I’m starting to feel like the third wheel in this patient’s care.
In this essay, I offer a public apology.
It’s to all of the doctors who aren’t GPs, perhaps on behalf of all of us who are GPs. My apology is for getting annoyed when You Don’t Write To Me. Tell me if you recognise these situations.
1. A 78-year-old comes in with his wife, wearing his hospital ID wristband (pssst, med students: this is a Cardinal Sign of a Recent Admission for Something Serious as the Patient is Still Too Tired to Remove the Band). “Well, I’m sure they’ve written to you doc about this whole thing.” What, no. “This whole thing with the heart.” What heart thing? “They said they were writing to you.” WHAT heart thing omg. His wife pulls out eight boxes of medications from the tote bag including clopidogrel, dapagliflozin and bisoprolol. “They told me to come see you this week.” What heart thing omfg. A NSTEMI? STEMI? CCF? Both? “They said you’ll need to organise the tests?” Sure. Yes. The Tests, yes certainly.
Luckily this happens to me weekly so I know what the admitting team probably wants: a CXR to monitor the CCF, repeat UECs to check potassium and eFGR, and repeat scripts for all these new medications.
Indeed, I’m correct when the discharge summary does arrive two weeks later asking the GP to Please Repeat UECs 48-72 Hours Post Discharge.
2. A 32-year-old woman attends for an updated Workcover certificate of capacity. She tripped at work, landed heavily on her left knee and her MRI impressively shows a multitude of acute pathologies resulting in an inability to walk. Since the last certificate, she’s seen the physio five times, and the orthopaedic surgeon twice. The physio has written to me five times, and the orthopaedic surgeon not at all. I assume there’s a plan for surgery, given the patient’s symptoms, age and MRI findings, but I’m unexpectedly quite stuck when the woman says, “Can you update the CoC with the surgeon’s plans, too?” +/- surgery, I write. “Can you outline a rough time for when I can be back at work? Return to work plan depending on +/- surgery. “Can you at least write the alternative duties I can do?” Sure can, thanks to the 12 pages of the physio’s assessment and common sense. Recommendations may be revised depending on orthopaedic review, I add. You know, for medicolegal.
3. An 87-year-old widowed and mighty independent woman sits down and loudly announces “Obviously doc, you’ve heard The News.” I 100% have not heard The News. “It’s spread everywhere. I’m going to start chemo next week”. Sigh. “Didn’t the oncologist write to you?” No. “The bowel surgeon sent me to her.” I didn’t know that. “The bowel surgeon had a letter from the oncologist.” I don’t. “Check your system, you should have the letter, too.” I really don’t. “Did you check?” Yes, still nothing. “I listed you as my GP, though.” Yes, I’m sure you did. “She didn’t tell you the CT scan showed the spread everywhere? I’ve only got another six months maybe.”
I didn’t know the colorectal surgeon was worried about metastatic disease – he was happy at the last review. I wasn’t cc’ed in the CT report, I wasn’t cc’ed in the referral to the oncologist, I wasn’t cc’ed in the letter back from the oncologist to the colorectal surgeon, and I feel like an absolute idiot.
I feel like the loser kid completely excluded from the lunchtime activity. I feel like I’m sitting alone at a table, while the cool kids are laughing and smirking at me in a language that I can’t understand. I feel like … I feel like the third wheel in this patient’s care.
Sorry, I suppose this sounds less like apologising, as promised, and more like complaining – but give me a second, I’m getting there.
Here’s what I did to manage the three above situations:
1. Asked my receptionist to please call the hospital’s radiology department, pathology department and ED, and chase all the possible investigations and correspondence available to date. The raised troponin and BNP dated 10 days ago confirmed my suspicions: probably an NSTEMI and heart failure. The raised potassium on the last set of bloods also needed follow-up (done, twice, by the time the discharge summary arrives). Also sent an email to the GP liaison officer, just generally complaining a little. All of this takes longer than the appointment and is unpaid work.
2. Asked my receptionist to please call the orthopaedic surgeon’s rooms and check if the GP letters were ready and say we really needed them for the Workcover paperwork. Certainly, but they needed a written request from the patient (really?), confirmation from the orthopaedic surgeon that he was happy for his letters to be sent out to a GP (really?? I was the referrer!), and a letter from me to help “expediate this”. All of this takes double the time of the appointment and is double the amount of unpaid work.
3. Asked my receptionist to please call the radiology service and ask for a copy of the CT, and then to call the rooms of the specialists and beg for the secret letters between the colorectal surgeon and oncologist. Certainly, but they’ll have to check that the specialists are happy for their letters to be sent out to a third party. I. AM. THE. PATIENT’S. GENERAL. PRACTITIONER. In absolute annoyance, I spend 30 minutes at the end of the day carefully writing an extremely passive-aggressive letter to both specialists explaining that I am doing my Absolute Best to care for this patient as her regular GP but it is Really Hard when I am kept out of the loop of Absolutely Everything and it is Not Feasible for my receptionists to sit and chase imaging reports and letters for all our patients because we, too, are busy in general practice – and surely not as Busy as them of course, but I would be Extremely Grateful if we could try for Open and Timely Team-Based Communication to best care for this Lovely Dying Patient. I cc both specialists in this letter, and their receptionists. Interestingly, I start getting included in (some) correspondence after this, and perhaps it was worth the hour (of unpaid work) it took to organise all of this.
Still no apology, though. What a misleading introduction. No, there is an apology. Here it is.
I don’t think discharge summaries are delayed because the junior doctors can’t be bothered writing them. They are overworked and exhausted and the discharge summaries are probably the absolute lowest priority item on their four-page to-do list.
I remember this. I was a junior doctor once, on a busy rotation with 40 inpatients daily, working 80 to 100-hour weeks. Each discharge summary might take 15 or 20 minutes and that time just does not exist.
Same with the letters from the specialists, especially the hospital outpatient clinics. I never receive letters from public hospital antenatal clinics, or fracture clinics. Sometimes I’ll get letters from multidisciplinary meetings.
But, again, I have worked in these clinics before I was a GP. I remember the antenatal clinics being double-booked, and scheduled to run from 9am to 12pm, but actually ending at 3pm because the lists were so packed, and the consultants promptly left at 12pm to start theatre lists or do private consulting. Where was the time to sit and dictate GP letters for 70 patients?
And finally, I don’t think I’m the loser GP that the specialists undervalue. I think they just forget or triage GP letters as Category 9.
It is mightily hard to sit and do two hours of letters and paperwork, unpaid, at the end of our long and draining workdays. In fulltime clinical roles, we don’t get protected or paid admin time, and realistically we probably need at least one full day of it anyway, which is not possible. So, yes, the letters turn up eventually when the doctor has free (unpaid) time.
I am actually deeply and truly sorry for when I get annoyed and frustrated with specialists and hospital doctors for their lack of communication. We are all on the same side and I’m sorry when I am demanding or irritated. Your workload is horrible, and some things just have to be prioritised lower, and I suppose that’s going to be things like GP letters. I know you are trying and doing your Absolute Best for our patients.
So, please accept my apology as a tired GP, and perhaps this helps you understand it more from my side.
Dr Pallavi Prathivadi is a Melbourne GP, adjunct senior lecturer at Monash University, 2024 RACGP mentor, and newly appointed member of the Eastern Melbourne PHN Clinical Council. She holds a PhD in safe opioid prescribing and was a Fulbright Scholar at the Stanford University School of Medicine, and previous RACGP National Registrar of the Year.
