Plans for restart following COVID-19 should consider the whole system including the impact on diagnostic services, not just the demands of frontline clinics

Editor – The Royal College of Physicians’ teach-in ‘Resetting of services post COVID-19’ on 29 June 2020 had some helpful advice and observations.¹ Concerning was the recommendation by one of the speakers that physicians should consider arranging diagnostic tests prior to seeing patients as a way of mitigating the impact of social distancing and return to work.

As a neurophysiologist running a diagnostic service, I would like to outline the adverse consequences of pursuing this route.

• Most diagnostic departments struggled to deliver a timely service prior to COVID-19. Any increase in referrals just shifts the problem onto another area of the hospital.

• There are shortages of diagnostic unit staff.

• Most diagnostic units have reduced throughput due to social distancing. They are unable to increase numbers to compensate for other specialties.

• Many investigations require a breach of social distancing. Whether phlebotomy, a nerve conduction study or electrocardiography, the investigator will be less than 1 metre from the patient.

• Investigations take time. Each neurophysiology referral needs triaging, administering, recording and reporting. The referral typically requires 20 minutes of consultant time, 20 minutes of secretarial time and over 2 hours of physiologist time.

• Investigations are not without harm: phlebotomy has the risk of haematoma, electromyography can result in compartment syndrome and computed tomography delivers radiation. The risk of injury is considered appropriate if there is advantage for the patient. When the measure of utility is reduced, the burden of unnecessary risk is increased.

• The sensitivity and specificity of every investigation is highest when there is a high pre-test probability of an outcome prior to an investigation. When diagnostic tests are ordered in a scatter-gun approach, the sensitivity and specificity of the investigation is lowered. Two per cent of the healthy population have changes on their electroencephalography (EEG) which would be in keeping with epilepsy. Having identified this on EEG, the patient would receive an unnecessary driving ban.² This approach therefore violates the principle of ‘first, do no harm’.

• Every investigation can produce ambiguous results. Investigations rarely give a yes/no answer and a reporting diagnostician needs to have as much clinical information as possible prior to the investigation to help focus the investigation and guide interpretation.

• Unnecessary investigations generate unnecessary anxiety for patients.

• If all referrals are made without a history, I am unable to prioritise my limited resource and those who are genuinely unwell will need to wait longer.

I wish all physicians the best of luck in dealing with the aftermath of COVID-19 and the resetting of services. Rather than adopt an approach which risks shifting workload from one part of the hospital to another, there is another way: working together we can create ‘one-stop-shop clinics’ and true multidisciplinary team working. This has been pioneered in breast cancer diagnostics and orthopaedic clinics. This approach leads to better relationships between clinicians, fewer hospital visits for patients and better outcomes all round.