Michael Patkin's
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Publication history, Reflections & comments
Writing a patient's discharge summary is a tedious chore to many hospital residents and consultants. Yet to the doctor in general practice, the arrival of this summary is necessary both for his further treatment and for explanations to the patient or his relatives. The gap between is all too common and frustrating, if not at times downright dangerous. In an age when televised pictures from the moon travel a quarter of a million miles to be seen in less than a second, it is worthwhile looking at the mechanics of communication between hospital and general practitioner.
What does the referring doctor need to know when his patient arrives at the surgery or is visited at home for the first time after leaving hospital? The needs seem fairly obvious. He wants to know the diagnosis, with a brief résumé of the history as seen in hospital. He wants to know the treatment, the course of the illness, the prognosis, the outline of long-term management, what treatment the patient is currently having, and in what way this may need to be modified. He would also like to know what complications occurred during the patient's stay, no matter how modest the attending surgeon or physician may feel about this distasteful subject. On those occasions when the patient has a malignant condition or a poor prognosis, he would like to know what the patient was told about the nature of his trouble.
Detailed reports of differential white cell counts or blood gas analysis are not wanted, if they are normal; as window dressing they may impress the recent graduate, but they take up space and make unnecessary work for typists, hindering the onward flow of significant information.
Ideally, and also as a practical possibility, a discharge summary that is typed but not signed could be in the post to reach the referring doctor in the next morning's mail. Business firms with a good record in this type of approach soon score over less efficient competitors, and much can be learned from current trends in commerce.
An article by J.L. Boland in a leading Australian monthly business journal [1} analyses the planning and administration of typing pools for large organizations. It is well worth a detailed study by those who run large hospitals. Experience has proved the advantages of economy (up to 60% of running costs), continuous flow, faster output and better working conditions for typists, where the "typing centre" has been organized on efficient lines by a supervisor with the necessary technical knowledge and personal ability. Nowadays, internal telephone dictating equipment Is readily available, whether for hospital or for business corporation. Objections on the grounds of the confidential nature of medical correspondence can also be met by practical measures.
For the hospital resident, to whom writing a discharge summary must often seem a necessary evil to be put off as long as possible, this type of system has obvious advantages. As he sits in the ward office after the morning. round, with the clinical histories in front of him, he picks up the telephone, dials one number to obtain control of a recorder in the "same day" flow to be typed each afternoon, and listens for an exchange signal to notify that a machine is available; he then dials another number, and the machine is ready to record.
At an arbitrary but convenient time each day, such as 2 p.m., the taped cassettes from the "same day" recorder are transferred to the typing, desks. Typists shift their attention from more routine work done in the mornings, and the discharge summaries are made out to catch the end-of-day postal sorting. A carbon copy of the summary placed on the front of the clinical notes awaits the doctor's signature in the ward office the next morning. Any major blunders in the letter can be rectified with an additional note to the referring doctor, or by a telephone message on the rare occasions when a critical mistake in drug dosage has been made.
Such a system would be a major change. In his article, Boland states that the establishment of a typing centre is a major commitment. It requires the enthusiastic support of top management to obtain trial and final acceptance by middle management and staff, ranks that can easily be transposed to those in the hierarchy of a hospital. He goes on to say that the introduction of such a scheme should not be hinted at during the period of pre-study, and that detailed planning is necessary. It is also an exercise in public relations within the organization, which is usually successful to the point of enthusiasm.
In hospitals there may be some special points of difficulty not yet met with in business. Harassed first-year residents may find it an added strain assuming the function of junior business executives, as well as the medical responsibilities they have for the first time. There are some simple special techniques to learn, such as spelling out unusual words or names with a phonetic alphabet. During the dictation other numbers may be dialled for playback and correction, or for changing the belt when a signal indicates that the, recording time is running. out. In one or two locations an independent dictating machine may be better. A sudden rush of work, or the aftermath of fatigue from a heavy night in the operating theatre or the wards, may leave the resident with little inclination to get over the chore associated with the discharge of a patient from hospital. The occasional senior consultant will feel, wrongly if business experience is any guide, that not having his personal "girl Friday" will impair his work. The design of some wards may not have the necessary quiet small area of bench space near a telephone.
In everyday terms, however, the likely benefits are great, with less physical movement of records and a more even flow of work. The family doctor, or another referring specialist, wants to know about his patient on discharge from hospital, not some weeks later. This is one situation which gives the lie to the old tag that "no news is good news". '
[1] Rydge's, December, 1969
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The Medical Journal Of Australia February 14, 1970 P.292
No news is bad news
Communication is the lifeblood of any human situation. I wrote this editorial with some passion at a time when I was a family doctor, and relied heavily on information from the hospital after a patient had been treated there.
Just a few months later I was back in the surgical stream at a large hospital, and faced with the chore of writing discharge letters and summaries to the relevant GP. It's hard work, particularly when a back-log develops during a busy period, and it's not a satisfying task in the way it is usually looked at.
The mechanics of generating this information should be as simple as possible, and it should be clear just what information is useful.
How chatty should a discharge letter be? Generally they are cold impersonal documents. Having them computer generated would at least save the backload of unwritten letters. To make them warmer and less formal risks causing huge offence on rare occasions. Litigation and the loss of trust in many directions will mean medicos will stick to the safe impersonal course. It may be different in a private practice situation where the two doctors and the patient know and like each other.
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