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PATIENTS WAITING
956 Professor Rhodes emphasises that his figures refer only to of South-East London with a high immigrant population. Our own figures refer to a lower-social-class urban area in Liverpool characterised by a preponderence of ill-nourished women of high parity. The figures for other areas are likely to be of interest, and consideration of the factors underlying any variations found may indicate which of Professor Rhodes’ suggested lines for further investigation are likely to prove most fruitful.
TABLE II-MEDICAL CLINIC HELD IN A SUITE WITH CONSULTING AND EXAMINATION ROOMS
one area
Department of Obstetrics and Gynæcology, University of Liverpool.
BRYAN M. HIBBARD.
CRAMP *
and unaccustomedly low-heeled shoes. The multipara slops around in comfortable slippers suspended on the big toe. Both bend their back and not their knees as the bulge gets in the way. During pregnancy nocturnal cramps can nearly always be averted if abuses of feet and posture are prevented during the day and the foot of the bed is not tucked in too tightly at night. In predisposed people leg-cramp can frequently be produced by wearing gum-boots, fur-lined boots, or ill-fitting shoesparticularly shoes tight across the metatarsal arch. Manifestations may be immediate, but, when they are delayed until the small hours of the morning, connection of cause and effect goes
SiR,—The enthusiastic primipara buys
unrecognised. NORMA MAC LEOD.
London, W.8.
PATIENTS WAITING
SiR,—The survey Waiting in Outpatient Departments by the Nuffield Provincial Hospitals Trust, noticed in your annotation (Sept. 11), is a useful and interesting contribution to the published work on outpatient departments. There is one aspect, however, on which comment is required. Table n of the report (p. 52) lists mean consultation-times for doctors seeing new and return patients in twelve specialties. This information is of obvious importance-for example, in planning -to ensure that consultants are not so pressed for time that other aspects of clinic organisation are unreasonably subordinated, to avoid underloaded clinics, or to provide for a reasonable number of doctor-sessions in new departments of given numbers of designed to deal with the attendances " The definition of consultation-time used in the patients. report (p. 10)-" the time the patient spends in the consultation suite "-is, however, unsuitable either as a basis for appointment systems or for the other purposes we have outlined. Tables I and 11 show the progress of the first few patients in two medical clinics which we have surveyed; to simplify these tables, patients’ visits to other facilities, before or after the times shown in the tables, have been omitted. These tables illustrate some of the differences between time spent by the doctor in dealing with a patient, and the patient’s time in the consulting suite. Patients may undress, wait, and dress in the suite while the doctor consults with another patient. Even patients who do not undress may wait within the suite-for example, in eye clinics. Thus patients are usually in the suite for a longer time than that spent by the doctor in dealing with them. In some "
TABLE I-MEDICAL CLINIC HELD BY A REGISTRAR IN A CONSULTINGROOM WITH CUBICLES
*
r1=new
patient;
R= return
patient.
t Patient visited 3 other facilities before
returning
to
cubicle
to
dress.
r1=new
patient;
patient. consulting-room after dressing.
R = return
t Patient re-entered
new
clinics, however, their time in the suite is shorter, because the doctor often writes case-notes for a minute or so after the patients have left the consulting-room, and this necessary part of the consultation-time may add to it appreciably in clinics such as obstetrics, where the average time during which he sees each patient is short. An indication of the large differences introduced by measuring mean consultation-times in the way chosen in the survey is given on p. 19 where it is said that in one study 30% of the patients were found to have waited in cubicles for over 10 minutes. The length of time which patients spend in consulting suites is made up of several components which result from existing conditions and methods. To apply these times in practice is to assume that no change in organisation will occur within the Even with inadequate accommodation consulting suite. improvement is seldom impossible, and in new departments more suitable forms of organisation should be envisaged. These require a fairly close definition of the times taken by doctors and others for various activities, if, for example, doctors are not to be delayed by lack of a sufficient number of rooms. Our own studies of this subject, which are shortly to be published as a Planning Note by the Scottish Home and Health Department, included a direct record of the doctor’s work by the professional members of our team who were present in the consulting-room. Rates of work were later discussed with all consultants. The results of the observations were compared with the weekly and annual work-loads and numbers of doctor-sessions for each specialty at each
hospital. From our results, we conclude that the method of measureof " consultation time " used in the Nuffield report gives mean times up to twice those actually spent by doctors on consultations, including writing case-notes. It is important that these patients’ " consultation times " should not be used as a measure of the doctor’s time. ment
London School of Hygiene and Tropical Medicine, W.C.1.
Edinburgh.
W. BRASS. J. K. HUNTER M. J. BLANCO WHITE.
BLOOD-SAMPLES FROM EAR-LOBE PUNCTURE
SIR,-We should like to reply to the letter from Professor Worth last week. Although in our article (Aug. 14) we made no comparisons in subjects with congestive heart-failure, 5 of our subjects had severe pulmonary disease with a Po2 between 50 and 60 mm. Hg. In these subjects the mean arterialcapillary P02 difference was 3-3 mm. Hg. In 4 subjects with a P02 over 80 mm. Hg the difference was 0-6 mm. Hg. The numbers of subjects are too small for valid statistical analysis, but the trend agrees with Professor Worth’s observation that the arterial-capillary difference is greater at low levels of Po2. But we do not think that the difference, even at low levels of Po2 is important in routine clinical work. Department of Therapeutics and Pharmacology, Queen’s University, Belfast, 12.
