Working with IT and the general practitioner

Published on 14/03/2015 by admin

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Last modified 14/03/2015

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Chapter 46 Working with IT and the general practitioner

Michael J. Golding

ED AND THE GP

The disciplines of general practice and emergency medicine may be thought of as two ends of the one spectrum of true generalist medical practice. While emergency medicine focuses on the more acute end of the spectrum, the similarities between the specialties are greater than the differences, although the differences are sufficient to mean that working effectively in one field does not predict success in working in the other.

Unfortunately there is often a poor relationship between doctors working in emergency departments and GPs: emergency department staff too often reflect negatively on the work of the GP in the community. GPs generally deal with one patient every 15 minutes; many will work faster than this. (A resident medical officer (RMO) in emergency department is rarely able to deal with more than one patient an hour.) In that time the GP takes a history, performs an examination, formulates a diagnosis and management plan, organises investigations and initiates treatment. The GP must provide feedback to the patient, address immediate concerns of both the patient and family, and document the encounter.

Admission procedure

General practitioners will often try to avoid referral to the public health system. They are aware of the constraints of the system and the lengthy process the patient will be subject to in many emergency departments. However, investigations in the private system may take days, so the GP who suspects an acute illness is required to refer the patient for emergency assessment.

What many admitting officers do not understand is that GPs on the phone are not generally asking if a patient should be referred to the emergency department—they are telling you that there is a patient that requires review or admission. Too often questions from the emergency department’s admitting officer to the GP appear to be an attempt to prevent a referral rather than to facilitate care for the patient. Equally frustrating to an experienced GP, who is aware of the complex medical and social history of a patient, is to refer a patient to the emergency department for admission, only to have the patient assessed by a junior doctor and then sent home. The lack of value in this type of assessment has led to development of ‘third-door’ initiatives by which GPs refer patients directly to inpatient teams if their patients require admission.

Discharge procedure

Patients being discharged from emergency departments are routinely told to follow-up with their GP ‘in the next couple of days’. But, in many areas, patients find it hard to get an appointment with a GP in this time frame, and emergency departments need to recognise the difficulties many people have in organising appropriate GP follow-up. Often, discharging a patient to a GP is equivalent to doing nothing at all, and discharge management plans should not depend on GP review in less than three days without prior agreement with the GP directly.

Patients who die in the emergency department may have had recent contact with their GP; the GP may have been managing the illness prior to their death. The GP should be notified of the death as soon as possible, using dedicated forms or standard work practices. The GP can then contact the family, with whom they may have enjoyed a long-standing relationship. The GP may also be able to help with a death certificate and avoid an unwarranted coroner’s examination. Most importantly, the GP is often able to help the patient’s family and friends through the grieving process and defuse their fears and concerns about the treatment provided in the emergency department.

Communication

The general practitioner can be a useful colleague when dealing with the ‘difficult patient’. Their relationship is often based on trust and multiple interactions over a long period of time. By involving the GP in management decisions the emergency department may have a greater chance of successfully implementing treatment and management plans. The patient who frequently re-presents to the emergency department can often be better managed in cooperation with the GP.

The emergency department registration process should include asking patients if they give permission for their presentation to be discussed with their local medical officer (LMO) as well as updating the LMO contact details. It is usually better, but not essential, to make the phone call in the presence of the patient.

Communication is particularly important when the GP has asked to be notified of the outcome of an emergency department referral. Effective communication is a prized skill of GPs and is strongly emphasised during their training, so any failure of communication (verbal or written) by the emergency department to the GP following a referral to the emergency department (or other hospital department) is an endless source of frustration. Adverse events and complaint rates can be reduced by communicating directly with the GP about the outcome of a consultation. Each emergency department should have a list of local GPs with their phone numbers. Divisions of general practice are usually very well organised and helpful: they can often provide current lists of local GPs and their hours, availability and capacity for bulk billing. (Put copies of this in the waiting room.) Some divisions offer a uniform referral form.

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