Dr Sean Ninan is a Specialist Registrar in General (Internal) Medicine and Geriatric Medicine working in the Yorkshire deanery, UK.
When I was 20 I travelled round India, a wonderful beguiling country with some of the worst administration I have ever encountered, much of it unchanged from systems introduced during the Empire.
I have fond memories of the trip but there were many frustrating experiences too. Taking out money from the bank, for example, was particularly painful.
You enter, make your way to reception and explain that you would like to take out some money. They ask you to take a ticket, and you wait in the queue. After some time, patiently waiting you reach the front of the queue.
“Saving, deposit or withdrawal?”
Another queue. When you reach the end of that queue – “Overseas customers to window number three, sir.”
And when you explain that you would like to take out 5000 rupees, you are provided with a note to take to the cashier’s queue who eventually provides you with the money you need.
To someone brought up in Britain, it was clear that this system was highly inefficient with unnecessary bureaucracy and needless extra steps introduced in what should be the relatively simple process of taking out some cash.
I wonder whether, because we are so used to our current hospital admissions system, we cannot see the unnecessary waste of resources. We had an internal Major Incident Planning exercise (MAJAX) in our trust recently. As with many other trusts, demands are pushing us to breaking point. A&E was full. There was nowhere for patients to be clerked. There was nowhere for patients to be seen and we were asked by management to try and not keep patients in hospital for any longer than necessary.
The problem of rising admissions and demands on acute trusts is a complex issue that I won’t try to address here. But it did get me thinking of our admissions process.
How many times have you been told by a patient –
“But I’ve been asked all this already.”
“It should be in my records.”
“The A&E doctor wrote all my medications down.”
If you were designing an admissions process for patients, would you arrange it so that a patient, dealt with a triage nurse, an A&E junior, perhaps an A&E senior, then, several hours later, a medical SHO, perhaps a medical registrar, and then, a medical consultant?
There is too much duplication in this process. It takes too long. It leads to history taking by chinese whispers, where the patient’s story is sometimes accidentally mutated into something different to their initial presenting complaint. Sometimes I look at the ambulance sheet and wonder how the story of what is going on with the patient has changed so much in such a short time through errors in history taking.
Why would you arrange an admissions system where one doctor does a quick, rudimentary assessment taking e.g. 20-25 mins that has to be followed by a further more detailed assessment taking e.g. 45 minutes. Why not just do it in 45 minutes at the beginning for those patients who seem likely to need admission to hospital or at least likely to need to be reviewed by a speciality (in my case “the medics”).
This would require a completely different way of working. A&E teams and medical teams would have to work alongside each other, junior doctors sharing the responsibility for seeing patients and senior doctors sharing the responsibility for reviewing patients.
This would require teamwork and co-operation, concepts not normally associated with relationships between medics and A&E doctors. However, through this process, medics might realise the difficulties in making decisions without all the information available. Whilst A&E doctors might learn to consider what the causes of “collapse, uncertain cause” actually are (sorry, couldn’t resist!). We might learn to be more polite to – and about – each other. We might learn skills and knowledge from each other. It would surely be better for A&E junior doctors who could concentrate on what is going on with the patient rather than figuring out how to “sell” their story to the medics.
There is an elephant in the room of course – the four hour wait. My feeling is that there should be a target time within patients should be seen and not one to rush people out of A&E. Perhaps an area where medics and A&E doctors work together to see patients being considered for admission might be considered separately. The other issue I have with the four hour wait is that you have to be seen within 4 hours in A&E but there can be long waits of several hours for patients to be seen once they have been referred to the medical team. Patients should not have to wait so long to be seen if they are seen just once, but we give the doctor some time to see patients properly.
I know what I propose might meet with much resistance – from medics who want to stay away from A&E, from A&E docs that don’t like medicine, and from systems and departments that are firmly entrenched in their ways.
But surely it just makes better sense? It would be on my wishlist of how to change hospitals. This, and no bleeps, and no faxes, and shared electronic records between primary and secondary care….
Oh well, night shift tonight. “I’m sorry. i know you’ve already told another doctor all this but I just want to go through things again…”
I agree that there could be less repetition. The challenge is getting people in front of healthcare professionals with the correct expertise. If these can be the first and only person that the patient sees, then fine. If repetition is required to make this happen otherwise, then it may be a necessary evil.
I commonly hear the argument that “we’re all geriatricians now” because all doctors care for frail older people. Yet all doctors do not care for frail older people well, or with expertise (which I would argue is the hallmark of the training undertaken to become a specialist in geriatric medicine).
We can’t train all doctors to be a geriatrician because training in the specialty, legitimately, takes five years – and if we all trained to be geriatricians then nobody would have any time to train to be cardiologists, respiratory physicians, etc. So other doctors need core skills in the assessment in frail older patients and they need support from those with more specialised expertise in frailty and the problems commonly seen in later life.
Some hospitals may be able to resource services where all frail older people see a specialist geriatrician first but the number of older people attending hospital is increasing faster than is the number of specialists – so I think some repetition may be necessary, even if it could be reduced by some considerable amount.
Great post. I certainly share your frustration at the inefficient duplication of work – and I’ve also seen it (understandably) annoy patients and relatives when they are being clerked for the ‘n’th time. Having said that, I have seen histories change and develop over time, and it’s not that uncommon for a whole new complaint to mainfest itself on the post-take ward round that was not mentioned at all in the A&E or MAU notes. I think this comes back to Adam’s comments about the importance of being seen by the most appropriate person from the outset. I agree that not all general physicians are geriatricians just because they look after older patients, and equally not all older patients have the frailty and multi-morbidity that would require geriatrician input.
There is definitely room for improvement within the existing structure of many admissions pathways, but in addition to this I wonder whether the way forward is the development of specialist acute geriatric units, or teams of acute geriatricians who can provide early input.
I was interested to read about MACE (Mobile Acute Care of the Elderly) Teams in a recent article in JAMA – is this the future of geriatrics in secondary care?
Histories do change and we should revisit things. Different doctors may also think of different approaches which may (or may not) be useful.
Key is that repeating things should be to clarify/improve things, my just “routine” meaningless repetition. I worked in one hospital where pt was “reclerked” again after moving from aau. It meant that when you were doing a ward round there was a mass of repeated useless information, which amounted to ?UTI anyway!
Key, as you say is for appropriately trained people to do it right the first time. For frail older people, I think this means an SHO supervised by geriatricians training eg junior doctors in management of frail older people, with a sound understanding of geriatric syndromes such as frailty and delirium, informed by the priniciples of comprehensive geriatric assessment.
This is just the reverse in India unlike the banking system. Here usually a consultant or another doctor admits the patient with the history taking responsibility and the waiting time is very less. Moreover the presenting complain and history changes with the number of people taking history. In geriatric age group the complains are vague. doctors make it worse by using medical terms.
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