London Journal of Primary Care 2009;2:86–7
# 2009 Royal College of General Practitioners
London Landscape
Triangulation Surinder Singh Senior Lecturer in General Practice, University College London Medical School, London, UK
Keywords: primary care, referral, triangulation A letter from an optometrist arrives and recommends that I refer a 12-year-old child who seemingly has a unilateral ‘6th nerve palsy’. The family are originally from eastern Europe and have been in the UK for five years. I, personally, do not know the child or family for that matter. As is practice policy I call the patient in to see one of us. The mother duly arrives with the 12-year-old girl. Mum’s English is no better than moderate and she has problems understanding some words. I had quickly scanned the notes before the family arrived and it is clear that the eye problem has been recognised before. Accordingly, the child was diagnosed three years previously with a 6th nerve palsy and arrangements for follow-up had been made. Unfortunately the family ‘DNA-ed the appointment’ in the previous year. The letter highlighted this non-attendance but also stated that yearly follow-up was unnecessary since the palsy was stable. And so to the consultation. It started well, with Mum saying that she wants a referral because the optician said so. I respond by saying that because the nerve palsy had been noted before, unless there was anything new to report, a referral was unnecessary. ‘Why don’t you just refer her’ mum asks? Now she is becoming a bit irritated and I can see that she is directing some of this at her daughter, the patient. There is another request for a referral. I think to myself that it would be so much easier to refer. However, I persist and try explaining again, though also noticing that I am now running 15 minutes behind schedule. I terminate the consultation by printing off the ophthalmologist’s letter and asking her to discuss with her husband (who’s command of English is greater, I am told). The following day I call the optometrist. I point out that I am the general practitioner and the child’s eye problem had been noted before and follow-up at the hospital deemed unnecessary. The optometrist clearly remembered the girl since it was such a marked palsy and that he didn’t quite understand how this could
have escaped anyone’s attention over the preceding years. Additionally, the mother had said ‘no one had ever seen the child with this eye problem’, hence the urgent recommendation for me to refer the child to a specialist. When I pointed out that the child had been seen previously in which case a re-referral was not necessary, I almost heard a sigh of relief. I also pointed out that the ophthalmologist thought yearly reviews were unnecessary. A week later I see the father of the child. He also asks me for a referral. Thankfully he has come with the letter which I had printed off and he is aware that it recommends a referral. After listening to the father I pointed out that a referral was unnecessary because his daughter had been seen previously. When he mentioned that the optometrist recommended referral I then had to point out that this was only said because his wife had specifically mentioned that ‘no one had ever seen her bad eye before’.
Conclusion This is a tale of two consultations – each lasted over 15 minutes plus a series of phone calls to verify facts, liaise with the optometrist and ensure all could be done for this girl with quite a marked nerve palsy. There is also a bit of soul-searching on my part (why didn’t I just agree to the referral?) and an uncomfortable two weeks when these consultations took place. All for what? An unsatisfied customer (what does this say about choice?), perhaps one less patient going to hospital, a unit of resources for the next patient. Primary care at the coal-face; sometimes hard, emotionally-charged, sometimes dysfunctional and uncomfortable – especially in an inner city context where, it is highly likely that the patient will get their referral because they’ll go to another doctor or another practice to get what they want. How long can the fight go on?
Triangulation
ADDRESS FOR CORRESPONDENCE
Surinder Singh Senior Lecturer in General Practice Research Department of Primary Care and Population Health University College London Medical School Royal Free Campus Rowland Hill Street London NW3 2PF UK Email: [email protected]
87
# 2009 Royal College of General Practitioners
London Landscape
Triangulation Surinder Singh Senior Lecturer in General Practice, University College London Medical School, London, UK
Keywords: primary care, referral, triangulation A letter from an optometrist arrives and recommends that I refer a 12-year-old child who seemingly has a unilateral ‘6th nerve palsy’. The family are originally from eastern Europe and have been in the UK for five years. I, personally, do not know the child or family for that matter. As is practice policy I call the patient in to see one of us. The mother duly arrives with the 12-year-old girl. Mum’s English is no better than moderate and she has problems understanding some words. I had quickly scanned the notes before the family arrived and it is clear that the eye problem has been recognised before. Accordingly, the child was diagnosed three years previously with a 6th nerve palsy and arrangements for follow-up had been made. Unfortunately the family ‘DNA-ed the appointment’ in the previous year. The letter highlighted this non-attendance but also stated that yearly follow-up was unnecessary since the palsy was stable. And so to the consultation. It started well, with Mum saying that she wants a referral because the optician said so. I respond by saying that because the nerve palsy had been noted before, unless there was anything new to report, a referral was unnecessary. ‘Why don’t you just refer her’ mum asks? Now she is becoming a bit irritated and I can see that she is directing some of this at her daughter, the patient. There is another request for a referral. I think to myself that it would be so much easier to refer. However, I persist and try explaining again, though also noticing that I am now running 15 minutes behind schedule. I terminate the consultation by printing off the ophthalmologist’s letter and asking her to discuss with her husband (who’s command of English is greater, I am told). The following day I call the optometrist. I point out that I am the general practitioner and the child’s eye problem had been noted before and follow-up at the hospital deemed unnecessary. The optometrist clearly remembered the girl since it was such a marked palsy and that he didn’t quite understand how this could
have escaped anyone’s attention over the preceding years. Additionally, the mother had said ‘no one had ever seen the child with this eye problem’, hence the urgent recommendation for me to refer the child to a specialist. When I pointed out that the child had been seen previously in which case a re-referral was not necessary, I almost heard a sigh of relief. I also pointed out that the ophthalmologist thought yearly reviews were unnecessary. A week later I see the father of the child. He also asks me for a referral. Thankfully he has come with the letter which I had printed off and he is aware that it recommends a referral. After listening to the father I pointed out that a referral was unnecessary because his daughter had been seen previously. When he mentioned that the optometrist recommended referral I then had to point out that this was only said because his wife had specifically mentioned that ‘no one had ever seen her bad eye before’.
Conclusion This is a tale of two consultations – each lasted over 15 minutes plus a series of phone calls to verify facts, liaise with the optometrist and ensure all could be done for this girl with quite a marked nerve palsy. There is also a bit of soul-searching on my part (why didn’t I just agree to the referral?) and an uncomfortable two weeks when these consultations took place. All for what? An unsatisfied customer (what does this say about choice?), perhaps one less patient going to hospital, a unit of resources for the next patient. Primary care at the coal-face; sometimes hard, emotionally-charged, sometimes dysfunctional and uncomfortable – especially in an inner city context where, it is highly likely that the patient will get their referral because they’ll go to another doctor or another practice to get what they want. How long can the fight go on?
Triangulation
ADDRESS FOR CORRESPONDENCE
Surinder Singh Senior Lecturer in General Practice Research Department of Primary Care and Population Health University College London Medical School Royal Free Campus Rowland Hill Street London NW3 2PF UK Email: [email protected]
87
