Referring: “That patient looked at your Consultant – They should take over their care…”

Now I am writing this mid-week for one very good reason. I am on annual leave! Never two better works spoken (well ‘pay day’ is also nice..)! So on a Tuesday morning I sit here in my lounge, cup of tea in hand, cat asleep on the sofa, and BBC Breakfast talking about something I have no idea about.  Bliss. It certainly trumps the usual fight to a computer to update the patient list, finding out I’ve misplaced 4 patients and can’t find where they’ve been moved (hospitals love to play musical beds with patients when the day time doctors go home…), and that I already have a list of jobs as long as my arm before the shift has even officially started. Like I say, today, is bliss! But, dear reader (I say reader as I only think my readership extends to my mum currently), this is not why I am writing this today. Today I am writing to tell you about my biggest hurdle as a doctor.

Referrals.

They can just be SO awkward. I mean painfully awkward. And as a junior doctor, it is my role to do the referring.

So for those of you who don’t know about what a referral is, please let me explain. There are two types. The first is a simple referral where advice is sought.  Now a patient is under the care of a consultant in hospital. For example, a lady with a bowel cancer under a colorectal surgeon. If this lady then develops a heart problem, we then need to get some advice from the heart doctors – the cardiologists. This is a simple referral. The second type is permanent and about handing over care. For example, a patient comes in being looked after by the surgeons and then has their surgical problem fixed. However they are still unwell with some other medical problems. The consutlant surgeon would therefore want a medical doctor (not a surgical doctor) to officially take over their care i.e. a transfer of responsibilities.

It is this that I hate.

You see my consultant on his ward round will simply see a patient and then as he walks out away from the hospital bed state the patient is surgically fit and so “transfer to medics” to manage the ongoing medical issues. As I ink the words onto the notes page (I am carrying about 5 patient sets of notes by the way and can’t feel my arms anyway by now), they are blotted by the solitary tear shed from my eye as I realise I will be the one making that “transfer to medics”. Fast forward 20minutes and I sit at the ward desk, preparing to make the ‘transfer to medics’ phone call. This has a number of stages.

Number 1: Make sure you know what is going on with the patient. This is not always easy….

Number 2: Make sure you have your confident “No no we are completely done with this patient” voice ready

Number 3: Have an air-tight reason why you cannot possibly look after this patient anymore and they must take over

Number 4: Say a little prayer

So here we go. I am locked and loaded as they say in the movies. I make the call. Here is the reality of that call:

[Ring Ring]

Medical doctor: “Cardiology Reg”

Me [surgical doctor]: “Hi it’s Nick Knight, FY1 to Mr X the consultant surgeon”

Medical doctor: “And?”

Me: [awkward pause as I swear under my breath] “I’d like to discuss a surgical patient that we feel is fit for surgical discharge but has ongoing cardiology issues. We would be grateful if you could take over their care. May I give you some more details?”

Medical doctor proceeds to ask me 10 million questions, investigation results and things that I am not even sure I had even heard of – even in medical school.

Medical Doctor: “This is an innappropiate referral – I am NOT accepting. You clearly have no clue about this patient.”

Usually too you might get told how sh*t you are as well. So, with that wonderful, heart-warming exchange, I hang up the phone and move down the list to the 2nd of 5 referrals that my consultant has made me do.

Once again, I find myself wishing I had trained as a vet….

Moving on from this horrible scenario I want to share very quickly (as I have a very busy day of putting my feet up and soaking my annual leave joy) with you something called SBAR. SBAR is a communication tool that the NHS uses. I think it is pretty cool and to be honest could be used in many businesses and walks of life. Here’s what it stands for and a working example:

S – Situation

e.g. “Hi it’s Dr Nick Knight, I am the surgical F1 on call, I have a patient I’d like to discuss who I’m very concerned about”

B – Background

e.g. “Mr X is a 54 year old male smoker with a background of diabetes, who has presented with atypical sudden onset chest pain

A – Assessment

e.g. “He is tachycardic with a heart rate of 110, and an ECG showing ST-segment elevation in leads V1 and V2”

R – Recommendation

e.g. “I believe he is having an atypical presentation of a myocardial infarction and have started him on acute coronary syndrome protocol but would like some more recommendations from you on how to further manage this patient?”

A great tool – one we could all use to promote continuity of communication.

Right, my tea needs topping up and I am sure their is a Christmas movie I NEED to watch on television…

Have a great week all!

Dr Nick

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