Dumfries has had a Doctors Handbook since 1992. We have revised and updated this each year to the point that it now extends to an impressive, some might say overlong, 336 pages. The paper version was handy as a pocket book but became out of date very quickly. Updates could only be introduced by adding sticky labels or a new and expensive print run. It was on this background that we decided to go paperless at the end of 2012. Our goal was to produce an app accessible on all PCs and mobile devices throughout the hospital. We toyed with the idea of bringing in outside help but decided ultimately on an in-house solution, drawing on the expertise of Calum Murray (Education Centre) and Pete Robinson, Pete O’Connor and Brian Currie (IT).
Why the need for a Doctors handbook? Mainly because we staff our hospital at night with relatively inexperienced members of the medical team ie those less likely to provide the answers to some of the problems that present out of hours than consultants. This is a particular issue at the beginning of August (Google the “Disgruntled A&E SHO’s 7th August” blog to see an altogether different solution!) and for hospitals such as ours because more often than not the most senior doctor on site for medicine is CT2 or less in experience (for the non-medics reading, this means less than 4 years since qualifying). Patient expectations have increased considerably in the last 10-20 years and complaints over poor standards of care have increased dramatically. An evidence and expert opinion based Doctors Handbook is one way of reducing risks to patients at night… and of protecting the juniors. If a patient’s condition deteriorates but it can be shown that the doctor was following best practice then it is likely that the treatment was correct and that the doctor was not responsible for the deterioration. I should perhaps stress at this point that if a patient’s condition deteriorates unexpectedly at any time of day or night and the doctor isn’t sure what to do then he or she should of course also phone the consultant!
It could be argued that we live in a perpetual state of information overload already and don’t need yet more information. It is certainly true that doctors on call have access to unlimited quantities of information, but is it the right information and is it readily available when needed? Let us take Community Acquired Pneumonia (CAP) as an important and common medical condition. Googling gives around 2,990,000 hits. The first 5 of these are for Wikipedia, eMedicine, British Thoracic Society Guidelines (twice) and Boots Web MD. If we discount the patient website then it’s quite likely that a junior doctor searching for information online about pneumonia will open one of the others. For it to be worthwhile having our own handbook then we have to be seen to be offering something that the others don’t. So do we?
Wikipedia first. It is all too tempting to dismiss Wikipedia, though it does occasionally have its uses. Crucially however the Wikipedia entry for Community Acquired Pneumonia makes no reference to the British Thoracic Society Guideline and doesn’t even mention the CURB65 score (non-medics, this is a score that tells us the severity of the pneumonia) though you will find this if you follow a link to ‘Pneumonia’. It is also fairly long at 4929 words and I have no idea of the expertise of the people who wrote it. By contrast we can see exactly who wrote the emedicine Community Acquired Pneumonia article. This is a scholarly work but more textbook than handbook and more American than British. No disrespect to American guidelines but we practice medicine differently and the antibiotic recommendations, for example, are not transferable.
Which brings me to the British Thoracic Society guidelines. These were published in 2009 and have been endorsed by a number of learned societies including, among others, the Society of Acute Medicine and the Royal College of Physicians. They are by any criteria very well written and intensely practical guidelines but at 61 pages probably not quite the accessible read required by the on-call doctor for medicine at 2am in the morning when confronted by a febrile, breathless patient with coarse crackles and inflammatory shadowing on his or her CXR. Excellent as a reference though.
So what parts does our handbook reach that Wikipedia, emedicine and British Thoracic Society do not? First, we have ensured that at well under 1000 words the Community Acquired Pneumonia chapter is more handbook than textbook. For those reading this on NHSD&G’s network, click this link to view the page, Community Acquired Pneumonia (CAP) Handbook Page . For those reading externally, we have reproduced the page as a screenshot that can be accessed by clicking here Community Acquired Pneumonia on Flickr .(When loaded, click on image – to enlarge select ‘view all sizes’ at top of page and then click on ‘original’). Second, we have based the chapter on the British guideline distilling what we think are the really important messages from it. Third, we have had the chapter approved by our respiratory physicians which means that it reflects current best practice in Dumfries. And fourth we have included an electronic link to the British guideline BTS Guideline in case the on call doctor wants a little bit more advice or background to a particular recommendation.
Work on the Handbook continues apace. At the time of writing this blog we have ‘gone live’ with around half of the content updated and converted to electronic format (see below for the sections completed so far and the respiratory chapter headings). Juniors can access the Handbook from the intranet home page but not yet on ward iPads or their mobile phones (coming soon). We are indebted to a huge number of colleagues Acknowledgments for their help with revision and anticipate calling on many others over the coming weeks. We rather hope that our new improved electronic Handbook will become an indispensable part of medicine in Dumfries. All comments, suggestions and feedback welcome, particularly if you spot a mistake. What price a surgical, orthopaedic, obstetric, paediatric or psychiatric handbook? Delighted also to hear from colleagues from other health boards. Best to contact us by emailing firstname.lastname@example.org
Professor Chris Isles is a Retired Consultant Physician and Clinical Teaching Fellow. He is also one of Dumfries and Galloways premier Baristas.
Next week will see our first guest blog by Professor Jason Leitch, Clinical Director for NHS Scotland.