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