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Independents' Day

It’s a dirty job, and I’m not going to do it


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I’m quite happy, as a selfless and uncomplaining servant both to the NHS and to you, dear reader, to do all the dirty jobs no one else wants to do.

One of these tasks I set myself is to read and ridicule stuff (eg, NICE guidance) to save you the bother of having to do it yourself.

And so it is with some recent research in the British Journal of General Practice about GPs’ processing of discharge summaries.

What this paper found was that actions requested in hospital discharge summaries, such as medication changes, investigations and referrals, were not completed in 46% of patients aged 75 and over after an emergency admission.

We’re clearly sifting out the rubbish and acting only on what’s important

And we all know why that is, don’t we children? It’s because these ‘GP to sort’ requests for follow-up/referral/investigation/medication revamp etc etc are so stupid, pointless, incomprehensible, irrational, ambiguous or deranged that we treat them with the contempt they deserve.

So far, so obvious. But then the paper’s conclusion goes seriously off piste. ‘These results,’ it says, referring to the 46% we shred, ‘are an indicator of the importance of careful processing of discharge summary information.’

Er, no. Because, as the paper signs off, ‘associated harms were uncommon and were of moderate severity’. In other words, we are carefully processing the discharge summary information, at least to a safe level, because we’re clearly sifting out the rubbish and acting only on what’s important.

So these results are actually an indicator of the importance of discharge summaries to be more logical, judicious and realistic in their requests.

Or, better still, rather than dump all this crap on us, for secondary care to fund its own community housemen.

Because, yes, I’ll do the dirty jobs, but even I draw the line at this.

Dr Tony Copperfield is a GP in Essex


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Readers' comments (8)

  • Oh no you made me look...

    The authors seem to have assumed that drugs issued caused no harm!

    They didn't identify harms relating to drugs
    which were changed.

    ...or any of the multiple reasons why senna, morphine, zopiclone, paracetamol, and oxycodone should not have been recommended by anyone in the first place..

    I would call for a follow up piece where they look at how many of these recommendations were actually contraindicated based on the comprehensive (well it can be/used to be) lifelong primary care record.

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  • I would not mind these requests quite so much if they told the patient to come to us to collect the new scripts. What really pisses me off big time is when they expect us to contact the patient and then organise an appointment etc. I feel like writing to the offending hospital specialists and saying something like ' this patient of mine says they feel unwell. Please phone them and organise the full suite of hospital tests and make them better. '

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  • Well said Tony. Recently there has not been much worth reading on Pulse 😠

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  • I beg to differ with the responses (and the article) along with the blanket generalisation that all such requests lack merit or a sound basis. What tends to happen ,in my experience, is the same arrogant disregard which is displayed towards abnormal investigation results that the GP cannot understand or be bothered to attempt to understand.

    An example: someone has a hbA1C checked and it is abnormally low. "Good stuff" says Consultant in Primary Care, " they are not diabetic". What this clinical genius has failed to note is a raised bilirubin, slight anemia (hb=114 (female)) but normal hematinics and no other LFT derangement."File the results, nothing to see here" says GP. Turned out the patient had a haemolytic anemia due to an inherited red cell membrane issue.

    Admittedly some of the secondary care requests are hard to fathom, but usually, with a little thought, the hospital clinicians reasoning becomes clear. What is also clear to me, and I've spouted on about this before, is a lack of diligence in primary care which is an enduring theme as far as I can tell.

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  • many thanks to the previous comment author for sharing your wisdom with us. unfortunately I see very little value in being smug about that not so elegantly worded example of picking up some rare pathology of indeterminate significance. Haemolytic anemias due to inherited membrane defects are mostly mild and require no treatment or a little folate, or if not mild- will be picked up anyway.
    I am sorry to hear that you also seem to need to focus hard to see "hospital clinicans reasoning", so that you can carry on with doing.. "due diligence". So I'll explain. Vast majority of their requests for referrals to other specialties/more tests/GP follow up are due to:
    a. them not knowing the patient
    b. not knowing condition/not being comfortable with managing anything outside their specialty (examples- GP to refer to gastro for management of reflux, refer to ENT for chronic perennial rhinitis, refer gynae for irregular periods, refer dying patient for CPAP or respiratory rehab)
    c. not having time or resources to deal themselves.
    Because of this last point I still have sympathy with the stupidity of most requests on discharge summaries that come to me and give them consideration they deserve (usually means shred them AFTER I've red them).

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  • Dr Tea- You mention time and resources.... Whilst I am in no doubt Hospital Consultants on the whole are working themselves silly, these are fluid concepts and some consultants are well known for being either 1) lazy 2) very good at finding reasons why some of their patients should be referred to other specialties rather than simply being told their is nothing wrong with them. Consultants don't give us orders, they can make suggestions we can decide to follow

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  • Northwestdoc makes a very salient point- consultants opinions/requests for action are made in an advisory capacity and we are free to act upon them or dismiss them after considering whether or not they are valid. But to come to a fair conclusion does require the exercising of ones capacity to think along with an evaluation of what we know about our patients.

    I am very impressed by Dr Tea, who on seeing the anomalies I mentioned, conclusively and confidently established without any further work-up that the problem was insignificant.Perhaps he/she has the ability to dream up the bloodfilm findings without it having been done; and at the end of the day, if it signifies something bad, well, not to worry because the patient will be back and suffering.And will then get a hematology referral. He/she demonstrates an excellent approach to managing uncertainty, something his/her patients would be grateful for and the assessment of "undifferentiated findings and clinical uncertainty" (which are actually quite differentiated and glaring when thought about), a forte of us GPs , is also inspiring. Its easy to say that is irrelevant when the diagnosis is made, and less easy to make the diagnosis. The focus he/she has shown on diagnosing issues early is also thoroughly reassuring for his/her patients.

    The other point to consider is usually after a patient has been admitted, observed and treated over the period of their stay, issues which need evaluation by someone are identified. Some of these may not require additional specialist input, as determined by the GP, but that does not mean the issues have disappeared. And if no further referral is deemed necessary, assessing these will be the GPs job.

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  • I am glad this is turning into a sort of a good debate. I still remember writing, however, that I shred discharge summaries (with mostly stupid requests within them) after I've read them, not before (although, maybe should reconsider)'
    Now that I think about the issue... here we are lucky if we get any discharge summary at all. They've been replaced by discharge medications summaries that contain no useful information about why patient was admitted, and where, and under who's care, and what was found etc. CCG had no interest in influencing this nasty habit to change, by the way. Maybe that's the reason why seeing a discharge summary (with inevitably unworkable/unrealistic/unnecessary recommendations) is sort of a novelty, so I read them

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