GP to chase…

OK, listen up. I have had a gutful of ‘GP to chase’ discharge summaries from our local centre of excellence tertiary hospital. AMA guidelines are quite clear about this – if you order a test, you are responsible for the result including followup and patient management.

It is not uncommon for patients to spend a week or so in the tertiary hospital, then lob up in my clinic a week later – without a discharge summary, list of medications – basically not a Scooby-Doo about what happened during their hospital admission and battery of investigations, let alone what the discharge diagnosis (if any) was.

Not cardiac” is NOT a diagnosis for the patient sent in with chest pain for investigation ?ACS. I am glad that the patient can recall that they passed their stress test and angiogram … but puzzled why they’ve been discharged on a statin, ACE-inhibitor and beta-blocker with cardiac clinic review if the diagnosis is not their heart – and given their ongoing chest pain, perhaps consideration of other causes might be warranted? Were these even considered?

Worse still is the arrival of the discharge summary some six weeks later…suggesting that the patient needs an urgent CT pulmonary angiogram and “GP to chase serum homocysteine and D-dimers”.

I am a rural doctor. I usually know my patients quite well. Give me a call, send me a letter – even give the patient a scrap of paper to bring to me – but DO NOT ask me to chase results on test you’ve ordered or neglect to convey important information. It’s 2014 and even in rural Australia we have got access to phones, fax, email. Use them to communicate!

…and do NOT ask me to chase your investigations. I am not your community intern.

Meanwhile, here is a quick quiz for junior doctors who seem to be confused over the difference :

JUNIOR HOSPITAL DOCTOR QUIZ

CAN YOU SPOT THE DIFFERENCE?

This is a labrador.

He likes to “chase things’ and will roll over on command.

This is a GP.

Generally friendly but do not ask him to chase or rollover for you

WARNING – HE MAY BITE !!!

 

 

 

Grrrrrrrrr!

 

 

Comments

  1. says

    Hi Tim
    I am guessing that there are a very scared batch of green interns out there now!

    I consider myself an expert in this field. And I can justify my claim…
    1. I work in a small ED and on the inpatient ward – discharging patients back to GP follow up
    2. I run a local GP practice which has to deal with the incoming flood of paperwork, emails, electronic letters etc. soooo many formats, templates, styles to consider.
    3. My wife is one of the senior GPs up the road from my ED – trust me, I do not write letters asking her to “chase up results”.. couch is way too lumpy for that.
    4. I helped develop & beta test a secure messaging system / info sharing network for Hospital / ED /GP / Clinic communication.

    So here is what I think the minimum requirements are if you are discharging a patient (from ED or ward) who has outstanding “relevant” results or need active review / action from the GP within a few weeks. The classic is the MSU that is not back yet, on empirical oral ABs…

    (A) A quick phone call to the GP’s office in order to confirm the patient actually is known to the GP!

    (B) A copy of the results are CCed to the GP with appropriate clinical notation from the lab / Xray

    (C) If the problem is new or not ‘standard operating procedure’ then a phone call to the GP in person – not a message left at reception! This process requires a little Q&A session which cannot be done over email / text / twitter etc. This allows the GP a chance to clarify, object or refuse the requested follow up

    (D) a discharge letter should be written and either – handed to the patient if appropriate / reliable
    – sent to the GP by fax, mail, email, secure message at least 24 hours prior to
    he patient turning up at the clinic anticipating “follow up”.

    (E) Discharge letters need to be succinct, to the point and NOT contain every test result ordered during the 3 week ICU stay! It needs to contain:
    – a useful working diagnosis,
    – a clear plan of action,
    – to highlight any changes in the patient’s prior care / medications
    – what follow up is already arranged [save double handling]
    – Exactly what the team would like the GP to ‘chase’ or review
    – a clear time frame for such review

    (F) AS you say – the test result remains the responsibility of the doctor who requested it – having said that most GPs are nice people and love to follow up their patients…. but, that does not mean you can offload your responsibility. If the result comes back with anything other than what was actioned, planned, empirically treated – then you have to call the patient / see them again or call the GP to advise that they did not follow the plan prescribed

    I think you have inspired my teaching session this week mate – watch out new grads!!
    Casey

  2. says

    Thanks Casey. Similar situation for me, a I am both the GP and the ED doctor

    Actually ED tend to do this sort of thing well. Its a high risk area and ED has put a lot of effort into sorting this.

