Referral or follow-up?

Introduction

When patients ask their doctors if a preventable problem could have been avoided by earlier investigation or referral, the doctors can be in an unenviable position. Given the information available at the time, the response will often be a qualified, “yes.” It must be a qualified response because the aspects of the problem considered during earlier encounters with patients are often unknown. The matter is further complicated by issues of trust, professional ethics, and the law.

This article discusses information flows that may have reduced the risk of Ms Smith (see box opposite) developing symptomatic renal impairment. The risk could have been reduced at three different points.

• If her underlying vesicoureteric reflux had been diagnosed and fully investigated in childhood

• When her chronic pyelonephritis was discovered

• During the intervening period when no follow-up was arranged.

Early detection of underlying problems

Children aged ≤7 years with urinary symptoms, fever, or several non-specific symptoms and signs should be tested for urinary infections because, in some circumstances, prophylaxis can prevent recurrence. Guidelines are available, but the research that underpins the advice was published too late for Ms Smith. Were Ms Smith a young girl today, any primary care or emergency clinician who saw her would probably have access to this evidence base as part of their clinical software, or through access to guidelines on the internet.

Undergraduate education, postgraduate training, and continuing professional development are more traditional routes of knowledge transfer. Unfortunately, traditional sources of knowledge are relatively inefficient: our stores of knowledge decay over time, and our brain's working memory may become overloaded. Prompts and reminders at the point of care are useful adjuncts to an overworked human brain for certain tasks. Some doctors worry that use of such electronic aids may …