The good slut
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7462.409-a (Published 12 August 2004) Cite this as: BMJ 2004;329:409All rapid responses
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Dear,
we live in times of lies and deception.
truth is what we hear from authorities.
Nuremberg is 1984 is 2005?
Or are we all listening to the same news,
through different fillte3rs, but are
Gleichgeschaltet..;
I do not dream I tell you how it is:
reigned by self-ism,
parle pas francais?
We fight wars in distant countries
to win against "terror",
which, indeed is a word.
1984 again.
When it comes to care and the people:
I tell how it is (for me).
And I see that there are so many children
running in armut.
Poverty is an issue not just in Africa.
To make my point,
we should be able as GP`s
to arrange admission to home,
hospital (gatekeeper).
I am not a friend of inventing diagnosis
to get A admitted.
Same principle is right for war.
1945. It was said:
the highest crime at all
the crime against humanity,
the start of a war without reason.
this land (is my land)
is reigned by a person,
who would have been convicted
to the highest crimes.
Well. I tell you what.
Unlike Dr Kelly, I do not plan
to comitt suicide.
It will have been a Kelly job.
r
And in the states they ask the question,
if the state really should provide schule,
education, education, education.
remember?
Competing interests:
None declared
Competing interests: No competing interests
"The good slut" by Dr. Farrell highlights the little documented
problem of social admissions.
Social admissions are frustrating for all concerned – the GP, the
surgeon and the general medical physician. Typically, the “medics” cop the
brunt of it. However, there are more social admissions to general surgical
units than is commonly appreciated by the rest of the medical fraternity.
Examples include patients with chronic abdominal pains, surgical post-
operative disasters, biliary colics on the elective surgical waiting list,
elderly patients who live alone complaining of vague abdominal pain and
the list goes on. In the increasing litiginous arena of healthcare, the
doctor is afraid to send these patients home due to fear of
repercussions. Nevertheless, “social admissions” waste valuable resources,
depriving genuine patients elective surgical operations and scarce health
resources.
There are several possible remedies.
1. The discharging of social admissions needs to be managed by
administrators. Once the doctor has decided that there is no acute problem
requiring admission to hospital, the further diposition of the patient
should be managed by non-medical staff. This liberates medical staff from
time consuming negotiations.
2. Resources for geriatric patients in the community needs
improvement. A lot of social admissions are for reasons of acopia.
3. Patients should be billed daily for hospitalisation. Even a
nominal amount each day would go a long way to free up beds. This is not
being unkind or inhumane. The public needs to realise that health care is
not free. There are associated opportunity costs and social admissions to
hospital are actually detrimental to the overall health of the community.
There is a prevailing urban myth that charging patients to access public
health disadvantages certain patient groups and may prevent patients from
presenting for valid medical attention. There is no real evidence for
this.
4. Elective surgical lists need more efficient management. The
cancelling of cases is a false economy. A common example is the patient
who requires a cholecystectomy but is forced to wait a long time for an
operation. In the interim, costly social admissions are bound to happen
due to episodes of pain unresponsive to oral analgesia.
5. Better liason between community health care providers and hospital
staff. Social admissions can be more easily prevented if the patient is
not actually on the hospital grounds.
Competing interests:
general surgical trainee
Competing interests: No competing interests
One cannot but appreciate wholeheartedly the honesty and sense of
humour in Dr.Farrell's article!When I started to work in this country in
general medicine in 1996 as a naive overseas doctor,one of the earliest
things I learnt in the medical admission unit was to filter the true
medical admissions from the so-called social ones.But after a period of
time, when you start realising the pressure the GP's are under and also
about the social background of many of these elderly 'social'
admissions,you tend to accept these as part of life.Interestingly some of
these social admissions do turn up to have acute medical issues, for example, Pulmonary Embolism.
Yes,we medics are more accommodating than our surgical brothers
and what if the GP's think we are sluts-we are saintly sluts!
Competing interests:
None declared
Competing interests: No competing interests
It does become demoralising - the tendency for surgeons to persuade
Casualty Officers (who are often surgical trainees) to admit non-specific
abdominal pains under the medics for example. My response is that if the
patient has pain sufficient to warrant admission they may have a surgical
problem eg perforation into the lesser sac (I was previously on a surgical
rotation). An example of unilateral decisions is when psychiatrists refuse to see any patients who have consumed alcohol even when the amount is trivial and the patient is suffering a previously undiagnosed psychotic illness (I speak from experience).
The attitude that everything another specialty doesn't want
(unilaterally) general medicine must accept is morale sapping and
illogical. Perhaps other specialties should be stripped of numbers to
reflect this decrease in their workload?
Competing interests:
None declared
Competing interests: No competing interests
RCAM begs to warmly disagree with the 'Utterly Misguided BMJ
Insinuation' that 'General Medicine' has always been 'La Belle Slut'
(Pardon Our 'Ethical French') of the Global Healthcare System.
It is the 'Official College View' that Complementary and Alternative
Medicine (CAM) not only 'Gloriously Claimed' that 'Highly Distinguished
Title' countless 'Millenia' ago ; but is also 'Unashamedly' still giving
every single one of her 'Over-The-Counter-Clients' (and 'Cheeky-Little-
Pretenders') an 'Exceedingly Satisfying Run' for their 'Shekels'.
