Perpetual rediscovery

It was with wry amusement that I read a letter to “The Times” by James Harrison and published in 2003 relating to a “new discovery” about the health of Adolf Hitler, and noting that the conclusion was well-known and previously published. He termed this “perpetual rediscovery”.

During the last week – the first week of 2018 – there have been two responses to an article in the same paper which quoted England’s chief nurse as saying that missed outpatient appointments were a plague, and were costing the National Health Service perhaps as much as £1bn annually.  The subsequent correspondence pointed out that the problem of missed appointments could be resolved very simply – by overbooking.  Thus all slots would be filled, and in the rare event that everyone turned up it would just be rather a busy clinic. In any event, as the NHS did not charge if patients failed to attend, I don’t believe that any money would be lost at all; in fact, because no investigations would be generated, missed appointments might actually save money.

It was a system I used myself.  When managers questioned it, I responded that what was good enough for airlines was good enough for me.  Total rigidity was mad.  Wearing my rehab hat I used to book 45 minute slots for new patients in the multi-disciplinary clinic, because there was always a vast amount of stuff to deal with, including all the physiotherapy, occupational therapy, social work and psychology aspects of long-term severe disability.  A no-show left us all sitting doing not a lot for a long period.  Crazy – not least as for these patients the major cause of a no-show was a transport failure.

I write to “The Times” a lot.  I had four letters published in 2017, taking my total to around 70 which I reckon is a hit rate of about one in eight.  I keep a copy out of vanity.  Thus is was that I was able to recall a previous article about missed appointments, in which it had been suggested that “no-show” patients should effectively be fined (the idea was that a refundable deposit would be forfeited for a non-attendance).  In my response I said:

“…about half of missed appointments are missed because of administrative error – the appointment is sent to the wrong address, for instance… Overbooking ensures the doctor works at full efficiency.”

I annotate all my scanned letters by date, and was thus able to see that I had written this 28 years ago.

Perpetual rediscovery is, in part, a failure of institutional memory.  There is another “perpetual” in the arcane art of outpatient booking – a curious issue which I call the endless loop syndrome. Let’s suppose a patient cancels and the clinic doesn’t know. What happens next is as follows:

  • Let’s say the patient rings to cancel the day before the appointment (January 30th), and is re-booked by central appointments for 5th March
  • The patient doesn’t appear in clinic, so the clinician, not knowing of the cancellation, completes a “did not attend” (DNA) form, which generates another appointment booking through the local clinic desk. However this takes a day to process, so this re-book is for 12th March as the 5th is full
  • Patient receives the letter confirming their own rebooking for 5th March
  • Two days later they receive a second letter generated through the DNA, for 12th March. The letter says “Due to unforeseen circumstances your appointment with Dr Bamji has been changed to the 12th March”
  • The patient thinks this change refers to the appointment they made for the 5th, but this of course remains on the system
  • On 5th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 27th April
  • The letter confirming this is received by the patient on the 11th March, and they assume it refers to the appointment the following day, so they don’t turn up
  • On 12th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 9th May

And so on ad infinitum, potentially.  Actually it usually stopped after three our four iterations, because the irate patient would ring my secretary to ask what the hell was going on, and she would untangle the mess.

I monitored my DNA rate over several years.  It remained quite steady at between 10 to 15% of new appointments, and slightly less for follow-ups.  If I enquired of one of my “regulars” why they had missed, there was a reasonable excuse 90% of the time; they were ill, a relative was ill, transport had failed to collect them, snow had confined them to the house etc.  Just 10% forgot.  Text message reminders are all very well but, if generated the day before, leave no time for an empty slot to be re-filled.  And occasionally the patient had died so they were unlikely to respond – or their relatives were so devastated, and busy with arrangements, that cancelling an outpatient appointment, if indeed they knew of it, was the last thing on their mind.

So I was amused to read someone else’s solution of overbooking.  Twice.  I wonder if either of them had attended any of my trainee lectures on how to run outpatients – or indeed read my letter from 1989.  I doubt it.  Nihil novi sub sole (Ecclesiastes 1:9).

