Tuesday, 20 March 2012

Outpatient clinic

Lake seen through reeds and trees
Lakeside, May 2011
Outpatient clinics are stressful, from my point of view, anyway. I don't know whether the patients find them quite so difficult, since all they experience is the frustration of almost always being seen later than their appointment time. Although parking at the hospital is enough to make anyone feel cross when they finally reach their clinic waiting room.

My clinic runs from 9.00 a.m. to 12.30 p.m., at least in theory. New patients get half an hour, follow ups only fifteen minutes. Four minutes late and you might have lost a quarter of your appointment time, except I'll probably have to run late because there's no way I can complete any sort of sensible consultation in eleven minutes. Four minutes early and you're probably going to wait for half an hour because the people before you were late or were particularly chatty or had complex conditions that needed some extra time.

I sit in my clinic room with the patients' cards and the computer showing the clinic list. I have reviewed the cards in advance so I have an idea of what I'm going to encounter, and have a chance to research any conditions I haven't come across before (this is starting to seem pointless; see below). Every minute or so, I press the 'Refresh' button, which re-loads the list and shows if anyone has checked in at the reception desk.

It is 9.18, and it seems my 9.00 patient has DNA'd (Did Not Attend) and my 9.15 is late. I click 'Refresh'. The updated screen shows that at 9.17, the 9.00, 9.15 and 9.30 patients all turned up together. Oh boy. What a great start to the morning.

Or, it is 8.58 and my first patient is at 9.15. I click 'Refresh'. The updated screen shows that the 9.30 patient has already arrived, so I can see him at 9.00 and get ahead. What a great start to the morning!

Here are some examples of consultations, which have been changed from the real ones, but are close enough to give you an idea.

The referral states that the patient has IBS (Irritable Bowel Syndrome) with symptoms of diarrhoea. I'm a bit shaky on the guidelines, so I make sure I have copies ready for us to go through. The patient arrives: IBS is old hat, the latest diagnosis is colitis, which is what the subject of the consultation will be. And we discover that I don't know what you actually do with golden linseeds.
The referral asks me to advise on a diet that will help a type 2 diabetic reduce blood sugars. A typical day's diet history is faultless in terms of sugar, saturated fat and complex carbohydrate intake, and when I check the results on the computer the last tests were done in 2010 and show all blood results within the desired range. Both of us are confused.
The referral states the patient has a Syndrome that I've never heard of. I do a fair amount of research in advance into what it is - it turns out to be a relatively rare endocrine condition marked by excessive hormone production - and I fail to find any relevant dietary guidelines. We will have to work it out together. The patient DNA's.
The card shows that a very overweight patient wants to lose weight, having tried for ages without success. The patient arrives and announces that thanks to a support group, 5 kg has already been lost, and motivation remains to lose more. All I have to do is say thank you for taking the trouble to come and let me know! And write to the GP.
The card shows that the patient needs in-depth dietary advice, and only speaks Urdu. It is 30 minutes before the patient's appointment at the start of the clinic, and I have no idea whether an interpreter has been arranged, or what to do if there hasn't. The admin team arrives and saves the day, showing me how the system shows that an interpreter has been booked. We manage very well, although some concepts don't translate well - I was very confused about 'fish fingers' until it became clear it wasn't the conventional sort.

After the clinic, I have to make sure that all the notes are written up on the cards, and each patient is 'outcomed' on the computer (a nice example of verbing of nouns) so that follow-up appointments can be arranged. Letters are written to the referrers of new patients, if there has been a change in treatment and a new prescription is needed from the GP, or if the patient has been discharged. This week's ambitious target was to try to get all of this admin done on the same day as the clinic, and I managed it!

The manager of the department is very supportive, and encourages using pro forma letters. She didn't exactly say that we didn't have to write when a patient is discharged, but gave the strongest impression that it wouldn't be considered unacceptable. I am still suffering from having to take days off as Annual Leave or forfeit them altogether, meaning that I have to squeeze five days of work into just four, but I'm still writing discharge letters; I think it's the right thing to do.

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