> > Certainly routinely
> > passing your sports medicine to someone because of
> > their surgical rather
> > than their sports medicine credentials is no good
> > thing.
>
> That is fine if you are sports medicine trained, but
> I'm not. So I tend to hand on the sports medicine
> problems to someone who is. However I am plastics
> trained so I will happily do difficult facial
> lacerations with cosmetic implications.

With you on that- appropriate training and expertise is more important than
base speciality. I do not claim that sports medicine is part of core A and E
work (an understanding is important in the same way that an understanding of
anaesthesia is important). But sports medicine should be dealt with by
sports physicians of whatever background rather than routinely by general
orthopods, GPs, Emergency Physicians, Occupational Physicians,
rheumatologists etc. A and E is just a possible base speciality. But if I
get you right, you don't routinely follow up your difficult faces- does
someone else (including GP) follow them up? (Maybe not necessary, but I tend
to like to see all my trickier faces back myself- to the extent of often
removing the sutures myself) What about tendon repairs?

> I would rather see the patients
> with the SHO's so that they get the benefit of seeing
> the whole thing through. That is quite difficult to
> arrange as invariably they are not on duty when the
> clinic is on. How do you get the SHO's to benefit from
> this?

I agree. Used to do this in Paisley as a SHO- you'd bring back the patient
to review yourself and then seek advice at the time. Wouldn't work so well
in Warwick (here we do a week of nights; in Paisley it was one night at a
time). Took a bit longer too. SHOs always get written feedback on every
patient they refer to clinic. Yes, ideally I'd like to run the clinic more
as a teaching clinic (would take longer, but I think an appropriate use of
time) with the referring SHO. >

> > there
> > are certain conditions for which clinics are useful.
> >
> I'm sure there are, but it is a question of priority.
> Limited resources, where best to use them?

As I say, by concentrating on the critically ill patients, clinics and
availability for advice I can spend a high proportion of my clinical time
making a difference- probably considerably higher than if I spent more time
seeing unselected patients. Achieves maximum benefit per unit of consultant
work done.

> > Give the consultant a
> > fixed session for seeing the patient (otherwise
> > you'll have complaints if
> > the patient waits because the consultant is tied up
> > in resus or away on
> > other duties)
>
> that is great if you have enough senior cover for
> both. We don't. Which means we could be called away
> from clinic. Now we have patients who have a booked
> appointment being kept waiting and getting even more
> irate than if they are given a more flexible time and
> told they may have to wait if there is an emergency.

I don't know how much staffing your department has, but a couple of 1 or 2
hour clinics a week in return for a corresponding reduction in hours of
shopfloor cover shouldn't usually cause too much of a problem. Maybe I
concentrated too much on complaints. The fact is it is simple bad manners to
ask the patient to come back at a certain time when you haven't made a
particular effort to be available to see them at that time.

>
> > Stream it into a separate area. Been
> > tried. It's called a
> > 'clinic'.
>
> Again great if you have the space. We would have to
> take it from some other area in the department.

If you're short of space, you can move your scheduled reviews out of your
department into outpatients (and call it a clinic)
> Well that depends. Do you have a dedicated nurse for
> the clinic? Is he/she extra or pulled off the shop
> floor. At present if I had nursing support for a
> clinic it would be at the expense of the shop floor.

Dedicated nurse for clinic. Extra. That's an advantage of doing a clinic-
managers see it as a different service so you can get the staff.

> Is there anyone else in the hospital that could
> provide the help/advice needed? If so why not get it
> sorted there and then.

No there isn't. Other specialities do not have A and E consultants (indeed
mainly don't have consultants in the hospital when there isn't an A and E
consultant). That's why the hospital employs A and E consultants. Certainly
a consultant in another speciality can give a better opinion on an
appropriate case than I can. I can accept the same for a SpR. What I can't
accept is that for an A and E case a SHO in another speciality can give as
good an opinion as a consultant in A and E. The old view of calling SHOs in
other specialities just perpetuated the idea that an A and E consultant was
the equivalent of or inferior to an SHO in a more important speciality.

> We encourage our SHO's to get
> advice from the various specialities - after all that
> is what specialists are for - to give specialist
> advice.

Yes- specialist advice. Not advice on A and E problems.

> Now I don't know about you, but I'm not good
> at everything and it is often better for the patients
> to have advice or see a specialist then wait and see
> me and still need further help. In those cases where
> it can't be sorted like that then they can be brought
> back for review, but I can also be available on the
> shop floor. what do your SHO's do when you are in the
> clinic and need help with a patient? refer them to the
> next clinic?

My SHOs use the consultant covering the floor or (if it concerns a
subspeciality interest of mine) come into clinic to ask me for advice or
wait until clinic is finished- as do the other consultants in the department
(we have no problems here using each other as a source of advice). If
another speciality is better at dealing with the condition, they refer to
that speciality (although sometimes an initial A and E consultant opinion
will expedite the referral). But I would emphasise the fact that A and E is
now a speciality in its own right. There are certain aspects of patient care
that we know more about than other specialities.

> A lot of the radiology isn't availabvle same day
> anyway. I can't get U/S scans for fb's, bone scans,
> MRI's etc. on the same day. Which means they would
> come back to clinic, I write out the form, they have
> the investigation some other day and then come back to
> the clinic later on.

Can do. However the way our radiology works is it's a lot easier to get
urgent imaging if you discuss in person. Also, from time to time
radiologists can give surprisingly useful advice as to the most appropriate
imaging. So the patient comes to my clinic, gets an opinion, gets a
radiology appointment and then an appointment for review by me.


Matt Dunn
Warwick


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