The magic word
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7497.948-a (Published 21 April 2005) Cite this as: BMJ 2005;330:948
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As a radiologist, I am appalled by the sort of behaviour displayed at
Sunderland where performing an investigation is regarded as an enormous
favour, to be bestowed only after an appropriate amount of grovelling on
the part of clinicians.
All that most radiologists would ask for is a clear account of why
the test is requested, and the clinical question to be answered, relevant
history and findings, and notification of any possible contraindications.
In my department, the use or omission of the word 'please' has no
bearing whatsoever on whether a test is performed. If we felt that
strongly about it, we would print it on our forms to save clinicians the
trouble.
Incidentally, in the private sector, nobody cares whether tests are
"ordered" or "requested", or whether the supplicant has said "please", and
reports often begin with the phrase "Thank you for referring this patient
....".
Competing interests:
None declared
Competing interests: No competing interests
Dr Spitzer reminded me of a conversation one of my colleagues had
with a Radiology Consultant when we were (very) junior doctors. The
conversation was along the lines of the appropriateness of the
investigation for the patient's symptoms and included the following
exchange:
Junior Doctor - "Yes, that's why I ordered the abdominal X-ray"
Radiologist - " ORDERED ! - I think you mean "Requested" - we're not
bloody McDonalds !"
Competing interests:
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Competing interests: No competing interests
I had been a doctor for 20 years when I took up a new post as a
general practitioner. One day I wrote an x ray request form for a man with
a painful knee. Seven weeks later the form returned to my desk, annotated
in red and initialled by a consultant radiologist. My request had been
declined. It seemed that there were some difficulties in reading my
handwriting but there appeared to be enough information understood to deem
my request out with the royal college guidelines for an x ray of the knee.
I later received an apology. My patient didn’t get his x ray.
Presumably, my mistake had been to forget the word ‘please’ on the form
and in my indignant letter of objection to the professional discourtesy.
My experience at the hand of a medical colleague has not encouraged me to
change my discourteous ways.
Competing interests:
None declared
Competing interests: No competing interests
Does saying please cost nothing? - In theory yes (and I would be the
first to encourage courtesy of this type on all request forms). However, I
wonder about the “hidden” costs incurred with this particular
radiologist’s policy.
To personally bleep and summon every clinician in a large trust to
enforce his policy each time it is breached must be somewhat time-
consuming:- I can easily use up an entire “programmed activity” just
trying to track down a couple of dozen medical SHOs regarding their
appraisals, never mind contacting every new member of the entire medical
staff. Is this really an appropriate way to use precious specialist time?
Also, we are told that the “...radiographers have all been told to
reject forms without a ‘please’ on the request.” There would be an obvious
clinical “cost” incurred here, and I dread to think of the potential
delays in appropriate treatment that might occur when request cards for
“?pneumothorax” are rejected (as an example).
The other “cost” is one that might not be apparent to a radiologist
cloistered away from the ire of patients and relatives upset at delays in
investigations. I already spend a lot of my time acting as an apologist
for the failure of the NHS to carry out diagnostic investigations in a
timely manner. I have become quite adept at explaining away delays,
sometimes to the patient’s satisfaction (though usually not my own).
However, I don’t think an excuse such as “I'm sorry you missed your CT
scan yesterday Mrs Jones, – the request was rejected because the word
‘please’ was missing from the form” will go down too well somehow.
Competing interests:
None declared
Competing interests: No competing interests
I wonder if the consultant Radiologist included the words "thank you
" in his reports?
Competing interests:
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Competing interests: No competing interests
Courtesy seems to stem from contact with radiologists (and radiology
staff). In 2003, I related a similar experience(1) where I was taught the
value of "Please" by a radiology technician. The lesson has stood me in
good stead over the years as it has done with Doctor Spitzer.
Sundaram V Ramanan MD FRCP
(1) Ramanan SV, On Writing Prescriptions,BMJ (2003) 326:750
Competing interests:
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Competing interests: No competing interests
Boorishness of Consultants
I read with horror your article on "the Magic Word" in the
B.M.J. USA, July 2005. How dare a consultant behave
in the way you describe! To bully a junior is
unforgivable. Not only was he wasting your valuable
time, but he was setting up a precedent which was not
justified. Manners maketh man and this radiologist had
no manners! His behaviour was boorish in the
extreme. I have met such arrogance in a consultant, but
fortunately it is rare. Perhaps he would like you to kow
tow to him!
I recall as a house surgeon at the Monkwearmouth and
Southwick Hospital in Sunderland sixty years ago,
being told that a houseman is the lowest form of
animal life. Evidently things have not improved much
since that time! Although you were in a position where
it was very difficult to complain, certainly a protest to the
director of the hospital would have been appropriate on
your part.
As a child I remember the disgusting smell of the
Sunderland Royal Infirmary 78 years ago - the smell of
paraldehyde pervading most of the hospital. Perhaps
the smell has disappeared but the bad odor remains.
Competing interests:
None declared
Competing interests: No competing interests