https://meditropics.com/letter-to-editor/
To
The Editor,
Sir,
I read with interest the editorial “Writing a Good Patient Referral” authored by Professor Aprarna Agrawal in Medicine Clinics from the Tropics, Vol. 2, issue 2, August 2023. Fortunately, I did work in the same institution 23 years ago. I really appreciate the author’s view and the need to write a good substantive referral in a hospital setup among those who could be helpful in-patient care and outcome.
The author has tried to highlight many caveats and emphasized the need for different aspects of the body of a good referral to avoid a poor outcome. A good communication is backbone of medical practice.
I have worked abroad and in India and would like to share some points as per my experience about the referral content.
In paragraph one, I feel the word “primary care doctor” should be rephrased as “doctor or team primarily seeing or caring for the patient” as it gives an unclear impression that the referral could only be established between primary care (1st level) and tertiary Care (3rd level) of patient care. The level of healthcare is widely classified into primary, secondary, tertiary levels of care and sometimes a quaternary level. [1] Although it has been clarified in the second paragraph that the focus is on hospital care only.
I would like to highlight a special note about mentioning any drug allergy in the referral note, which is generally being ignored in referrals in the Indian context, as I have witnessed. The problem here in India, there is paucity of organised medical records, a large number of patients having a language barrier, low literacy rate and scattered medical care with lack of continuity of care. It is common to see that the patient has bits and pieces of papers from variety of clinicians from hospitals or small practices. So, during history and assessment, a note of allergy should be made and included in the referral record. This could prevent the prescription of a drug the patient is allergic to by a clinician who is not primarily involved in the patient’s care, rather, their role is ad-hoc. Not to mention, severe reactions to drugs could lead to severe morbidity or death within hours. It’s very hard to pick up such an event and rescue, especially in the nighttime when there is a scarcity of staff strength, and more focus is diverted towards emergencies.
Furthermore, in hospital medicine, the focus is generally more on diagnosis and management, and there is a danger of missing simple things that could avoid major incidents. Traditional ward history taking teaching recognize the list of medication as a significant part of the history but undermine the drug allergy information, except a few. I was amazed to see that the history of allergy is given high importance in western medical practice, as important as the patient’s name and demographics. From my experience abroad for over 20 years, I can recall two cases where a major anaphylactic accident could be prevented only because “severe paracetamol allergy and tramadol allergy” were noted in the patient’s referral record respectively. It’s worth mentioning how common advice about paracetamol or tramadol can be. [2]. Moreover, in this era of globalization, medical records could be needed beyond country boundaries, where a clinician could expect this on the record. I witnessed many Indian hospital discharge letters/ referrals abroad without a note of “drug allergy”.
I am unsure if, in the case of an emergency, if a consultant referral is indicated, whether this still needs to be signed by a consultant. Does this not undermine the skill of a resident? If this is the standard local hospital protocol, it could be discussed to avoid delays in patient care.
The author very correctly advised that a phone call is a good thing to facilitate the referral and its need. However, I am a bit afraid in this mobile phone age, where it’s possible to connect anywhere (an advantage), but the flip side is the issue of confidentiality. It’s not uncommon for hospital doctors to be in cafeterias and at common places in the hospital, and patient details could be disseminated among unrelated persons not involved in the patient’s care. I believe, a simple question could potentially avoid this, to check with call receiver “it this safe to discuss about a patient’s referral?” One should give thought from a legal aspect. I do not know how far it’s possible, but a verbal or written consent of the patient regarding a specific referral is a good practice to consider as well.
There is hope to address many concerns raised by the author and to my worries. The digital interface, a hospital intranet system with patient records and ongoing updates, could go a long way.[3] I have experienced this in working in foreign hospitals. Electronic records and communication are time-saving and could include demographics, medication details, allergy records, past medical history, and it’s easy to access relevant details. In addition, it has the advantage of time logs, accountability, replies and responses, and action alerts. It can serve as evidence in court should a problem arise, helping to justify the actions and steps taken.
Lastly, I praise the author for bringing up this important practical topic of concern and nicely outlining the ideal content and context of interdepartmental referral at the tertiary care level. This is certainly going to help both trainees and experienced professionals.
Dr. Manoj Sundarka
Honorary Consultant Physician, BG Clinic ,Delhi
MD,MRCP London, DGM London, FIACM
MRCP Edin, DCN-UCL, London, BCom
References
- Todd, John Walford and Scarborough, “Medicine”. Encyclopedia Britannica, 5 May. 2023, https://www.britannica.com/science/medicine. Accessed 10 October 2023.
- Harig A, Rybarczyk A, Benedetti A, Zimmerman J. Clarification of Drug Allergy Information Using a Standardized Drug Allergy Questionnaire and P & T: a peer-reviewed journal for formulary management [Internet]. 2018 [cited 2023 Oct 10]; 43(8):480–504.
- Kotoulas A, Stratis I, Goumenidis T, Lambrou G, Koutsouris DD. Short-term adoption rates for a web-based portal within the intranet of a hospital information BMJ Health & Care Informatics [Internet]. 2019 Apr 1 [cited 2022 Aug 1]; 26(1): e100004.