Sir,In his recent editorial Dr Abdallat touches on some important points about communication skills and the professionalism of doctors.1 Though his assertions might be true as generalisations it would be misleading to apply some of them in National Health Service (NHS) practice. (My comments are confined to the NHS.) For example, it would be wrong to say that “the term consultant . . . means a person who is consulted”. The problem lies in the fact that language has evolved beyond this original literal usage. Today Consultants (capital ‘C’) are not Consultants because they are consulted, rather they are consulted because they are Consultants. Such status is conferred by appointment only on specific individuals who assume ongoing ultimate clinical responsibility for particular patients within a certain area of medicine or surgery. Though only those who have completed approved specialist training may be appointed Consultants, not all those who are suitably qualified are appointed. It would be misleading to say that a Staff Grade doctor who sees a patient referred to a department may be called a consultant (small or large ‘c’ — they sound the same), even solely for the purposes of that referral. Likewise if a General Practitioner refers to, or confers with, a General Practitioner colleague.

It is wrong to say that onwards referral should not proceed “without the knowledge and consent of the primary physician...”. In making the referral, the primary physician passes on clinical responsibility for a particular problem to a Consultant. When the Consultant sees the patient their interests come first, and if onwards referral is indicated then it should occur. In practice, one of two paths is taken, depending on the degree of clinical need. If onwards referral is unquestionably in the best interests of the patient the Consultant should do this without delay, and at the same time inform the primary physician. When the need is less clear, the Consultant should air the arguments for and against onward referral in the report to the referring physician, and state clearly that the responsibility for the decision about onwards referral has been passed back to the referrer.

The question of ‘writing orders’, or not, which occurs in the context of in-patient referrals, when one team consults another, is a difficult one. Should the consulted team write a list of things to do, or should they go ahead and organise the investigations and treatments they feel are necessary? Which is the more courteous? The terms of the referral might suggest the more appropriate response, but the final arbiter should be the patient's best interests.

Some points in the editorial which clearly do apply within the NHS are worth emphasising. The suggestions that the referrer should prepare the patient's expectations; should clearly indicate the scope of the referral to the Consultant; and that the Consultant should present a timely report to the referring physician, are all very apt and we would do well to heed them. The final assertion that “open communication is the cornerstone of a successful consultation” is worth serious contemplation.