What a PAIN!

I haven’t written a lot recently, although I’ve had more than enough material for a book already. The problem is, after a particularly heavy day at work (and those are the ones I’d be more inclined to write about) I usually just want to zone out when I get home so I usually do.

Anyway, so I’m now about 6 months into my first job and already my eyes have been opened more than I expected. I always knew that “how things should be” and “how things are” rarely follow the exact same tracks, but it’s disappointing, and I try to keep my standards as high as practically possible.

Nowadays some patients expect to be treated like customers (they’re even referred to as “clients” in some NHS literature) and therefore if they don’t get what they want, regardless of what they need, they get upset. This is something of a common theme; when a patient goes to see a GP they expect an intervention, whether it’s anti-biotics, an x-ray, blood tests, whatever. What they don’t want to be told is that their low back pain can be helped with exercise and posture improvement, or that their cold is not swine flu and doesn’t require medication. What this means for the radiology department is that we’re constantly getting x-ray requests for things that are just completely unjustified, and our job as radiographers is to weed these crappy requests out. Unfortunately a lot of people find it easier to just do it. I’m not one of those people; radiology referrals have fairly clear guidelines and they’re not difficult to find. I’d rather take the time to get the full story from the patient and determine whether the x-ray is needed instead of exposing a patient to unnecessary radiation. A lot of the time these crappy requests are actually fine, they’re just missing information- not surprising when GPs are only given 10 minutes per patient.

This is a difficult problem to tackle, as when you hand the request form back to the patient they are completely within their rights to take it to another hospital where they may not be questioned, and thus the fee for that examination goes onto someone else’s books. I have absolutely no doubt that this has happened to patients that I have refused to irradiate, even after explaining my reasons to them. But what can I do?

Recently I picked up a form for a 29 year old female patient which had only three letters in the Clinical Information section: LBP. This section is meant to contain relevant information so that we can justify the examination- things like fell onto outstretched hand or ?osteoarthritis are enough for the radiographer to understand why the examination can go ahead and which images they need to produce.

LBP means low back pain, an affliction suffered by many due to things like poor posture or years of manual labour. It’s unfortunately a sad fact of life, and the guidelines clearly state that there’s no need for x-rays except in certain very particular circumstances, none of which were applicable to this patient. She was young, otherwise fit and well, had no family history of osteoporosis or spine pathologies, and had suffered no trauma. Her only problem was that she was unable to sit in her office chair for more than a couple of hours at a time without feeling pain in her lower back. And this had been going on for two weeks. I explained why I wasn’t going to do the x-ray, and that even if I did it would have absolutely no effect on her future treatment; the GP would give her exercises to strengthen her back muscles and probably recommend a better office chair. She seemed annoyed and didn’t like my quick explanation of the ALARA principle, instead choosing to assume that I was being lazy because I couldn’t be bothered to do her x-ray. Sure, my laziness lead me to speak to her to find out more information about her pain, then phone the GP (7 minutes on hold after navigating their hideous phone menu) to ask if he was looking for anything in particular in this patient’s spine (I also took the opportunity to direct him to the Royal College of Radiologists’ guidelines which are freely available online), and then to explain the concept of risk vs benefit to a woman who just wanted to know why her back hurts.

I can’t say I made any friends in that particular encounter, and I’m pretty certain I was branded a jobsworth by all parties involved… I can see why the just do it attitude is so popular! Can’t say I’ll be adhering to it any time soon though.

2 Comments on What a PAIN!

  1. Mark Cassidy
    June, 24th 2013 at 12:43 pm

    That’s a really concise & effective account of “how things are” – you wouldn’t object if I posted the link for students?

    The very first clinical audit I was involved with, back in the mid 90s (that’s 1990s not 1890s), focussed on reasons why GPs requested lumbar spine. Most popular answer by some margin was “the patient prefers an active investigation”. Distressing that we seemed to have progressed so little. And commercialisation of our health services isn’t going to take us forward; sound clinical decision-making is always distorted when there is money to be made. (I too loathe the language of ‘client’ and ‘service user’)

    One small point. I’m not sure how freely available the RCR ‘iRefer’ guidelines are. Obviously, all heath service providers should have institutional access, but otherwise an individual sub is £60!

    Do keep on doing it right. I look forward to hearing more from the ‘front line’.

  2. Cherry Black
    June, 24th 2013 at 1:34 pm

    The problem is, if they’re not the same GPs as the ones you encountered, they’ll definitely have been trained by them. Not quite sure how we’re supposed to implement change…

    I agree on the availability of iRefer, you only need an NHS email to register for free but that still means that it’s out of reach for many.

    Share the post all you like- just reiterate that it’s not an example of academic writing!!

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