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Both Maskell and Roberts rightfully called for better communication in diagnostic test requests.[1][2] Maskell also commented that radiology without context is like a game of "Where's Wally?"[3] Although practicing physicians often have direct and indirect interactions with diagnostic specialties, such as histopathology, radiology, biochemistry, and microbiology, they may lack training experience in these specialities and understanding of their personnel’s work process. For instance, my medical school in the UK does not schedule students to have mandatory diagnostic specialty placements. This could mislead our future physicians to think these specialties have a giant computer or crystal ball that can diagnose everything. But think about why we need physicians, not just computers, in these diagnostic specialties: it is because these physicians also make differential diagnoses like the ward physicians, and require clinical contexts of patients.
Roberts made an excellent suggestion of using SBAR handover in diagnostic test requests,[2] although I also heard of an orthopaedic surgeon's self-portrait of being a “victim” of lengthy SBAR handover.[4][5] In the NHS, it is often the most junior persons’ duties to fill test request forms. When talking to the diagnostic departments, some juniors may have experienced handover hostility,[6] and received questions like "Who is the most senior person that look at this?" and "Where is your senior?" The juniors may have to say, "Sorry, the consultant is in the operating room and will not be back today." That leads to further delay in patient management and discussion of clinical findings.
With the horrendous rota gap situation, NHS junior doctors are often doing shift work and may not even know enough clinical contexts of the patients.[7][8] If we want to improve communication in diagnostic test requests, we not only need to reform medical training, but also tackle the difficult handover and rota gap situation in the NHS.
References:
[1] Maskell, G. Impossible errors. BMJ 2018, 361, k2427, 10.1136/bmj.k2427.
[2] Roberts, A. Co-conspirator with the radiologist in impossible errors. BMJ 2018, 362, k3116, 10.1136/bmj.k3116.
[3] Maskell, G. Giles Maskell: Radiology without context becomes a game of “Where’s Wally”. https://blogs.bmj.com/bmj/2017/10/31/giles-maskell-radiology-without-con... (accessed Oct 31, 2017).
[4] Goh, S. Communicating effectively by lamenting the issues correctly. https://www.bmj.com/content/361/bmj.k1704/rr-3 (accessed Apr 25, 2018).
[5] Yeung, E.Y.H. Re: Communicating effectively by lamenting the issues correctly. https://www.bmj.com/content/361/bmj.k1704/rr-4 (accessed Apr 26, 2018).
[6] Al-Rais, A. Why we should avoid handover hostility. BMJ 2017, 356, j1272, 10.1136/bmj.j1272.
[7] Oliver, D. David Oliver: Is the ward round dead? BMJ 2017, 356, 10.1136/bmj.j635.
[8] Yeung, E.Y.H. Are we rushing patients home? We honestly don't know. https://www.bmj.com/content/362/bmj.k2864/rr (accessed Jul 6, 2018).
Competing interests:
I have been paid for working as a physician, but not for writing this letter.
Lack of clinical details in diagnostic test requests
Both Maskell and Roberts rightfully called for better communication in diagnostic test requests.[1][2] Maskell also commented that radiology without context is like a game of "Where's Wally?"[3] Although practicing physicians often have direct and indirect interactions with diagnostic specialties, such as histopathology, radiology, biochemistry, and microbiology, they may lack training experience in these specialities and understanding of their personnel’s work process. For instance, my medical school in the UK does not schedule students to have mandatory diagnostic specialty placements. This could mislead our future physicians to think these specialties have a giant computer or crystal ball that can diagnose everything. But think about why we need physicians, not just computers, in these diagnostic specialties: it is because these physicians also make differential diagnoses like the ward physicians, and require clinical contexts of patients.
Roberts made an excellent suggestion of using SBAR handover in diagnostic test requests,[2] although I also heard of an orthopaedic surgeon's self-portrait of being a “victim” of lengthy SBAR handover.[4][5] In the NHS, it is often the most junior persons’ duties to fill test request forms. When talking to the diagnostic departments, some juniors may have experienced handover hostility,[6] and received questions like "Who is the most senior person that look at this?" and "Where is your senior?" The juniors may have to say, "Sorry, the consultant is in the operating room and will not be back today." That leads to further delay in patient management and discussion of clinical findings.
With the horrendous rota gap situation, NHS junior doctors are often doing shift work and may not even know enough clinical contexts of the patients.[7][8] If we want to improve communication in diagnostic test requests, we not only need to reform medical training, but also tackle the difficult handover and rota gap situation in the NHS.
References:
[1] Maskell, G. Impossible errors. BMJ 2018, 361, k2427, 10.1136/bmj.k2427.
[2] Roberts, A. Co-conspirator with the radiologist in impossible errors. BMJ 2018, 362, k3116, 10.1136/bmj.k3116.
[3] Maskell, G. Giles Maskell: Radiology without context becomes a game of “Where’s Wally”. https://blogs.bmj.com/bmj/2017/10/31/giles-maskell-radiology-without-con... (accessed Oct 31, 2017).
[4] Goh, S. Communicating effectively by lamenting the issues correctly. https://www.bmj.com/content/361/bmj.k1704/rr-3 (accessed Apr 25, 2018).
[5] Yeung, E.Y.H. Re: Communicating effectively by lamenting the issues correctly. https://www.bmj.com/content/361/bmj.k1704/rr-4 (accessed Apr 26, 2018).
[6] Al-Rais, A. Why we should avoid handover hostility. BMJ 2017, 356, j1272, 10.1136/bmj.j1272.
[7] Oliver, D. David Oliver: Is the ward round dead? BMJ 2017, 356, 10.1136/bmj.j635.
[8] Yeung, E.Y.H. Are we rushing patients home? We honestly don't know. https://www.bmj.com/content/362/bmj.k2864/rr (accessed Jul 6, 2018).
Competing interests: I have been paid for working as a physician, but not for writing this letter.