bs_bs_banner
Letters to the Editor
General correspondence Audit of inpatient referrals I was very interested in the recent article by Brown et al.1 comparing speciality referrals made from inpatient general medical units in regional and metropolitan hospitals. The authors state that there is no available research on inpatient referrals published. In fact, there is one historical comparator which we published in the 1980s.2 This was a somewhat similar study but was done over a 6-month period prospectively when two units, both of which were general medical units with a special interest in respiratory medicine, recorded all of their inpatient and outpatient activity. There are some interesting comparisons with Brown et al.’s study. The Teaching Hospital unit in our study (consisting of one consultant, one senior registrar, one registrar and one intern) averaged 16.4 admissions per week compared with Monash’s 11.6 and the District General Hospital’s (one consultant, one registrar and one intern) 19.7 admissions as opposed to West Gippsland Hospital’s 10.7. In our study, there was no difference in the range of pathology seen between the two hospitals, but we also found a significant difference between the Teaching Hospital and the District General Hospital in the number of referrals made to other specialists. The Teaching Hospital averaged 0.26 referrals per admission (including
References 1 Brown MG, Campbell D, Maydom BW. The undivided patient: a retrospective
geriatrics) compared with Monash’s 1.74 and the District General Hospital’s 0.13 compared with West Gippsland’s 0.69. I would suspect that the units involved in Brown’s et al. study were more generously staffed than those in Yorkshire in the 1980s, and together with the much smaller number of admissions, this documents the reduction in clinical experience now offered to junior doctors. Brown et al. correctly point out the dangers of over-referral and speculate on possible causes including greater availability of subspecialists and fear of litigation. Our feeling in the 1980s was that the disparity largely reflected better general medical skills and greater confidence in dealing with a wider variety of conditions among physicians working in District General Hospitals rather than major metropolitan teaching centres, together with a reluctance to bother one’s busy colleagues with routine or banal medical conditions which any physician should be capable of managing. Received 23 October 2014; accepted 31 October 2014. doi:10.1111/imj.12692
G. Simpson Thoracic Medicine, Cairns Base Hospital, Cairns, Queensland, Australia
cohort analysis of speciality referrals made from inpatient general medical units comparing regional to metropolitan practice. Intern Med J 2014; 44: 884–9.
Author reply We thank Simpson1 for commenting on our paper2 and also for alerting us to his historical comparator study3, which has also compared inpatient referrals in a Teaching Hospital and District General Hospital in the 1980s. It is indeed interesting to note that this study also showed a significant difference between the Teaching Hospital and District General Hospital in the number of referrals made to other specialists. We agree that in the 1980s, this difference may have reflected greater confidence and general medical skills in dealing with a wide variety of conditions among physicians working in District General Hospitals rather than major teaching centres. It is certainly interesting to note the change in patient load over the last two decades. We do not entirely agree
2 Simpson FG, Wilson J, Peake MD, Cooke NJ. Audit of workload of physicians with a special interest in respiratory medicine. Br J Dis Chest 1987; 81: 150–4.
with Simpson that this correlates with a reduction on clinical experience offered to junior doctors. There have certainly been important moves in recent years to ensure safer working hours for junior doctors that may in some ways have limited clinical exposure compared with two decades ago. However, we suspect that the change in patient load is more a reflection on the increasing complexity and expectation of patients along with advances in medicine, which have made management more complex as the years go by. Received 22 February 2015; accepted 22 February 2015. doi:10.1111/imj.12741
M. Brown and D. Campbell General Medicine, Monash Health, Melbourne, Victoria, Australia
© 2015 Royal Australasian College of Physicians
589
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Letters to the Editor
General correspondence Audit of inpatient referrals I was very interested in the recent article by Brown et al.1 comparing speciality referrals made from inpatient general medical units in regional and metropolitan hospitals. The authors state that there is no available research on inpatient referrals published. In fact, there is one historical comparator which we published in the 1980s.2 This was a somewhat similar study but was done over a 6-month period prospectively when two units, both of which were general medical units with a special interest in respiratory medicine, recorded all of their inpatient and outpatient activity. There are some interesting comparisons with Brown et al.’s study. The Teaching Hospital unit in our study (consisting of one consultant, one senior registrar, one registrar and one intern) averaged 16.4 admissions per week compared with Monash’s 11.6 and the District General Hospital’s (one consultant, one registrar and one intern) 19.7 admissions as opposed to West Gippsland Hospital’s 10.7. In our study, there was no difference in the range of pathology seen between the two hospitals, but we also found a significant difference between the Teaching Hospital and the District General Hospital in the number of referrals made to other specialists. The Teaching Hospital averaged 0.26 referrals per admission (including
References 1 Brown MG, Campbell D, Maydom BW. The undivided patient: a retrospective
geriatrics) compared with Monash’s 1.74 and the District General Hospital’s 0.13 compared with West Gippsland’s 0.69. I would suspect that the units involved in Brown’s et al. study were more generously staffed than those in Yorkshire in the 1980s, and together with the much smaller number of admissions, this documents the reduction in clinical experience now offered to junior doctors. Brown et al. correctly point out the dangers of over-referral and speculate on possible causes including greater availability of subspecialists and fear of litigation. Our feeling in the 1980s was that the disparity largely reflected better general medical skills and greater confidence in dealing with a wider variety of conditions among physicians working in District General Hospitals rather than major metropolitan teaching centres, together with a reluctance to bother one’s busy colleagues with routine or banal medical conditions which any physician should be capable of managing. Received 23 October 2014; accepted 31 October 2014. doi:10.1111/imj.12692
G. Simpson Thoracic Medicine, Cairns Base Hospital, Cairns, Queensland, Australia
cohort analysis of speciality referrals made from inpatient general medical units comparing regional to metropolitan practice. Intern Med J 2014; 44: 884–9.
Author reply We thank Simpson1 for commenting on our paper2 and also for alerting us to his historical comparator study3, which has also compared inpatient referrals in a Teaching Hospital and District General Hospital in the 1980s. It is indeed interesting to note that this study also showed a significant difference between the Teaching Hospital and District General Hospital in the number of referrals made to other specialists. We agree that in the 1980s, this difference may have reflected greater confidence and general medical skills in dealing with a wide variety of conditions among physicians working in District General Hospitals rather than major teaching centres. It is certainly interesting to note the change in patient load over the last two decades. We do not entirely agree
2 Simpson FG, Wilson J, Peake MD, Cooke NJ. Audit of workload of physicians with a special interest in respiratory medicine. Br J Dis Chest 1987; 81: 150–4.
with Simpson that this correlates with a reduction on clinical experience offered to junior doctors. There have certainly been important moves in recent years to ensure safer working hours for junior doctors that may in some ways have limited clinical exposure compared with two decades ago. However, we suspect that the change in patient load is more a reflection on the increasing complexity and expectation of patients along with advances in medicine, which have made management more complex as the years go by. Received 22 February 2015; accepted 22 February 2015. doi:10.1111/imj.12741
M. Brown and D. Campbell General Medicine, Monash Health, Melbourne, Victoria, Australia
© 2015 Royal Australasian College of Physicians
589
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
