A visit to the travel clinic, checklists, and the need for more medical specialism

Jul 09, 2013




I went to the travel clinic at Western General Hospital in Edinburgh this morning. I wanted a Yellow Fever jab, so that I could visit Zambia and enter other countries such as South Africa.

I am always fascinated by what bits of medicine can be usefully hived off into specialist semi-independent areas (see a BMJ piece I wrote here). Dentistry and much or most of eye care and hearing problems. But I think there are great opportunities to disassemble much of generalist clinical care: for instance, when I lived in France and my children were sick, we called an office paediatrician to see them. It seems to me compelling that somebody focussed full time on kids, will provide better care because their clinical experience is greater. We need office practitioners, but primary care needs those with proper specialist domain expertise.

The counter argument is perhaps dominant in the UK. Here, the view is that allowing patients to go to specialist services risks increasing transaction costs as people have to subsequently be redirected to the correct clinician. This is the familiar argument for ‘generalists’: patients do not know enough about who to access, and in any case, specialists cause increased health care expenditure. For many domains of clinical practice, I do not buy either of these explanations. Nor, does the continuity argument carry much weight anymore for a large proportion of the population. I like the Tudor Hart GP model, but there are just very few people around with his ideals, or commitment. Indeed in the English NHS there seems a concerted attempt to deny people specialist care, with much dermatological care reverting to the standards of the 1950s). So what did I observe this morning?
First, for all the publicity about checklists, they are already everywhere — and appropriately so.
Second, the ability to have specialist knowledge (e.g. particular problems in North Zambia) at one’s fingertips, powerful. Much knowledge can be codified usefully.
Third, the service is thankfully in the hands of clinicians rather than managers or insurers. So, since I do not want to take Larium, I was not faced with a lecture on the subject, merely an acknowledgement that I had considered the issue. No doubt when the NHS is fully sold off, I will be forced to waive my right to free treatment if I do contract malaria.
Fourth, computers wreck traditional consultations. The dreaded Excel spreadsheets and Access databases drastically reduce eye contact and human interaction. Eventually, clinical consultations will consist almost entirely of documents that are the subject of target measurement geared to ensuring a political party is re-elected. And that is before the data is sold off — or more likely stolen by the spooks and then sold to the insurers….. In this particular domain, the need for documentation, is perhaps inevitable; batch numbers of vaccines are important. And part of the need for revaccination owes little to science, but to administrative fiat, in that immunity may be lifelong (and therefore you do not need a booster every 10 years). Nevertheless, the situation reminded me of when I was a young medical registrar and I worked for a consultant who was a senior figure in the Medical Defence Union (MDU). His clinical notes, as one would expect, were meticulous. The downside being that if he was to actually talk freely to patients, his clinic throughput was so low, that the rest of us had to race through— and in the absence of careful clinical notes. Technology in some of medicine increases, rather than reduces time pressure, because much of it is not designed for the patient’s benefit.
Finally, do not use highly trained and expensive clinicians to deliver most care. Once you move to a consultant delivered service, rather than a consultant led service, you end up with increased costs, and you deskill those who want to be experts. The latter are the people you need when the checklist falls short.

(And yes, based on my n of 1 experience, I would recommend the WGH travel clinic).

Post by Jonathan Rees

Clinical academic and skin watcher at the University of Edinburgh

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