Prioritisation

Jephson Gardens, Feb 2012

My main weakness over the first weeks of my first dietetic job has been the tendency to accept referrals and agree to review patients that a more experienced Dietitian would discharge from their care. Without the experience to be certain that my practice is safe and correct, I have tended to want to review patients to make sure that all is well, and to find out whether my recommendations worked. This is commonly found with new Dietitians, and a sign of increasing confidence is to reject a referral or discharge a patient from dietetic care.

What this has meant is that my caseload is rather too big, and I wasn't able to review all my patients last week. This is fine, because if there had been any cause for concern, the ward staff would have bleeped me or called the office, which they actually did once or twice. New referrals kept coming in, and those patients have to come first.

When you are interviewed for a job as a Dietitian, invariably there is a question about prioritisation, which goes like this:

"It is Friday afternoon and four referrals have been received in the dietetic office. What do you do?"

Then they describe the four different patients, who usually are as follows: one overweight patient on a ward wanting healthy eating advice, one person with newly-diagnosed diabetes about to be discharged home, one malnourished in-patient with poor appetite, and someone who has just had a nasogastric (NG) tube placed and needs a regimen for feeding through the tube. What you do is offer the overweight patient an outpatient appointment, go and see the person with diabetes before they go, tell the ward staff to give the malnourished patient food, snacks and supplements and re-refer if things don't improve, and tell them to use the emergency regimen for NG tube feeding that has been drawn up for just such contingencies, until you can see the patient on Monday.

Up until last Friday I had thought it was a useful exercise to ensure that candidates can make the right choices when demand for dietetic input exceeds the number of hours in the working week. Last Friday I discovered that it is actually a very accurate description of real life. I had new referrals for a patient with type 1 diabetes, another who was obese, a third with Crohn's disease, another with a reported BMI of 15 kg/m² (which is seriously underweight), and I was on a ward reviewing a patient receiving an NG feed. And it was 2 o'clock on Friday afternoon.

It all went to pieces through an unprecedented chain of events that meant I had to spend a long time on the ward sorting out a potentially harmful situation, and then reporting a 'Clinical Adverse Event'. It's interesting to find that as the end of the working week approaches, priorities sort themselves out - three of the referrals ended up being somehow much less important than I had originally imagined, and, for the first time, I rejected a referral. It felt good.