JEAN H. M. LANGLANDS WILLIAM F. M. WALLACE.
TABLE II-MEDICAL CLINIC HELD IN A SUITE WITH CONSULTING AND EXAMINATION ROOMS
one area
Department of Obstetrics and Gynæcology, University of Liverpool.
BRYAN M. HIBBARD.
CRAMP *
and unaccustomedly low-heeled shoes. The multipara slops around in comfortable slippers suspended on the big toe. Both bend their back and not their knees as the bulge gets in the way. During pregnancy nocturnal cramps can nearly always be averted if abuses of feet and posture are prevented during the day and the foot of the bed is not tucked in too tightly at night. In predisposed people leg-cramp can frequently be produced by wearing gum-boots, fur-lined boots, or ill-fitting shoesparticularly shoes tight across the metatarsal arch. Manifestations may be immediate, but, when they are delayed until the small hours of the morning, connection of cause and effect goes
SiR,—The enthusiastic primipara buys
unrecognised. NORMA MAC LEOD.
London, W.8.
PATIENTS WAITING
SiR,—The survey Waiting in Outpatient Departments by the Nuffield Provincial Hospitals Trust, noticed in your annotation (Sept. 11), is a useful and interesting contribution to the published work on outpatient departments. There is one aspect, however, on which comment is required. Table n of the report (p. 52) lists mean consultation-times for doctors seeing new and return patients in twelve specialties. This information is of obvious importance-for example, in planning -to ensure that consultants are not so pressed for time that other aspects of clinic organisation are unreasonably subordinated, to avoid underloaded clinics, or to provide for a reasonable number of doctor-sessions in new departments of given numbers of designed to deal with the attendances " The definition of consultation-time used in the patients. report (p. 10)-" the time the patient spends in the consultation suite "-is, however, unsuitable either as a basis for appointment systems or for the other purposes we have outlined. Tables I and 11 show the progress of the first few patients in two medical clinics which we have surveyed; to simplify these tables, patients’ visits to other facilities, before or after the times shown in the tables, have been omitted. These tables illustrate some of the differences between time spent by the doctor in dealing with a patient, and the patient’s time in the consulting suite. Patients may undress, wait, and dress in the suite while the doctor consults with another patient. Even patients who do not undress may wait within the suite-for example, in eye clinics. Thus patients are usually in the suite for a longer time than that spent by the doctor in dealing with them. In some "
TABLE I-MEDICAL CLINIC HELD BY A REGISTRAR IN A CONSULTINGROOM WITH CUBICLES
*
r1=new
patient;
R= return
patient.
t Patient visited 3 other facilities before
returning
to
cubicle
to
dress.
r1=new
patient;
patient. consulting-room after dressing.
R = return
t Patient re-entered
new
clinics, however, their time in the suite is shorter, because the doctor often writes case-notes for a minute or so after the patients have left the consulting-room, and this necessary part of the consultation-time may add to it appreciably in clinics such as obstetrics, where the average time during which he sees each patient is short. An indication of the large differences introduced by measuring mean consultation-times in the way chosen in the survey is given on p. 19 where it is said that in one study 30% of the patients were found to have waited in cubicles for over 10 minutes. The length of time which patients spend in consulting suites is made up of several components which result from existing conditions and methods. To apply these times in practice is to assume that no change in organisation will occur within the Even with inadequate accommodation consulting suite. improvement is seldom impossible, and in new departments more suitable forms of organisation should be envisaged. These require a fairly close definition of the times taken by doctors and others for various activities, if, for example, doctors are not to be delayed by lack of a sufficient number of rooms. Our own studies of this subject, which are shortly to be published as a Planning Note by the Scottish Home and Health Department, included a direct record of the doctor’s work by the professional members of our team who were present in the consulting-room. Rates of work were later discussed with all consultants. The results of the observations were compared with the weekly and annual work-loads and numbers of doctor-sessions for each specialty at each
hospital. From our results, we conclude that the method of measureof " consultation time " used in the Nuffield report gives mean times up to twice those actually spent by doctors on consultations, including writing case-notes. It is important that these patients’ " consultation times " should not be used as a measure of the doctor’s time. ment
London School of Hygiene and Tropical Medicine, W.C.1.
Edinburgh.
W. BRASS. J. K. HUNTER M. J. BLANCO WHITE.
BLOOD-SAMPLES FROM EAR-LOBE PUNCTURE
SIR,-We should like to reply to the letter from Professor Worth last week. Although in our article (Aug. 14) we made no comparisons in subjects with congestive heart-failure, 5 of our subjects had severe pulmonary disease with a Po2 between 50 and 60 mm. Hg. In these subjects the mean arterialcapillary P02 difference was 3-3 mm. Hg. In 4 subjects with a P02 over 80 mm. Hg the difference was 0-6 mm. Hg. The numbers of subjects are too small for valid statistical analysis, but the trend agrees with Professor Worth’s observation that the arterial-capillary difference is greater at low levels of Po2. But we do not think that the difference, even at low levels of Po2 is important in routine clinical work. Department of Therapeutics and Pharmacology, Queen’s University, Belfast, 12.
JEAN H. M. LANGLANDS WILLIAM F. M. WALLACE.