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The embroider’d cloths of hell

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‘Had I the heaven’s embroider’d cloths,’ I think, as he shuffles painfully into the room. But even Yeats can’t help me as the consultation starts, like so many, with utter confusion.

‘I thought I was seeing the physiotherapist about my back,’ he begins. He being a stoical, elderly man with crumbling joints but intact mind – I know, because of his impeccable score on the obligatory dementia screening. ‘But she said she couldn’t deal with my back because I’d been referred about my hip.

‘If I want my back treated I need to be re-referred. Back to her.’ He says this with a barely perceptible raise of his eyebrow, betraying a dissatisfaction he’d never articulate.

I’m lost already. Back treatment? We need to back-track. So I click through the hospital communications until I find the key letter.

The pain clinic specialist has referred him to physio, yes, for his hip. And his back? Aha. The plan is some injections to his spine. Just as soon as he comes off that pesky warfarin he’s taking for the DVT caused by the immobility resulting from the pain in his back and hip, etc etc. He has an open appointment for when he won’t bleed all over the pain clinic carpet.

Hang on, though. His DVT was nine months ago. And the anticoagulation clinic letter states clearly: ‘Duration of treatment, six months.’ 

I quiz him on this. Yes, he has his blood tests regularly. Yes the anticoag lab advises on his warfarin dose and no, they haven’t told him to stop it.

Looks like he’s received three months’ unnecessary anticoagulant, which is novel, even if the drug isn’t. This, in turn, has delayed his back injections, prolonged his pain and resulted in a confusing appointment with a physio. And one with me, of course, to sort it all out.

Which I do. I tactfully inform the anticoagulation clinic that they’ve f***ed up, and ask them to a) stop rat-poisoning my patient and b) tell him they’re very sorry and won’t do it again. Then I give him the all-clear to ring the pain clinic. Job done.

So why’s he now back about his back? Because the pain clinic have told him it’s more than six months since he was last seen, so he’ll need a new referral from me. He says this apologetically. What this means is, his treatment has been delayed because of an error made by another department of the same hospital, which I spotted, and the result is that he has to suffer and I have more work to do.

Ah, patient pathways. Supposed to smooth the journey when all they do is spread shards of glass.

This I can cope with, sort of. It’s the utter inability to direct my anger in any constructive way that really gets me. Because when you’re dealing with huge, faceless, bureaucratic organisations in which responsibility is diluted and lost within the cogs of the system, there’s nowhere to focus your ire and the only alternative is to scream, which is what I do. Why does it have to be like this?

He looks at me quizzically. ‘Tread softly because you tread on my dreams,’ I explain.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield.

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Readers' comments (9)

  • Not as good (or bad?) as my patient under the knee clinic, discharged at 6 week follow up after surgery on his right knee, with a request that I immediately refer him back to their clinic so they could operate on his left knee!!!
    I could quote so many similar scenarios where the GP is left to sort out the chaos caused by just about everybody else involved in a patient's care. Depressing and time consuming.

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  • classic absolutely ridiculous overly beurocratic NHS. wouldn't happen here in Canada. A patient was given xray req for left hand but as the patients pain was the right they sensibly xrayed the right hand. Yes common sense! No request for another request form they just did the obvious. Of course this would be illegal in the UK. For some reason they have outlawed common sense in the UK your not allowed to think freely only to follow protocols guidelines and to tick boxes. The nanny state has even beaten common sense out of most other folk too.
    I cant wait til it all collapses

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  • A snapshot of so many of our consultations, and we're left with wading through the confusion and picking up the pieces.
    I find a quick and curt faxed reply written on the offending department's letter to me helps assuage my anger with these situations, and gets something done, usually.
    We're not these bloody hospital departments junior doctors, nor their secretaries.
    Such as when a Locum Consultant Gynaecologist ends their letter, "perhaps your GP can organise an ultrasound scan for you", with absolutely no clinical explanation nor indication as to why. Dictated at the end of their consultation with the patient, in the hospital outpatients. Give me strength!

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  • Treatment Pathways are very useful for many GPs because the training received by young trainee GPs from their trainers is so pathetic where the focus is just only on the consultation skills and nothing else. Even though there may be some flaws in implementing some treatment pathways, it is still much better to have them.

    I think this author wrote an article titled ''Garbage in and Garbage out''. What trainee GPs get during their training is nothing but garbage - hence at least such treatment pathways will enable them to become good clinicians.

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  • Treatment pathways turn us into technicians, not clinicians. It's not the same thing at all.

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  • Who was signing his repeat prescriptions for warfarin for those three months?

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  • Anon@1.45pm
    Responsibility of antocoag team managing this single aspect of the patient's care

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  • Things like this will continue to occur until such time as we get a GMC for managers.

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  • Have we got the gremlins out again? 1/7/15, 12:52 comment is somewhat off piste. Trainers are mentors, not teachers and registrars are adult learners.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder