Communication between specialties
As a doctor, you are not expected to be infallible, but you are expected to put yourself in a position to make a reasonable clinical judgment and manage the patient appropriately thereafter. This includes making an adequate assessment of the patient’s condition, arranging appropriate investigations and treatment and seeking a senior colleague’s advice when necessary.
Referrals
As part of the referral process, it is important to indicate the degree of urgency and provide all relevant clinical details
Many referrals are made within the hospital setting and include other specialties (same hospital or others), other health professionals (eg, speech therapists) and other agencies (eg, social services and voluntary sector).
The patient (or the carer) needs, therefore, to understand the reason for the referral and have appropriate expectations. As part of the referral process, it is important to indicate the degree of urgency and provide all relevant clinical details. It also helps to indicate what the patient has been told (eg, referral to a clinical oncologist).
Keeping each other informed
The divide between primary and secondary care is an area where communication can easily break down, particularly when patients are receiving long-term treatment.
If the patient is being given ongoing care as an outpatient, it is particularly important to keep the GP informed about his or her progress and treatment, as they may have a bearing on the GP’s own treatment of the patient (see, for example, the case reported in Box 17).
Box 17: Kept in the dark
A diabetic clinic in a teaching hospital diagnosed TB in a diabetic patient with a history of weight loss. He was admitted to hospital and, on discharge, was prescribed three months’ supply of ethambutol, rifampicin, pyrazinamide, isoniazid and pyridoxine.
A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment. He failed to attend his next appointment.
Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic. The GP had not yet received a discharge letter about the patient’s last hospital admission for the treatment of TB, nor had the diabetic clinic informed him of the diagnosis so his referral letter to the eye clinic made no mention of of the fact that he was taking ethambutol.
The patient attended the eye clinic several times over a month, but no history of TB or of treatment for TB was obtained, his visual loss being attributed to diabetes. However, his vision continued to deteriorate and by the end of this period he was only capable of counting fingers.
A week later, the patient attended the diabetic clinic. Only then was the diagnosis of ethambutol eye toxicity raised.
The patient was seen immediately in the eye clinic where the diagnosis was confirmed and the ethambutol stopped, but by then he had sustained a permanent loss of 90% of his vision.