    However the system is broke within the inpatient wards. Patients are discharged and the task of discharge summaries is relegated to the end of the day/week/month. It is not uncommon for summaries to be written by a junior who has never even seen the patient. Then there are delays in getting typed/posted etc. writing ‘GP to chase…’ Is both discourteous and courting disaster.

    I received a discharge summary on 21-1-14 for a patient discharged in mid Nov 2013. Nine weeks late! The average is 4 weeks. Hiddenwithin this particular gem was the instructions ‘GP to chase blood cultures’ and ‘GP to organise colonoscopy in two weeks’.

    I dont have access tot he pathology system at the tertiary hospital, so those blood cultures are unknown to me.

    I dont have access to a time machine – so that colonscopy is now 7 weeks overdue.

    I imagine that the reason ‘the GP’ is being instructed to refer the patient back for a scope, ratehr than the home team, is something to do with referral pathways and money.

    Might work for the accountants, but I couldnt give a fig. The patient has been left hung out to dry.

    The examples are legion.

    I should emphasise that this is NOT the fault of juniors. Nor is it confined to hospital doctors. We’ve all seen the terrible referrals from primary care to ED or clinic ‘please see and do the needful’.

    The way I look at it? If it is my name at the head of the bed or letterhead, then I need to be the one writing. When I see a patient in rooms for referral OR in ED/inpatient for transfer, I write the letter then and there. And pick up the phone. The letter goes by fax and a copy with the patient. Takes less than 3 mins to compose a summary letter.

    It is the responsibility of the Consultant to do the same. Make sure your juniors are writing the correct plan. Make sure the patient leaves hospital or your rooms with a letter fort heir doctor. Get the junior to fax/ring if it saves time, or use a secure message service.

    And do NOT game the system by asking for referrals back to clinic or for tests that you could order (the colonscopy in question being a great example) NOR order a test and devolve responsibility for followup.

    Its about better communication between professionals and patient safety.

    Rant over.

    • Casey says

      Agree Tim

      One of my tasks as senior doc is to police the DC summary output. We aim for completion in 24 hours – problem in big hospitals is this task is delegated to the intern, who is not allocated time to do a good job
      It is the afterthought of the team, rather than a core part of the plan!
      C

  3. says

    I recall an weekend as a resident at a big teaching hospital when we (residents, registrars and some consultants) were fed pizza (& beer afterwards) to complete 250 outstanding discharging summaries. Can’t comment on the quality of the letter but the heads of department were happy that there were no discharge summaries outstanding, Something to do with quality of care measurements for the health department…………!!!!

  4. says

    Mark, like me, you write a letter or discharge summary with the patient in front of you, whether sending to specialist from your room…or whether transferring from inpatient care in your rural hospital to a big tertiary centre

    Quite why discharge summaries are seen as unimportant and relegate to a task to be completed by the most junior, some days or weeks later, escapes me

    Your name at head fof bed? Then make sure the patient leaves with a summary and plan agreed.

    End of.

  5. says

    Hi guys.

    Not a GP or hospital doc, but I have to say I feel your pain with regards to discharge summaries. Working in areas where English is very much a second language (mine included), a good discharge summary is worth it’s weight in gold when trying to work out what is going on with a patient at home.

    I must say that my experience in Melbourne is that (most) GPs are far better at providing comprehensive health summaries (including past issues, allergies, medications and most recent reason for admission) than any hospital.

    In situations where information can be difficult, or impossible, to gather, a good discharge summary is more than a courtesy: it can be the difference between helping or causing harm.

  6. says

    I feel your pain and I do try and make sure my info to GPs is as tight as I can make it. I am sure I don’t always do this as well as I should nor police my juniors as well as I could….BUT I’d just like to add, this goes both ways.

