Rubbish referrals, really?!

I am inspired to write this blog by Sean Ninan, a fellow Geriatric Medicine Registrar and thoughtful doctor who recently blogged about ‘inappropriate referrals’ to specialty clinics such as the TIA service. Sean made the important point that these referrals are rarely inappropriate at all, but more diagnostically challenging; this challenge should enthuse us specialists as diagnosticians, otherwise we become protocol led technicians not capable of making other diagnoses.

In my first week back at work after sick leave I ended up in an argument with a colleague. We had just seen a young woman on the Stroke Unit with what had been labelled as functional neurological symptoms. As we left her room this colleague said “all that lady needs is a psychiatrist” in a very dismissive manner as though she had wasted our time. I was not impressed by his comment and said so, perhaps given my own recent experiences as a patient I was more sensitive than I should have been. Maybe her MRI scan had been plumb normal, maybe her examination findings were difficult to interpret, maybe she did have lots of psychological overlay but I firmly believe that these patients are exhibiting some form of distress that should be managed with as much compassion as the next patient with an infarct on their scan. I returned to the patient after the ward round and spent 45 minutes talking. She just needed someone to listen.

I overheard a couple of SHOs discussing the acute take the other day on the ward. “It wouldn’t be so bad if we didn’t get all this rubbish referred from A&E.” Hmmm. I know that I have had similar conversations myself in the past, frustrated by a system that forces us to dehumanise the job in order to survive. But now I’m a patient myself I would be horrified to think a doctor was referring to me as “rubbish”. Surely a doctor is a caring professional that puts their patients at the centre of their work, aren’t they? It is a very easy trap to slip into. Every hospital has a cohort of patients that are difficult to manage; the patient who has had 40 admissions with troponin negative chest pain; the patient who presents with recurrent seizures with a label of non-epileptic attack disorder. I cannot help feeling that these patients may have medically unexplained symptoms but these symptoms are still a manifestation of some form of distress, or maybe even represent pathology that we just do not understand or cannot measure yet.

So next time your heart sinks prior to seeing a tricky patient maybe we should ask ourselves ‘how can I help this person?’, which I’m sure was what we all said we wanted to do when we applied to medical school…

9 thoughts on “Rubbish referrals, really?!

  1. Couldn’t agree more with the underlying point, Kate. I guess the trouble sets in when the answer to the question “how can I help this person” is “I can’t”, or, sometimes even worse, “by seeing this person I think I am reinforcing their dependence on us and actually making things worse for them”. A good listen shouldn’t be beyond us, but I’m not sure that’s always enough. challenging patients medically unexplained symptoms shouldn’t make us lose our humanity, but neither should they make us lose our rationality.

    • If the answer is “by seeing this person I think I am reinforcing their dependence on us and actually making things worse for them” then surely the patient should be referred to somebody who CAN help? All too often the disparaging “you need a psych” comment is made, without any referral for a psych assessment/treatment. There are occasions when saying “I can’t help you” should be said but isn’t – instead the message conveyed is “it’s your own fault”. I cannot think of reason ever to lose compassion for a patient. Ever. That person is there because they need the help of a doctor, for whatever reason.

  2. A medically unexplained symptom may, to doctors using medical shorthand, mean rubbish. Taken in its normal English useage, however, the words are surely ones of humility, hope and curiosity. Simply put, the limits of medical science can’t as yet explain the patient’s symptoms – which is a humble admission of the current limitations of medical science rather than a condemnation of a patient as merely psychiatric. How did the term become a sink category?

  3. You should have worked in Emergency Medicine! We are more than aware that many of our patients are looked upon as ‘rubbish’ by others. Hence many if not all of us working in the specialty are viewed as the hospital janitors by the more salubrious specialties. However those of us in the specialty are there to care for people in all of their glorious colour. There is no doubt that some cynicism can creep in with age and dealing with yet another alcoholic/addict/homeless wretch can become wearing and take the shine off the more ‘exciting’ patients. But it is being there for our patients that is so important. Every doctor should constantly remind themselves that they have to care first and foremost and then get into the cerebral stuff. If people actually cared more then the system would work much better and our patients would benefit. But that’s a counsel of perfection and very hard to carry over the long haul.

  4. I have seen friends misdiagnosed with functional disorders (or ME/CFS, which to all extents and purposes is treated the same by the majority of medics), and the treatment received is appalling as a result. I would even go so far as to say it was often abusive. It is awful, but not in the least bit surprising, to read an account of this attitude from a professional’s perspective.

    I would argue that those with ‘medically unexplained symptoms’ need more, rather than less, input from physicians. It is horrific having to deal with distressing symptoms AS WELL AS self-doubt, lack of treatment or lack of explanation. I have mental health problems as a direct result of having my medical problems dismissed – and some physical health problems prolonged, whilst we’re at it. I can also tell you that the best doctors are the ones who say “I don’t know”, not the ones who cover their frustration at not being able to help by blaming the patient.

