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PATIENTS are commonly referred to the emergency department (ED) by their GP and these presentations are occasionally frustrating. Some of the time they have a clear reason for referral and even a letter. At other times, the reason for referral is less clear.
One of my favourite examples is probably the patient who presented, straight from her GP, claiming an abnormal test result that required prompt investigation and treatment. Except with no knowledge of either the type of test or its result. Needless to say, her experience in the ED was as unsatisfying to the patient as it was to the practitioner.
I saw a woman recently who had neck pain and had been referred by her GP with the results of a computed tomography (CT) scan that showed degenerative changes of the cervical spine with possible spinal cord compression.
I can appreciate the reasons behind this referral. Spinal cord compression is nail-biting stuff and not something I’d want to manage in my rooms if I were a GP. We can feel comfortable about managing a presentation like this in the ED of a major hospital where a specialist, a magnetic resonance imaging (MRI) scanner and an operating theatre are just a couple of floors away.
She was elderly and because she presented late in the day she sat in the ED overnight. At some point, she was put in a collar which would have done little to improve her neck pain. She was eventually discussed with a neurosurgical registrar and given that she had no neurological signs and that her CT findings were likely to be chronic, her case wasn’t considered urgent enough to be shoehorned into the next day’s fully booked list for the MRI scanner.
Once this had been communicated to her she left the hospital. None of her problems had been addressed despite her having spent an uncomfortable night in hospital. And while that outcome was frustrating, it’s certainly far from unusual.
I can imagine the GP’s disappointment when she bounced straight back with her problem unsolved.
In metropolitan Australia we have the luxury of being able to escalate a decision to the ED, the specialist, the super-specialist, and for patients at the margins of survival, the intensive care unit. We delegate decision-making to a higher power because we’re all confined within the limits of our scope of practice and we fear the consequences should we step outside it.
As a result, we all learn, whether we’re junior doctors, GPs, ED physicians or specialists, to make ineffective decisions or not to make them at all. Our health care system sometimes seems to prefer us to make no decisions rather than to make many good ones at the risk of getting one of those decisions wrong.
The expectation that a complex patient can only be managed by a certain specialist comes at a cost that often falls on patients themselves. My elderly patient met it by spending a miserable night in a scarce hospital bed.
It’s a familiar tale. It could be avoided if we acknowledged that there are many instances where asserting the authority of a generalist doctor to make decisions would benefit both our patients and our health care system.
In the context of an ageing population this change feels inevitable anyway. There simply aren’t enough specialists, and nor will there ever be, to tend to all of our ageing bodies. Referrals will necessarily be curbed and generalists will fill the gaps that specialists no longer can.
To some of our patients this change will be welcome. My generation of doctors, already struggling to secure vocational training positions, will be forced to embrace it. The ascendancy of the specialist physician has dominated the medical narrative in recent memory. It’s time we gave their generalist colleagues equal billing.
Dr James Dando is an intern at a major Sydney hospital.
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“Our health care system sometimes seems to prefer us to make no decisions rather than to make many good ones at the risk of getting one of those decisions wrong.” Spot on – very insightful! This, in my view, is a combination of super-specialisation and the fear/risk aversion that results from intolerance of imperfection, and a culture where the most risk-averse approach trumps. I have also seen many patients referred to ED nominally for further tests or to see a specialist, when a confident opinion was what was required (mine).
However, as an Emergency Physician, I see this second opinion as part of MY role. A GP is unlikely to manage a lot of acute neck trauma, so the radiology report that describes a risk of cord compression has to be taken seriously. The GP also may not have the range of colleagues on-site with whom they can discuss the case.
IN my view, therefore, the issue was not so much the referral to ED as the inability of the ED to resolve the issue for her. If she was elderly, an overnight stay is perfectly acceptable and safe – in an ED short stay ward – but NOT with hard collar immobilisation – which is an evidence-free zone for awake patients.
What happened here is that one person passed their risk-aversion on to another, in a sequence. Someone in that sequence, either through their own knowledge and judgement or by “phoning a friend”, could have done a realistic risk assessment, had a good patient discussion, and reassured her about her risk.
From a GP perspective, referring patients to the ED may be because access to public hospital outpatients is so difficult, and becoming increasingly more difficult because of referral pathways, central hubs and other mechanisms that are used to control demand and waiting lists.
We all feel frustrated by the health system that is unresponsive to ‘sub-acute on chronic problems’. Referral to public hospitals is a hit-and-miss activity in these cases, particularly when there is very little communication between GPs and the public hospital sector. Emergency departments increasingly control resources that GPs can’t access without referring in, and so may be the true gatekeepers of much of the public health system
I agree with most of this. A significant contribution also comes from our increasing failure as a profession to talk to our patients – the 90yo gets the same work up as the 40yo, rather than sitting and discussing what their expectations and goals are. A frank discussion about what we are doing will often end in completely different care delivered – and often better, cheaper, quicker outcomes from a patient’s perspective. Referral should not be automated – discuss findings with the patient and discuss (similar to consent) specialist referral.
I expect your elderly patient with neck pain would have told her GP to get stuffed if the discussion had included that the outcome of referral was actually to ultimately consider if she was a candidate for spinal decompression and she would have walked out of the surgery with a pain management plan, with both practitioner and patient happy.