Inappropriate referrals

The medical student had come to join me in transient ischaemic attack (TIA) clinic. I had taught him about diagnosis, differential diagnosis, investigations and management. We had just seen an interesting patient with recurrent stereotyped symptoms of tingling down one sided, preceded by a funny feeling in her head and usually accompanied by clouding of consciousness and sleepiness afterwards. I explained to him why I thought these were complex partial seizures.

“It must be so frustrating doing a clinic where half the patients haven’t even had a TIA,” he said. He had previously sat in a respiratory clinic where many breathless patients had been referred who didn’t even have lung disease.

I wonder why a student should think this way. I don’t find it frustrating that people in TIA clinic don’t always have TIAs. Diagnosis isn’t always easy. Patients may be troubled by their symptoms and their GP may be unsure as to the cause. I don’t expect 100% of cases to be TIAs. If it was that easy, I could provide the GP with a proforma of boxes to tick with investigations and management. Clearly, lots of completely inappropriate referrals might hamper the speedy treatment of patients with TIAs but that wasn’t the case so I have no reason to be annoyed. Besides if all I was doing was doling out aspirin prescriptions and carotid Doppler requests, the clinic wouldn’t be as interesting.

But why did the student think this way? He was merely emulating the behaviour of the hospital specialist. Complaining about “inappropriate” referrals is mostly a pointless exercise. They will always occur, you know they will occur, so just embrace it. I have written about this before, see “dogs tied to a bicycle”.

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