Competing interests:
Professor Joseph Chikelue Obi FRCAM (Dublin) FRIPH (UK) FACAM (USA) also serves as Provost at the Royal College of Alternative Medicine (RCAM) , Dublin ; where an Interdisciplinary Revalidation Initiative (IRI) has recently been proposed for Seasoned Practitioners in Complementary and Alternative Medicine. Please kindly visit www.RoyalCAM.org for more details.
Competing interests: No competing interests
If Simon Fountain -Polley and colleagues continue to keep issues
secret with coded messages in referral letters - they do the children no
favours at all. They will be going home with no strategies in place to
protect or assist them nor will 'problematic parents', (itself a rather
unhelpful blanket coded phrase) will have been advised as to what the
problem is considered to be. If there is a perceived problem it should be
taken up more straightforwardly so that most importantly mistakes
involving children are not repeated.
Competing interests:
Contributor to Waterhouse Report
Competing interests: No competing interests
If the general medical ward is the whore of acute medicine (1), then
the paediatric ward is her orphaned child. Spurned in infancy, she reaches
out to all who would smile at her or offer company. The paediatric ward is
similarly used by all and sundry as a haven, a kindly face for the
children of inadequate parents. Here too can a hidden message in the
referral be discerned - please admit - spare this child from their
problematic parents.
(1)Farrell L, The Good Slut. BMJ 2004; 329: 409
Competing interests:
None declared
Competing interests: No competing interests
I'm not sure whether I should be petulant or rather sad and ashamed
about my chosen profession. Liam Farrell's article will, I'm sure receive
many varied responses. Whilst his analogy to the oldest profession may be
quite apt, perhaps after 11 years of acute medicine my sense of humour may
be running out. More worrying is the dispair I see in the more junior
members of my team who have no right to feel that way. Through the
constant barrage of 'social admissions', many get turned off acute
medicine for good. Whilst other departments barricade themselves behind
the phrase 'that's the medics', medicine is unable to do the same, as a
medical cause of admission can never be ruled out. Perhaps abusing the
system with 'harmless little fibs' as Dr Farrell describes, may be viewed
to be for the 'greater good', let us not forget the potential for
acquiring disease with ill-thought visits to the 'whore of medicine'.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
On getting the BMJ through the post on Friday morning, while having a
cursory glance, the headline of "the good slut" caught the eye. My first
impression was of outright distaste. I made a mental note to oneself of
the tabloid-headline and wondered whether the new editorial setup was to
blame.Nonetheless intrigued, I read through the article and at the end of
it, could not help but have a wry smile. I had flashbacks of my SHO days,
where I spent innumerable hours clerking so-called "social admissions".
Anger and frustration was at the forefront and ones impression of GPs were
unflattering to say the least.
Time passed on, I became a Registrar and three years down the line, the
"social" admissions continue but my viewpoint has undergone a dramatic
change. One has learned to appreciate the difficult conditions GPs work
in, especially at night.
So the surgeons, orthopaedics are less keen to play ball- but if we medics
take a similar attitude, the question is who is going to look after these
elderly individuals, in dire need of some caring or social sorting in the
middle of the night? Think of a scenario where the medics refuse to admit
a 94 year old lady who lives alone. She has been admitted with a fall and
a fractured clavicle- and the orthopods refuse to admit-as "they will not
operate". Just imagine if the medics use the same logic.... perhaps
somewhere down the line, the medical bunch are a more compassionate
lot....
A huge thank you to Dr Farrell for appreciating this. It just makes the
job that bit more easier- when you understand that GPs are not sending in
the patients "just for the fun of it"- and do appreciate the problems we
face as well. In the present environment of cynicism, the secondary sector
would love to have more GPs like Dr Farrell- if only to narrow the gap a
little bit more.
Competing interests:
None declared
Competing interests: No competing interests
The good slut: guilty as charged.
I read Dr Farrell's Soundings with a mixture of pride and sadness.
I felt enormous pride in the fact that the utilitarian nature of
general medicine is recognised by our beleaguered colleagues in general
practice. I was also particularly impressed with the recognition of the
"game" we play when justifying such admissions to each other, couching the
awkward in the vaguest of terms so as not to offend one another.
But I also felt sadness. Sadness that as general physicians we don't
celebrate and embrace our role as the "last refuge of the lost". It is
time we ceased complaining about the unpredictable vagaries of a post-take
ward round and rejoiced in our ability to deal with all the difficult
conditions and situations that other hospital disciplines feel unable to
cope with.
The serious point to be made is that if some disciplines are "forced"
to take patients who they would rather not, that it probably follows that
this may well affect the standard of care those patients receive. The
passive acceptance with which general medicine takes all-comers ironically
means we simply get on with dealing with what we are given, quietly and
with perhaps only a little complaint.
If I was optimistic I would hope that this article might herald the
dawn of a new age of general medicine where we are truly appreciated for
what we are. In the absence of optimism I can at least consider that as
general physicians we might be unsung heroes.
Say it loud: "I'm a slut and I'm proud".
References;
1. Farrell L, The Good Slut. BMJ 2004; 329: 409
Competing interests:
A general physician
Competing interests: No competing interests