Doctors no longer need medical secretaries
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f226 (Published 11 January 2013) Cite this as: BMJ 2013;346:f226
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Although many of us can type at a reasonable speed we are much quicker at dictating. My secretary' s salary is a quarter of my salary and she provides that essential ( friendly) link between the patient and the hospital. Typing letters is in the 'marginal' time between answering the phone etc. With choose and book, ABC etc, the patient always calls the consultant's secretary. Interestingly all the respondants seem to be from secondary care. Would the GP give up their receptionist who is their main link with their patients?
Competing interests: I have a secretary with whom I have an excellent relationship such that if I dictate 'routine letter for condition x' I get a standard letter and if I dictate 'blah' she types 'I have not arranged to review this lady but would be happy to do so if she has further problems'. Don't ask....
Dear Dr Spence,
As a tremendously busy acute general paediatrician, I am compelled to respond to your BMJ article this week entitled doctors no longer need medical secretaries......In my job this couldn't be further from the truth... If I didn't have a secretary, I just wouldn't be able to function, and serious mistakes would happen. I cannot type quickly and am certain that I am not alone in this. Secretaries do NOT simply type, and a major part of what they do is totally unrecognised. One of the most important things that they do is take calls from parents... they also dont just simply type up letters, they are a safety net for identifying errors, they chase results, they help us to prioritise, take calls from social services, schools,take calls from non clinical senior managers.... type and fax urgent information to tertiary units, liaise with GP's, pharmacists, health visitors. I am required to act as a middle grade doctor regularly, AND do 4 clinics per week as well as cover the ward and the neonatal unit. If i couldnt put my out of office on and direct people to my secretary then I would just be a disorganised non functioning mess.There needs to be an appreciation of the exact role of the medical secretary in different specialities. as for voice recognition, it is dangerous and unreliable, particularly in the world of paediatrics... and it takes longer to check letters typed by voice recognition compared to those done by our secretaries.
furthermore as a hospital doctor,I have to account for all of my time used for clinical practice. I have to justify every penny spent. How can it be acceptable for GP's to be paid a GP's salary rate, for doing administrative duties? We don't have this luxury in hospital medicine as the pressures of our contract do not allow this.... we simply do not have the time ! I would NOT survive without my secretary, and I am sure I am not alone in this respect !
Competing interests: No competing interests
Thanks for the responses. You all make valid and important points that I largely agree with.
The article is really to question the status quo. We certainly need and greatly value our reception staff in General Practice and we could not function without them. But the dedicated secretary attached to a certain doctor , is this still a valid model ? Could Doctors do more direct communication with Patients ? Could we use IT to change the traditional model of the secretary ? I am not suggesting we sack the secretaries but merely consider doing things differently. The communication in my experience still remains poor with significant delays in correspondence and barriers to access . We can do so much better.
We need to think about about change and do in an organised and systematic way. IT has changed everything forever.
Competing interests: No competing interests
It's Dr Spence's role to be provocative and contoversial but I hope that no-one with any influence will take his suggestion this week seriously.
As others have said, our secretaries are so much more than typists and I'm not even that. Somewhere - I've failed to find it on google just now - is a letter Sam Galbraith wrote many years ago to a newspaper extolling the worth of his medical secretary above all other relationships. One of the medical secretaries in a ward in The Royal Edinburgh Hospital where I worked at the time had it on her wall and clearly appreciated that someone understood her true value.
Medical secretaries are currently under threat. Who else knows their value other than us doctors and our patients. This is a time when we need to stand up for them and explain how essential they are for the smooth running of our hospitals and clinics. If we lose them, not only will we have less time to be clinicians, but our patients and their relatives will lose strong allies and, due to our increased administrative workload, wait much longer for appointments.
Competing interests: I'd be a goner without our medical secretary
A couple of years before I retired the then general manager of our department proposed getting rid of individual consultants' or teams' secretaries and replacing them with a typing pool-type arrangement. I have never seen the consultant body so united in its opposition to something proposed by management: every one of us was clear that the role of the secretary has little to do with typing clinic letters - she is, as has been pointed out, a vital communication point for patients, GPs and other hospital staff. As well as this key role of acting as a contact point the secretary is ideally placed to both take and prioritise messages; does Dr Spence really think it would be a great idea for consultants in a clinic, the endoscopy suite or an operating theatre to be regularly interrupted by telephone calls, many of which are not urgent?
As regards the clinic letters, no, I couldn't type as fast as I could dictate (and neither could most of my colleagues). What is more, if a patient or a GP phoned up with a query about a clinic letter the secretary, who had typed it a couple of days before, could easily retrieve the letter and could very often answer the query on the spot. These personal assistant or clinical support roles are not part of "NHS bureaucracy" and should not be forgotten in the rush for greater "efficiency".
