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Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan


  1. It is a fair summary of the problem

    I am interested in what the solution is

    My simplistic mind says this

    “You’re a consultant in a tertiary hospital? That’s your name at the head of the bed? Fine. Then YOU need to ensure that there is a concise and clinically accurate discharge summary generated ON THE DAY of discharge – sent to the patient usual doctor. By all means get your ‘team’ (and that might include the most inexperienced member of the team) to make a call to the doctor, but be damn sure that the relevant information is handed over. Frame your systems approach to this as a ‘clinical handover’ compliant with appropriate Quality & Safety Standards. This is especially relevant if there are outstanding actions – such as dose titration, review of bloods or pending investigations.

    – Interns writing discharge summaries on patient why’ve never met doesn’t cut it.
    – Vague commandments for “GP to chase…” are inappropriate.
    – Concluding the ward round or outpatient consultation with the words ‘a letter will be sent to your GP’ is a fiction, when the typing pool takes 6 weeks to generate a letter and mail it out
    – Delegating the discharge summary to the least experienced member of the team is crazy

    “It’s YOUR name at head of bed. YOUR responsibility.

    “Transform discharge summaries into ‘clinical handover’ with same day transfer of information the norm, not the exception.”

    (COI – as a primary care provider I write my letters with the patient in front of me..give them a copy AND send a copy to the tertiary centre…it takes perhaps a couple of minutes and is important. if I can do this in a busy day seeing 35 patients, why can’t you? If the system needs to change change it. This is about safety!)

  2. A list of the common questions a patient should ask might help. It wouldn’t cover everything but at least helps to kick start the information gathering process. This could be given to the patient to think about. The patient could get a family member, friend or support person to add questions too.

  3. A list of the common questions a patient should ask might help. It wouldn’t cover everything but at least helps to kick start the information gathering process. This could be given to the patient to think about. The patient could get a family member, friend or support person to add questions too.

  4. George D Patrin says:

    We have gotten so far off-base with our sick care, referral, insurance-controlled medical system in this country. Tim – SPOT ON! Can we all please remember – “Who’s the patient?!” They need to be informed, yes! We should answer all their questions, yes! It’s our responsibility to provide the client (the patient) not only with a bill, but also, and MORE important, their discharge plan and now it fits into their overall health plan…which should be in the hands of their Primary Care Giver Team. A professional communicates, pushing the information out to the team. We should NOT be asking the patient to be the messenger, the case manager, and care coordinator…but we do! It’s time to stop it…and take back our profession and act professionally. The patient’s perception of what was done to and for them is not even adequate, but less sufficient.

    • Thank you George. I’m not sure there is any suggestion that the patient should be the ‘messenger’. However the issue of whose job it is on the hospital team to inform patients hasn’t been satisfactorily addressed for decades. We can demand all sorts from everyone but meantime it may be helpful to enlist the one person to whom successful resolution matters the most- nsmely the patient. Whether they share this information with their GP or not their knowing what happened while they were in hospital and what happens next will help.

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