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I don’t give a damn what NICE say



Jobbing Doctor looks at good reasons for referring onto specialist care, and when you needn’t.


I regularly give tutorials to registrars on referrals. A referral, for me, is when I ask a colleague to deal with a specific area of patient care. It is interesting to work out why we refer, and I have being doing an audit on it in my practice.

The positive side of making a referral is that it enables you to get some help with managing patients, and I am grateful for this.

One reason for referral is that I need special investigations done. This might include endoscopy, angiography and there are many others.

Another is for a curative procedure, such as an operation – varicose veins, or hernia repair, or cataract. This is obvious, really.

I will refer if I need help with diagnosis. This is not uncommon, although GPs are the experts at diagnosis. We sometimes like a second opinion (or if I don’t have a clue, a first opinion!)

I refer for management – complex diabetics with complications, adolescents with mental health problems, or cancer care. Often we get guidance on which conditions I think are appropriately managed in secondary care.

Too often, however, things are ‘managed’ in secondary care very badly, and don’t need to be: what is the point of serial junior doctor follow up of a stable condition? I do get intensely irritated by some FY2 telling me how to manage an elderly patient when they clearly haven’t a clue, and are managing them from a junior doctor’s crib sheet.

And whose bright idea was it to suggest that all thyrotoxicosis patients need to be referred? This really deserves a separate rant all of its own, but I don’t have time to moan about that today.

I also refer for relief. All Jobbing Doctors out there know exactly what I mean. A patient that you are trying your best to deal with, but seem to be getting nowhere with, and they keep coming back to you: the chronic somatiser, the persistent back pain, the fibromyalgia.

It is good to refer them to get a bit of a break. Eventually, when the hospital is equally hopeless in dealing with them, they come back to you, but you are empowered by the fact that a ‘specialist’ is equally maladroit with their symptoms.

I sometimes refer patients who have unusual conditions – such that I don’t see very often. But only sometimes.

I have a patient that I have diagnosed with an unusual lung condition – not life threatening, but unusual. For those who are interested, it is broncho-pulmonary aspergillosis. I’ve not seen one in 30 years of general practice, although I have read up about it.

The diagnosis has been made by a combination of the patient (returning as not improving), me (not being happy about initial proffered diagnosis), the radiologist (who suggested it as a possibility on X-ray films), the immunology department (special blood tests) and the respiratory consultant (whom I rang for advice).

There is nothing in this patient’s condition that is inherently complex and cannot be managed in primary care. Should I refer this patient, simply because I have not seen it before?

I don’t see why I should. The management is likely to be straightforward (steroids) and the follow-up can be perfectly well managed within the practice. Does the patient want to see a ‘specialist’?. No, what the patient wants is to get better after being slightly unwell with a productive cough and dyspnoea for four months.

No, I will manage it in the community. It is cheaper, more interesting, and develops trust between the patient and myself.

And I don’t give a damn about what NICE say.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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