Communication between specialties

As a doctor, you are not expected to be infallible, but you are expected to put yourself in a position to make a reasonable clinical judgment and manage the patient appropriately thereafter. This includes making an adequate assessment of the patient’s condition, arranging appropriate investigations and, if it is indicated, referring the patient to another practitioner.

Box 18: Case report

Poor communication with blinding results

A diabetic clinic in a teaching hospital diagnosed TB in a diabetic patient with a history of weight loss. He was admitted to hospital and, on discharge, was prescribed three months’ supply of ethambutol, rifampicin, pyrazinamide, isoniazid and pyridoxine.

A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment. He failed to attend his next appointment.

Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic. The GP had not yet received a discharge letter about the patient’s last hospital admission for the treatment of TB, nor had the diabetic clinic informed him of the diagnosis, so his referral letter to the eye clinic made no mention of the fact that the patient was taking ethambutol.

The patient attended the eye clinic several times over a month, but no history of TB or treatment for TB was obtained – his visual loss being attributed to diabetes. However, his vision continued to deteriorate and by the end of this period he was only capable of counting fingers. A week later, the patient attended the diabetic clinic. Only then was the diagnosis of ethambutol eye toxicity raised.

The patient was seen immediately in the eye clinic where the diagnosis was confirmed and the ethambutol stopped, but by then he had sustained a permanent loss of 90% of his vision.

Referrals

First of all, be sure the patient understands the reason for the referral and has appropriate expectations. You should also give patients an estimate of when they should expect to get an appointment, and tell them what to do if they haven’t been contacted within the expected time.

When making a referral, indicate the degree of urgency and provide all relevant clinical details (including the history, clinical signs and, when appropriate, physical examination).

His referral letter to the eye clinic made no mention of the fact that the patient was taking ethambutol

Communicating with patients

Patients who are kept informed about their condition and are involved in deciding on the appropriate treatment are more likely to comply with the treatment you suggest, and less likely to complain if things go wrong.

It is particularly important that you tell patients about the possible side-effects of drugs or treatment you are ordering, and that they know what complications to look out for and what to do if they develop.

Warn patients about the risks before carrying out any procedures or prescribing medication. “Informed” consent is dealt with in more detail in the MPS booklet, Consent to Medical Treatment in Ireland (contact our Communications Department to order a copy).

Warn patients about the risks before carrying out any procedures or prescribing medication

If patients are receiving treatment, tell them when to return for review and what symptoms or signs of adverse effects or changes in their condition to report. If possible, give them an indication of when they might expect to see an improvement in their condition, and when to call you if it doesn’t transpire within a certain timescale.

Document any advice you have given the patient. It is useful to document in the record any supporting literature or written information given to the patient.

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