Advertisements

Time heals – slowly

When I retired from the NHS having worked at Queen Mary’s Hospital, Sidcup for 28 years it was with some bitterness.  During the last two years the hospital had been threatened with a merger and the likelihood of losing its A&E and maternity departments.  I was quite sure that the merger would not solve the financial problems it was supposed to, and said so in fairly forthright terms, but was ignored.  Thereafter I was threatened with disciplinary action for speaking out, and had to deal with several mischievous attempts to interfere with my clinical practice and make my working life difficult.  Despite having workload figures far in excess of any of my colleagues in the merged Trust I was told, under the counter, that I was about to be investigated for cutting sessions.  Being 60 enough was enough. In one way life was great, but I could not help feeling that my retirement was engineered.  Within six months of mt leaving my rehabilitation unit had been closed, and my sessions in the rheumatology department remained covered by locums for over three years.  So much for any legacy.

As I had predicted the new merged Trust fell to pieces – for exactly the reasons I had stated.  So schadenfreude was the order of the day,, but I failed to get the General Medical Council to deal with one medical manager whose conduct I felt had breached professional guidelines.  I also expected Queen Mary’s, now bereft of acute services, to curl up and die.

My pessimism was misplaced.  Although the hospital is managed by one Trust and has clinical services from another two, in bits, there has been what appears to be a successful and remarkable transformation.  My previous experience of acute hospitals losing their acute services was dire, with almost inevitable closure.  But somehow Queen Mary’s has reinvented itself – admittedly with the help of £30m in investment, but it now possesses a large renal dialysis unit, and spanking new and completely up to date Cancer Centre, new outpatient facilities, a splendidly redesigned front entrance, and it looks set for a long future.  More to the point the staff that I left demoralised appear to have been re-energised, and when I returned for the celebrations to re-dedicate the hospital, and also its 100 years of existence, I came home feeling that my negative attitude was now quite unnecessary; the hospital had moved on, and so would I.  It was a great pleasure to meet up with the various dinosaurs of my era and agree that everything looked pretty good.

That’s not to say that one should forget the past; there are lessons to be learned, not least in how to do things so as not to upset and irritate people, as I have described in previous essays.  It has perhaps also helped that after 25 years of trying my book “Faces from the Front” has finally come to fruition!  You can find details at http://blog.helion.co.uk/tag/faces-from-the-front/. (A great gift for anyone with an interest in plastic surgery, the First World War, facial injury etc).

So time has passed and healing has occurred.  Nonetheless I am reminded of a poem I wrote that relates to experience:

When appointed consultants, we all seemed quite young –

Looked up to our elders and betters;

But time passes by, and we cease to give tongue

Or write all those Young Turk-like letters.

And then we all find that the new ones around

Are the ones now creating the fuss –

For they carry the torch of the bright and the bold

And the elders and betters are us.

Reinventing wheels etc

In the BMJ of 23rd April are listed the finalists for the BMJ Neurology team of the year awards, which include the Multiple Sclerosis team of UCLH for its integrated service.

Reinvention of the wheel? Failure of institutional memory? Left hand not knowing what right hand is doing?  All three possibilities come to mind when I read the nomination which “to everyone’s surprise” showed that urinary infections were the commonest cause of admission in patients with MS.

I am certainly surprised it was a surprise.  Indeed when I read this I was almost speechless.  I have known, and taught this for nearly 30 years.  I took over a Young Disabled Unit in 1985.  Over the next ten years I and my multidisciplinary team turned it from a long-stay unit with 15 residents to a dynamic rehabilitation unit with some 300 clients, the majority of whom had MS.  We provided a regular inpatient respite service, a helpline and regular outpatient review, which was supplemented in later years with bladder ultrasound.  The superb nursing staff were also alert to admissions of our clients to acute beds, from which they would be extracted as soon as possible – or at the very least they would make a trip to the acute ward to advise.  I taught all the trainee doctors that patients presenting to A&E with a sudden deterioration in their MS had an infection (usually urinary, but sometimes chest) until proved otherwise.  While deterioration was rapid, so was recovery if effective treatment was instituted rapidly.  I might add that, as a clinical point that will save some lives if anyone reads this, some patients with an acute infection regularly developed severe hyponatraemia which we attributed to acute adrenal insufficiency, and recovered with hypertonic saline and hydrocortisone; whether this phenomenon was related to previous high dose steroid treatment for relapses we never did determine.