    Don’t get me started on the quality of some (and by some, I mean A LOT) GP referral letters (or lack thereof) to EDs. We could ALL do a bit better at communicating with each other for the sake of our patients.

    • says

      Yep Domh, point wll made. Not about ED bashing (they get enough of that and I feel fiercely protective of my ED colleagues) – this is more about those inpatient teams that consider the DC summary an unnecessary after thought.

      Your comment does raise one issue – that of selection bias. When I was an ED reg I used to joke about the shorthand of GPFI (GP is &$@$ing idiot)…then I realised that the reason I saw so many fuff ED referrals was cos these were from the ‘please see and do the needful’ brigade…the good docs werent overly represented. Ditto the perception in ICU that all ED rferrals are duff

      Good communication is key, not inter-specialty bashing

      • CAsey says

        Hey Tim
        Great stuff
        Fuelling my SAMCC talk here – its a perennial problem that needs a new solution / perspective to fix
        C

  7. says

    Agree in principle with the concept that “you order the test, the result is your responsibility”, and this is reiterated in numerous Coronial reports in different states/territories.

    Rather than “GP to chase”, I phrase my letters: “If you’d be so kind as to call our path lab/radiology service for the __X__ (insert outstanding test name) result, I’d be most appreciative”.

    Same concept, different phrasing. Is it any less offensive?

    Also, a lot of us ED folk nowadays don’t have regular jobs. We flit about between multiple ED’s, in casual “gap-filling” roles. Sometimes I do 7 locum shifts in a row interstate, and can chase up my own results (until day 7, as I fly home the next day…), sometimes I do one shift in a local ED, and don’t go back for months, so I can’t go back to check results, unless I want to be calling the lab and the patient from home, and then have no mechanism to see them unless I go to their house (no), they come to my house (no) or I tell them to go back to the ED I saw them at, where they’ll get a Cat 5 and wait for hours, and get seen by someone else, (another ED doc, who I’d have to call to ask them to write a script for a different antibiotic if the MSU had a resistant organism)! Alternatively I could drive half an hour (or fly 5 hours interstate) in to work on my day off to check one MSU result, and then call the patient and offer them the choice of coming back in to see me while I waited there, or see their GP, (with a scheduled appointment), who can make one phone call, and get the result. Also, a lot of urban GP clinics work on 9-5 business hours, which covers about 1/3 of ED operating hours, and GP’s don’t work every day, so we have at best a 66% chance of not being able to call their GP personally (assuming their GP works 7 days a week) even if we wanted to.

    Having said all that, the benefit of ED letters is that the patient walks out with it in their hand, or it’s automatically faxed, unlike inpatient discharge summaries.

    I also work on the premise that the GP will know the patient better than me (I rarely meet my patient’s more than once), so decisions on things like stress tests, new anti-hypertensives, scopes, non-urgent ultrasounds, chronic pain meds etc absolutely require the GP’s input, and in-depth knowledge of the patient’s circumstances. I really value this!

    Great rant.

    • says

      Thanks Andy

      Again, reiterate that this post is NOT about ED bashing – you saps get enough as it is, plus are under pressure enough. I understand that shift work, the (necessarily) limited opening hours of primary care and the inevitable delay in some test result turnaround means that info flow can be challenging.

      That said, I find that ED generally does this well – they safety net, they manage risk.

      What I am ranting about is the abrogation of responsibility from inpatient teams – some of whom who have had patietn udner their care for a week or more…but delegate discharge summary to the most junior doctor, often as an afterthought….such that a discharge summary arrives up to six weeks pist discharge and has a list of “GP to chase…” Orders, not requests. No discussion or appreciation that the serum rhubarb ordered in big shiny teaching hospital may not be accessible to me in primary care, let alone the context in which test ordered.

      That is just not good enough.

      I see a patient in clinic or my small rural ED…takes perhaps five mins to summarise problems, the clinical question I am asking and response needed…and send patient with letter plus fax to wherever hey are going.

      Quite why the same doesnt happen on discharge from inpatient care continues to amaze me.

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