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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Monday 24 January 2011

On Being Ordered

My trust is about to introduce a new Hospital Information System. Being an earnest sort, I accepted an invitation to go along to a 2 hour briefing session specifically aimed at consultants. The audience were uncharacteristically lively; both of us asked a number of questions. The system looks very good and will undoubtedly be huge improvement. I’m not saying our existing PAS system is old but the Science Museum have said it is of historical significance and could they please have it when we’ve finished with it.

One aspect of this briefing did stick in the craw a little. It isn’t overtly pedantic. Well, okay maybe a little bit. But it rankles; neither spitting bile nor throwing-toys-out-of-the-cot but a jaw-clenching, finger-drumming, 10mmHg-systolic-rise type issue.

It is over the issue of “ordering” versus “requesting” of investigations. Now some people couldn’t give two hoots if it is a request or an order. I contend they are quite, quite different words. Similar, yes, but they have very different origins, connotations and subsequent implications.

A “request” is an entreaty, a polite and formal way of asking for something, a gentlemanly wish, an invitation, possibly involving discussion of the finer aspects. It comes from the Latin “requirere”, from re- (expressing intensive force) and quaerere “seek”.

“Ordering” is something else entirely. It is a unidirectional demand, a consumerist command, an authoritative diktat. Its etymology is quite different, from the Latin “ordinem” meaning “row, series, arrangement or rank” in secular, honorary or military orders. Its meaning of command is purely from the notion of “to keep in order”.

Many institutions have electronic radiology requesting. To some, paper requests seem quaint and faintly nostalgic. I did hear of a hospital that kept having to replace the computer screens in fracture clinic. Apparently the Orthopods keep scrawling on them and our PACS people can’t get all the crayon off.

Well, Order Communications or “Ordercomms” is the accepted technical description of the broader church of electronic requesting. Our dear College have just released a guidance document about how they should work. It is quite technical; I read it thoroughly and even understood some of the words.

I don’t think I’m being prissy, but being indirectly ordered to do something gets me rather hot under the collar. Whenever I hear a doctor saying the words “I’ve just ordered…”, I can’t help interrupting with a terse “No, you’ve just requested...”.

Junior doctors used to arrive with request card in hand, saying, “Can I discuss a case with you?”. Now it is a telephone call saying, “I have ordered this scan, why hasn’t it been done yet?”. I used to think that this change in behaviour and language was because most junior doctors learn most of their trade from watching episodes of House and re-runs of ER.

Perhaps Ordering is quite apt in the American setting. The relationship between clinician and radiologist is different, medical practice is different and the commercial aspect of medical practice is a factor. However, this model of practice isn’t appropriate for the UK NHS and it isn’t necessarily better.

Individual case discussion between radiologist and clinician is at the heart of good medical practice. The more complex and the more sick the patient, the more discussion there should be. The patient gets the right sort of scan, at the right time and the clinical question is answered. When I say radiologist, you could substitute any other speciality in there; when I say scan, you could similarly substitute any opinion, investigation or therapy.

I am convinced that this slide away from requesting to order has perniciously warped clinical practice. Not deliberately, mind. I don’t doubt that Ordercomms can streamline clinical work but it can inadvertently encourage the crucial discussion step to be skipped. Moreover, avoiding such discussion gets to be seen as an advantage, a positive benefit of the system.

Without discussion, the clinical question remains ill-defined, the patient often gets the wrong type of scan at the wrong time. The clinical picture is muddied; further investigations are often required to tidy up the mess. It wastes resources, delays management decisions and is fundamentally Bad Medicine.

So, when your hospital installs a new system, don’t settle for anything less than a system that facilitates “requests” and aids clinical discussion. It isn’t raging against the dying of the light, it is fighting US corporate hegemony and standing up for Good Quality British Medicine.