We also provided an effective pressure sore service. Regular physiotherapy helped prevent contractures and maintain mobility.  Occupational therapy home visits were a sine qua non. Our service was entirely integrated.  Our local district nurses involved in home care regularly exchanged information.  If a patient “went off” suddenly then infection testing was arranged at home.  Not infrequently I would write the antibiotic prescription.  Unit emergency admissions were organised not by GPs but by family or the district nurses by direct contact.  In this way we actually kept MS patients out of acute hospital beds.  All of this was done without any input from neurologists.

To return to my opening paragraph it appears to me that the UCLH team have reinvented the wheel.  I regret that my teaching in a suburban district general hospital never permeated to the centre to provide a lasting institutional memory, but perhaps the most damning indictment is that, until relatively recently, it was rehabilitationists who dealt with long-term MS patients and not neurologists, who concentrated on diagnosis (once made, there was little treatment, so many, though not all, lost interest). So the crossover of information from left to right hand was as limited as in a patient whose corpus callosum has been transected.  It is thus encouraging to see the growing interest and enthusiasm of neurologists in integrated long-term management.

Though our model was highly effective, and much appreciated by patients and their families, it was expensive.  The Unit kept afloat as much through my political lobbying as through its care success. Within a year of my retirement it had been closed down.

If you make a diagnosis and administer the treatment, and the treatment fails to work, it’s the diagnosis that’s wrong.

I once had a 17 year old patient with low back pain referred after the GP had become exasperated by his failure to improve – oh, and by the way, his ESR was 57 (for the non-medical reader, a high ESR is indicative of inflammation, infection or malignancy).

He was very stiff so I made a confident diagnosis of ankylosing spondylitis, not least because his SI joints looked fuzzy on the X-ray.

After two trials of different non-steroidals for a month each I put him on phenylbutazone. This didn’t work either. It now became apparent that his pain w as quite localised to the L2 region – which was just off the top of his original pelvic X-ray – and further investigation confirmed that he had osteomyelitis in L2 and L3 presumably from the discitis between. Common? No.

Corollary: if a physical sign doesn’t fit the diagnosis, reconsider the diagnosis.

An Indian gentleman in his 70s presented with typical symptoms of polymyalgia (pain and early morning stiffness across the neck and shoulders) and a high ESR. His son said he had just returned from India and had been investigated for an intermittent fever, but his malaria tests had proved negative.

I gave him some steroids (prednisolone-EC 10mg daily) for a fortnight; he did not improve at all. I assumed I had not started him on a high enough dose, and doubled it for another fortnight. Nothing.

So I followed the corollary and wondered whether this was some sort of malignancy (myeloma and prostate cancer can both masquerade as PMR) and did some further tests – bloods and a bone scan. I was inspecting the latter when a message came round from A&E that he had been admitted with a paraparesis; he had lost power and sensation in both legs..

Have you remembered the fever?

The liver tests were right up the Swanee and the scan showed a hot spot at T3. Osteomyelitis (probably tuberculosis) was the diagnosis on biopsy at the neurosurgical centre.

Patients with polymyalgia respond dramatically to steroids and the ESR comes shooting down; if this does not happen, then either we have some other unrelated pathology (as above) or we are dealing with some other sort of inflammatory joint disease. Medicine is like buses, not trams. You need to be able to make detours when things are not right, not just grind to a halt.

While this is a rather medical post, I am prompted to add it having just read “The Monogram Murders” by Sophie Hannah – it’s a Hercule Poirot story in the spirit of Agatha Christie.  Poirot tries to make the nice-bit-dim policeman, Catchpool, do some thinking for himself, pointing out repeatedly that facts are facts and you cannot ignore them when they don’t fit the theory.  You must make the analysis fit the facts, not the other way about.  In both these above cases I failed to do that.  As a corollary to that I estimate that every doctor will make at least two mistakes a year that result, or might have resulted, in serious harm to the patient.  I have.