Competing interests: No competing interests
I wonder whether Des Spence has any idea of the gulf between general practice (where an army of support staff shield him from day-to-day business) and hospital practice, wehere this is done by a single overworked secretary. Not only do secretaries type but they also calm anxious patients, rebook appointments, liaiase with other departments (and GPs), clarify instructions, pass on progress messages, give information about side-effects and one hundred other things that, if we consultants had to do them ourselves, would cause our work to grind to a halt.
Furthermore the experience of many using voice recognition software is not good; I could never get my system to understand Methotrexate, and spent more time correcting the mess that VRS left behind than I did typing in the first place. I am a slow two-finger typist. The use of overseas dictating services has also often been a nightmare, with contracts set up on the basis of an apparently skilled workforce but with results rapidly deteriorating; once the contract is gained, low-skilled typists take over and again one then spends inordinate time correcting all the errors. And who would be responsible if one slipped through? Many is the time my secretary has corrected a slip of my tongue, to my relief and the increased safety of my patients.
No, Dr Spence; when the consultant is away the service continues to run, but when the secretary is away everything falls to pieces. We live in different worlds.
Competing interests: I still have a secretary
I may not need a secretary but my patients need me to have one. I can't comment on primary care, but in secondary care it's vitally important for patients to be able to have direct access to someone who knows the system, understands who needs an urgent extra consultation, can chase investigations or drug deliveries and triage all sorts of clinical problems. The consultant and their nursing and medical team needs someone who can tell them which message needs dealing with immediately and which one can wait until the end of clinic. Perhaps this isn't the job description of a PA or a secretary. It's probably more the role of a care co-ordinator. But you wouldn't get away with paying anyone on that kind of job description on band 3 or 4.
Competing interests: No competing interests
All 3 of you are right - Dr Spence, Professor Ward and Professor Day. As a Consultant Surgeon I have no need of a PA nor a personal secretary.
My clinic correspondence is outsourced to India and a clerk files and sends the letters to the GPs and patients.
I do, however, have need of "patient liaison staff" (aka the secretaries in the department!) to oil the increasingly rusty wheels of the NHS behemoth and avert disaster when the wheels eventually fall off!
Communication in all its forms - personal, electronic, written - is the key to patient satisfaction and delivery of world class medicine.
Clerical staff remain a vital part of Patient Care in 2013 but the management system that employs them must move with the times and embrace technology too.
In my hospital the Trust iPad is carried by managers and Divisional Leads as a status symbol of their apparent worth to the organisation.
Those at the front line (doing the real work) must struggle on with endless hospital e-mails and poor mobile reception.
Talking to colleagues face-to-face is fast becoming a last resort!
Competing interests: No competing interests
We agree that most communication would be better done directly by doctors, but think that you underestimate the role that medical secretaries have played in the NHS. A consultant's secretary is not merely a typist and diary manager as you suggest. They can play a key role in supporting patients (and junior staff) navigate the complex bureaucracy of the NHS.
Recent interviews we have carried out on patient experience of care underlines this observation. People with cancer may need surgery, chemotherapy and radiotherapy, involving multiple appointments, procedures and staff – a “cast of thousands” as one patient commented. Patients and their companions often felt insecure and feared getting lost between different parts of their care along the pathway, worrying who was caring about them when they were not there. Unsure about who to contact when they thought they had been forgotten, some reported the positive role of the consultant's secretary who was able to find an answer and call them back. Others were paralysed when they could not find the secretary following restructuring and outsourcing. Some blamed lost letters and poor communication on this outsourcing, which may see letters flying halfway round the globe before landing back on the desk of a colleague.
Patients are supposed to have a cancer nurse specialist (CNS) who should help with this navigation; nationally 87% of patients reported having the name of a CNS, and 75% said they were easy to contact. But wide variation was reported for these questions between trusts and tumour groups. (Quality Health, National Cancer Patient Experience Survey 2011-12) Our patients reported uncertainty about which of the many support nurses was the CNS; they felt frustrated when calls were answered by a messaging service, and they missed the privileged access that secretaries have to individual consultants.
In the drive for efficiency savings and improved “productivity”, the NHS has become ever more impersonal. Systems and pathways appear to be in charge, with patients and staff often feeling less valued. Just occasionally, it is reassuring to have a real person you can call and talk to, who will try to resolve a problem rather than passing it to someone else.
Competing interests: No competing interests
Re: Doctors no longer need medical secretaries
This is all good debate. But the responses highlight the problem. There seems to be a wide variation in the amount of support Doctors are given and this is inequality across the NHS. This is really very important yet largely underappreciated aspect of NHS care. There needs to be a systematic review of admin support, communication policy, and how this is structured. Surely this is a quality of care issue ?
Also I think you might overestimate the level of admin support that GPs have ! Could we make appointments online? Some practices already do this.
Competing interests: No competing interests