    Thank you for being a voice of reason. Let’s hope others can follow suit.

  5. As someone who nearly died before being diagnosed with CNS vasculitis — and who had a surgeon who was certain I belonged on the psych ward rather than in treatment for neurological symptoms — I applaud your attitude, Dr. Granger.

    And I second the person above who said “I can also tell you that the best doctors are the ones who say “I don’t know”, not the ones who cover their frustration at not being able to help by blaming the patient.”

    These days, I don’t accept a dismissive or condescending attitude from a health care provider. I’m lucky enough to be able to go elsewhere if need be, to find someone better suited to my needs. But I started out, as I think many generally healthy people do, feeling that surely the doctor always knows best? The journey my family members and I took in learning to be advocates for ourselves as patients wasn’t an easy one, and it’s not one I would wish on anyone dealing with an illness.

    The older I get, the more people I know who have been mis-diagnosed or not diagnosed at all, only to find out later that in fact they do have a treatable illness. It’s frightening and infuriating, especially when it is the result of medical professionals making assumptions instead of asking questions.

    Thank you for sharing your thoughts with us.

  6. I suspect that female patients are most at risk of having the ‘functional’ label applied to them. It is my belief that most patients given that label will (if an assiduous doctor takes the trouble) ultimately be diagnosed with a medical condition. I consider it a form of abuse to deride and ignore a patient’s condition.

    No healthy person ever wants to go anywhere near doctors and hospitals (and quite a few unwell people don’t want to, either). The most thoughtful approach might be that the patient has not been given a proper work-up; the medical record is woefully inaccurate – terribly common, once you start checking; serious conditions have been ‘overlooked’ on scans; the patient has a rare condition; the patient has a condition which has yet to be given a name; and so on.

    The laziest thing of all is to describe such patients as ‘rubbish’.

    Speaking from personal experience, all my rare cancers – yes, multiple – were missed, every time by multiple doctors (including at a national cancer centre). I had to become a ‘walking Sloan-Kettering’ in order to get formal diagnoses and treatment. That is where the ‘battle’ comes in.

    I shall forever have contempt for doctors who dismiss patients as having ‘functional’ conditions. My GP became quite embarrassed 18 months ago – he was beginning to recommend psychological treatment because of failed, perfunctory work-ups. I decided not to communicate personally with him when.not long after, I had urgent surgery for 2 new high grade invasive cancers, and left it up to the registrar to advise him by phone post-operatively. It has reduced his swagger…

    I remind him that there is not a single other patient in world cancer literature with the particular collection of cancers that I have.

    From time to time, I consider writing to the ex-GP in the North of England who denied me a referral for my first cancer…who was keen to use the ‘functional’ label…

  7. I never forget the lady who presented to my training hospital regularly with her chest pain but never any rise in enzymes(we hadn’t heard of troponin back then) , I moved out into GP land and she came to see me, I agreed to see her each month and to give her an ECG at least once a year until we could work out what was wrong. Over the next year I heard about her abusive husband and her abusive brain damaged adult son and then we realized she hadn’t had chest pain and gone to hospital in all that time. I couldn’t fix her home situation but just being listened to was enough to cure her symptoms. Never dismiss a patient until you really do know what their life is like.

  8. I had untreated ulcerative colitis, misdiagnosed as IBS by a former GP, for 6 years, due to not passing visible blood, and receiving normal results on the tests my then-GP sent me for (though not a blood test or a colonoscopy, which would have picked something up). I reluctantly, and stupidly in hindsight, accepted the IBS diagnosis, and my then-GP’s patronising advice of trying to ‘relax’ (because that’s so easy when you have to make urgent trips to the bathroom 10+ times a day) and making sure I wash my hands thoroughly after using the toilet (i.e. it’s all in your head). My health deteriorated significantly prior to receiving an accurate diagnosis, and I had a cerebral venus sinus thrombisis stroke (a rare complication) a week later, in my late 20’s. I recovered, but feel that all of this could have been avoided if the original doctor I saw had only taken me more seriously. I assume it’s protocol when a young person arrives at ER having a stroke, but one of the first things I was asked was whether I used drugs (which I’ve never indulged in), and a blood sample was sent off to toxicology. Again, I didn’t tick the usual boxes.

    I’m not a doctor, but my perception is there’s a fair bit of ‘you don’t fit the textbook example’/’you’re too young to have X’ perceptions in medicine, which unfortunately results in people being written-off with functional illnesses who may have something undetected going on. I’m not suggesting that psychogenic illness isn’t ‘real’, but it seems to be a convenient diagnosis when ‘we really don’t know what’s wrong with you, but we won’t admit that’.

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