describe several similar instances every year, thankfully not all with such sad ends. The GP is well placed to provide the overview, but the key problem hampering this role is the quality of communication we receive from secondary care. This falls into two main categories: Prompt, but illegible and incomplete. Late, but typed and comprehensive. If GPs are to be the lead clinicians, then get us prompt, legible, succinct information. That would be a start. Competing interests: I know the author personally |
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Hugh C Rayner, Consultant in Renal and General Medicine Birmingham Heartlands and Solihull NHS Trust, Birmingham B9 5SS
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Dr Gannon blames the failures in the treatment of an elderly lady with renal failure due to metastatic breast carcinoma on the complacency of her doctors and the inadequacy of hospital systems to act as a safety net. I would suggest that ignorance of the significance of her serum creatinine results is a more relevant failing. Assuming the patient was about 75 years of age, her initial serum creatinine of 180 micromols/l is equivalent to a glomerular filtration rate of only 25ml/min/1.73m2, using the abbreviated MDRD formula to estimate GFR. This is severe renal impairment. As such, it should have prompted a referral to a renal physician, who would have requested an abdominal ultrasound scan as part of his/her assessment of any patient with newly diagnosed severe renal impairment. A renal physician would readily have adopted the lead clinician role that was lacking. The routine reporting of GFR estimates by pathology laboratories is recommended in part 2 of the Renal National Service Framework. This systematic advance will enable clinicians to interpret correctly abnormal serum creatinine results and avoid the error, made by Dr Gannon and the patient’s doctors, of thinking that 180 micromols/l is only ‘mild’ renal impairment. Competing interests: None declared |
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David J Young, GP / GP Tutor 6, Mayfield Rd, Chaddesden, Derby
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Maurice Conlon and Hugh Raynor are both right. My role as GP is evolving toward that of the traditional general physician. Complexity in hospital care and rising multiple morbidity demands that one physician becomes responsible for checking all the biophysical data in a patient journey. Awareness of the significance of raised creatinine tests is also rising,in part driven by the plethora of problems linked to cardiocascular drug surveillance.If, however, I was to gaurauntee a high level of safety I should want immediate e - mail links and software that sounds a claxon in the ear of my dedicated clerk for every abnormal test. Current reliance on paper communication to a GP in - tray ensures that my error rate will be as high as anyone else's and I anticipate full computerisation with relish. Competing interests: None declared |
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Bob Bury, Consultant Radiologist Leeds General Infirmary LS1 3EX
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Of course the GP should have the co-ordinating role. But now we are told (The Times, 28 March)that the future of general practice is to be large polyclinics, with little opportunity for doctors to get to know individual patients, and vice versa. So salaried GPs will turn up to their branch of Docs-R-Us, do their specified number of hours, tick lots of target-related boxes and then go home. They will probably earn more money, because the mega-practices will be geared to maximising income and they will enjoy a stress-free off duty life, because they don't know any of their patients well enough to worry about them (and on-call cover will remain an option that they can afford to decline). This will be much better for doctors' life style, although professional satisfaction will be largely a thing of the past. And of course, quality of care will nose-dive because the GPs, like the hospital doctors in this example, will be practising in 'silos'. Ah - brave new world! Luckily, an election looms, but will anyone draw the appropriate conclusions from this government's disastrous handling of the NHS? Competing interests: None declared |
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James N hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Editor, Craig Gannon has put his finger on the most critical area of patient care (1), the interface between specialities. Of particular interest to me as a GP working in a 5-doctor inner city training practice was his failure to highlight the coordinating role of primary care in the day-to-day management of patients with complex multi-system illness. There are lead clinicians who stand up, but they work outside hospitals and they are increasingly expressing their frustration with the subterranean labyrinths of secondary care. These troglodyte communities can hardly be blamed, the system is underpinned by multinational business interests; interests that eschew individual suffering for the expediency of profit. When the troglodytes emerge into the light of day, it is not to have meaningful communication with their primary care colleagues, for they wouldn’t know who they were, or where to find them. No, for these folk the light of day means an escape from unsatisfactory and overwhelming working practices. For a minority there is escape into the private sector. This is no accident because it is here that in small organisations doctors can rediscover the satisfaction of working with patients. Those of us in primary care also recognise that longitudinal relationships with patients and colleagues alike, provide great satisfaction, but are mindful that modern working practices are making this harder to achieve. These working practices are, of course, driven by the business interests already mentioned. So we must be on our metal if we are to avoid sliding into the same hole. There are some possible solutions. Firstly, it is possible to sustain longitudinal relationships provided that individual doctors know who their patients are and vice versa. In primary care this is embodied within the personal list system, a system that can be easily sustained if people give it thought. Yes, it can be demanding, and yes, it can be harder work, especially in the early days, but there are rewards. For this to work in secondary care there is a necessity for a robust administration that can work across boundaries. Electronic communication has enormous potential. So too do centralised records. But they could easily become wastelands of clutter and misinformation without a system of maintenance. Working across boundaries is a huge challenge. If we accept that multinational business interests are here to stay, at least in the short to mid term, then we need to find ways that direct financial streams into researching the interfaces between specialities. There will be rewards for all concerned. James Hardy, GP 1. Gannon C. Will the lead clinican please stand up? BMJ 2005; 330:737 (26 March). Competing interests: None declared |
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