For a second consecutive time the Malta Medical Journal has carried a disconcerting article about family doctor practice. On the first occasion it was about general practitioners not treating child psychiatric disorders adequately. This article was strongly condemned by the General Practice Population via emails, this column, and a peer reviewed article which is in publication. The second article is about lack of adequate information provided by general practitioners when referring patients to the vascular clinic at the Surgical Department. This latter article is fairer in its evaluation but falls short of an adequate discussion and fails to distinguish between the three types of doctors working in general practice (below). While admitting that the referral ticket format is general and of poor quality, they suggest a few changes which may improve the quality of information provided and indeed which is needed by the clinic.

Such an article should be taken in a good spirit of professionalism and in the context, which I am sure was the authors’ intent, of improving quality of care. It is no excuse for a GP not to provide information which is in the patients’ and specialist’s interest to know. The authors describe these being a history of any smoking, diabetes, cholesterol, exercise and any advice given, among others. Although the specialist seeing the patient will of course take a full history again, and have access to the patient’s file, good clinical practice on the part of the GP is preferred. Whether this will provide for better outcomes is another matter, as there is no excuse, on the other hand, for the specialist not to take a full history or to rely completely on the information that a family physician (or GP) provides. The study would indeed have been more complete if it were to indicate whether outcomes were affected as it is considered that the most relevant information are the details of the presenting complaint and the reason for referral (Bradley, 2006), although ideally, proper communication of patient information is important.

This article is not therefore intended to excuse or give feeble explanation as to why this occurs. It does however contend to portray the general situation in Malta as far as primary care services are concerned, which, like the ticket of referral itself, has remained practically unchanged for decades.

To be sure, exchange of information between GPs and specialists is poor both ways. There are many specialists who indeed type their discharge letters and mail them to the family doctors personally. This is by no mean the case generally, as admitted by the authors themselves, making an exception for their own clinic. There is no record however that this exception was communicated to doctors working in the community from patients referred to hospital. The authors painfully go out of the purpose of their paper to defend hospital colleagues as to why (lack of secretarial services) discharge letters are not given on time. This is not very helpful to the general practitioner who needs to follow up on patients, often on the day they return home.

But tit-for-tats is not the question here. The question is the system itself. While hospital doctors’ workloads prohibit discharge letters from being given on the day of discharge, it is similar factors that often prohibit family doctors from giving all information. Both are inexcusable and should be revised. Patients should be discharged with a discharge letter – if this is possible in private hospitals, which are held to a standard by health authorities, the same authorities should hold public hospitals to the same standard. On the other hand, the fact that GPs charge a pittance is not an excuse either – but it is a fact that filling out forms takes a considerable amount of time, and lack of understanding on the relevance of information on both sides of this rift (if I may be allowed to use this unfortunate term) is the reason.

More importantly, authors however fail to note from where the letters of referral come from – from the private sector or from our health centres; indeed whether some of them are GPs at all, given that even hospital doctors who are not listed on the specialist register as family doctors are still allowed in this forsaken country to practise family medicine because they still believe in the medieval thought that family practice compares to hospital practice as ‘O’ levels compare to ‘A’ levels. In this respect, the authors fail to define their proper population of study, which would have had to divide the populations of community doctors into:

1. Referral from health centres;

2. Referrals from the private sector of Specialist Family Physicians;

3. Referral from the private sector of non-specialist family physicians, (those who work in the hospital and do some general practice in the evening).

In this regard family doctors and general practitioners are still being confused, with a concurrent failure to recognise the specialist status of those on the Specialist Register. Main flaws with studies and surveys are failure to define and select one’s population of study. We indeed failed a Master’s thesis in family medicine for this simple reason in our faculty at Medical School.

How improper would it be to lump all ‘hospital specialists’ together in certain studies; the same applies here. This aside, doctors working in health centres are not allowed to put their personal details on tickets of referral other than their names and registration number. Conversely, private doctors, the family doctors, that is, usually use a rubber stamp with all details.

