CLINICS: What is all the fuss about???
* Outpatients is a nice environment to see patients.
* OPD nurses do nothing else, so clinics run smoothly.
* Appointment times can be met.
* Follow ups do not mingle with new patients causing resentment when a
new arrival is sent straight through.
* The patients behave well, are pleased to see the consultant and
therefore it is much less stressful to do.
* It is the one session of the week which is planned and therefore an
oasis of calm in a life of turmoil.
* They add balance to our clinical work profile.
* Not all patients can be seen treated and discharged in one
attendance so clinics fulfil a useful function especially in dept's like
ours that only has consultant cover in office hours and middle grade cover
until 1am.
* Returns can be planned, so workload more predictable.
* I have never had a single complaint from a clinic patient in 10
years (touch wood) so it seems to work for the patients.
* How many of our young, keen, able and enthusiastic shopfloor only
workers will burn out, I wonder, esp now it looks like we will never be
allowed to retire.
Paul
-----Original Message-----
From: Adrian Fogarty [mailto:[log in to unmask]]
Sent: Tuesday, December 17, 2002 10:04
To: [log in to unmask]
Subject: Re: Modernisation and collaberative study/ clinics
Well, I'm not quite with either camp on this one, I take the pragmatic
middle road! In our unit we have to provide some follow-up, largely because
of a migrant population with poor access to primary care. We have recently
reduced the physicians' input into this process as far as possible, so that
we now only see around 4 to 6 patients a day. They are generally quick and
can be sorted in less than one hour, and we juggle the usual second opinions
and resus etc during this "clinic". Being held in the minors area, where
we're very accessible to the SHOs, actually keeps us visible and "close to
the action" for a while, and perhaps that's somewhere halfway between Fred's
method and Matt's! (Gosh it's not like me to be so impartial, is it?) The
nurses also follow up a similar number of "dressings" only patients,
generally where there is no other follow-up option for the patient. Both
clinics are held early enough to allow nursing input without too much
disruption to the new patients. The last thing I want is to be interrupted
by a review patient in the middle of the afternoon. Our attendance figures
are pretty classical that way, not much happening until late morning, then
hitting a rather long and relentless peak from 12 noon to 10pm!
I don't like to get too involved with the clinics i.e. by that I mean I
don't like to indulge any particular special interest, but one naturally
develops expertise in those areas that do not have ready local access to any
other follow-up. For example:
I'll see partial thickness burns, generally just once at 3 to 4 days to
assess burn depth. Sure, I can't graft them, but I've got a good eye for
what needs or doesn't need grafting. We have recently acquired more plastics
cover in our site so this situation might change in the future.
I'll see knees, generally just once at 7 to 10 days as you can't diagnose a
meniscal tear on day one anyway. Our orthopods aren't too interested in
unselected cases like this so this situation is likely to remain. In general
I either discharge, physio or refer; it's a one-stop shop, nothing fancy!
I'll see those mangled hand/finger injuries that I repaired on day one
anyway. Now some of you might argue that I shouldn't spend 30 to 40 minutes
debriding/repairing a crushed finger tip, but to me this is what emergency
"medicine" is all about. Handing this on to another specialist is no
different, to my mind, from handing on my chest pains for someone else to
thrombolyse, or handing on my heads for someone else to CT. And since I've
worked on the crushed finger in some detail, I figure I'm the best placed
person to follow it up. Most just require dressings and advice, some
occasionally require control of overgranulation or require further
debridement.
And speaking of heads, I'll see those more "minor" head injuries who're
having problems (we're fully Galasko positive now, general surgeons have no
interest in heads anymore). And in the same area, I'll see those facial
injuries that weren't sorted on day one (usually because radiography is
difficult at that stage) and again, because we don't have any resident
max-fax cover.
Finally the SHOs can use the clinic for a "bridge" to access other services.
For example if they need a doppler for DVT, or a dermatologist or whatever,
but it's inappropriate or impossible to access these at 11pm then we welcome
these at the clinic, when it's dead easy for us to access these services
during office hours. Of course the SHOs must learn not to abuse such a
system. Sure, there are ways round some of these issues; we've recently
introduced out of hours "access" to doppler using a new bit of technology
called an answerphone! Sometimes the simplest solutions are the best...
Basically if there is ready access to a suitable clinic, I'll use it, or if
I can send someone to a GP, I'll do that. Much of what I see relates simply
to the exigencies of local service, although a very small part relates to my
interest and expertise. But I'm always on the look out for ways to reduce
our clinics to their bare minimum, for the reasons well articulated by
others on the list.
Well anyway, that's my non-partisan, rather pragmatic view. Sad isn't it?
Adrian Fogarty
----- Original Message -----
From: Renee Nilan <mailto:[log in to unmask]>
To: [log in to unmask] <mailto:[log in to unmask]>
Sent: Tuesday, December 17, 2002 4:31 AM
Subject: Re: Modernisation and collaberative study/ clinics
Just an additional thought... I offer all of my patients, especially those
that may have difficulty with follow up, the option of returning to the ER
and often ask patients to do so on the weekend to have an infection, burn or
laceration re-examined if I feel it is needed. We do not have a clinic in
the ER however have the ability to have patients follow up in our medicine
or family practice clinics next door. These are not staffed by the emergency
physicians.
Renee
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