But it is a serious flaw to mix health centre referral with private doctor referrals. Even though many health centre doctors work privately as family doctors, health centres are constrained in their very nature; not least because within that sphere, they are not acting as family doctors, but merely provide a service, and are not allowed to give personal details. The patient does not get to see the same doctor. It would have been interesting for this paper to discuss how feedback is given to doctors referring patients from health centres, as this can be a source of useful information for the department if doctors never get to see feedback from hospital specialists.

Secondly it is not always possible to know whether patients do suffer from diabetes or cholesterol etc, unless one does have a history. Patient registration, if implemented, should help in this regard; it would then also be easier to define one’s population, as patients would be registered only with the doctor on the Specialist Register. However I have it from a reliable source that since the task force document was ‘leaked’ out prematurely, this may have put the whole process of changing the primary care system on a political tightrope. Why this should be the case, for the life of me, is beyond my comprehension. But I say this, because if, as the authors suggest, a different ticket of referral for each department had to be made, and a more formalised information-providing referral had to be given, especially if GPs are required to print, as the authors seem to imply, and all this without revising the system, they are asking for an impossible task indeed. And if they do not understand this, they then cannot claim to understand the nature of family medicine which suffers from lack of adequate resources as much as the hospital specialities, which they defend, do.

Perhaps GPs should do a study of how many patients get a discharge letter in an appropriate time. I am sure we would get an avalanche of reasons by specialists, and they would be right, the point being that mutual understanding would take us a long way before publishing papers which carry little significance without a general understanding of the underlying situations. Communication is an issue – but it is a two-way process; and in fairness I think that information provided by the hospital to the family doctors for the immediate care of the discharged patient, is probably more significant, if not more important, than information which GPs/family doctors provide on their tickets of referral. The latter are more practical and know that what they write is often neglected as full histories are taken again. The reason they are referring the patient is the most important information which is needed (vide above). This, again, is not to excuse any given bad clinical practice, but one has to show why it is bad clinical practice in the first place and not mere lack of courtesy or opinion. This can only be shown if outcomes are affected or at least if it taxes on hospital doctor’s time. Given that hospital doctors have to take full histories, etc, this is improbable. There is no study that I know of where lack of information, which the authors refer to, has affected either the work of the doctors or the outcomes. And the authors in point of fact, make no reference of any study either.

The references used by the authors do not refer to any local studies and it would seem that this is an issue in other countries. This is the first study of its kind and hopefully will have positive outcomes, among which:

1. To continue revising the primary care system and promote the change started by the Minister for Health and Parliamentary secretaries.

2. For the government to continue to promote Vocational Training and make it obligatory for all doctors working in the community (with the exception of those on the specialist register); this is about patients’ rights, and not the right to work wherever one pleases.

3. To recognise the subsets of GPs/family doctors which continue to exist notwithstanding much lobbying on behalf of patients, and to address the issue of patient registration within a holistic system.

4. To set up an intra-professional dialogue on better communication between the community doctors and those in hospital.

As for the last point, this, the problem that was discussed in this paper has been around for at least 15 years that I remember. I once met the former president of the Medical Association of Malta (MAM) and asked him whether they can do something about discharge letters being sent with the patients. He was a hospital specialist and took it rather personally. Instead of at least humouring me with an appropriate answer, he said, ‘It is better to see that GPs fill out proper tickets of referral’. It seems that this state of affairs has not changed. We need to move from ‘us’ and ‘them’ attitudes. We need to move towards better overall health care. It is fair and good to produce articles of this type to promote this better health care; but their discussion must also show that there is a mutual understanding of respective systems.

This can be done by having persons from either side (if ‘sides’ there are) on board of the author team of such articles. It would at least avoid pitfalls such as this paper not distinguishing the fundamental differences between health centres and private practitioners in our dual system. It would show if there are any significant differences, if anything. It would identify whether doctors working in one environment fare better than in another – all in the name of the patient! If the situation is desperate, then this calls for a desperate measure – a measure to be sure which in this third millennium is more than due: that all doctors, whether private or public, tall or short, fat or thin, should be hooked up to a main computerised system. In such a small area with a population of less than half a million, we are an ideal country for this.

Bradley, C., General Practice (series editors: Parveen Kumar & Michael Clark), Suanders, Elsevier, London, Oxford, Toronto, 2006.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.