Saying ‘No Red Flags’ is a Red Flag

By Michelle Angus

I am sitting doing electronic triage of elective referrals to the tertiary spinal surgical service and have just read the eighth letter stating that the patient has ‘no red flags’ or other words to that effect.

This particular patient is: 

• over 50 years old

• post-menopausal

• drinks above the government recommended weekly maximal alcohol intake according to the GP record attached to the referral

• describing constant pain

All this information makes me wonder – what do we even mean by red flags and are these red flags being used to aid clinical reasoning, or do we now use this term as a medicolegal defensive mechanism within musculoskeletal care?

It reminds me of the words of Grant Syme speaking about the medial defence the surgeons have, compared to the allied health professions:

Image 1: The medicolegal protection of a spinal surgeon

Image 2: The medicolegal protection of an MSK clinician

If a patient did turn out to have a non-mechanical or sinister pathology in their spine, would a jury of peers feel that writing ‘no red flags’ in a referral letter was good enough to justify a thorough consideration of serious pathology on clinical assessment?

In 1991 the clinical standards advisory group (CSAG) was set up as an independent ‘expert source’ to advise the Ministry of Health.  One of its functions was to advise on the ‘Clinical Standards’ for patients with back pain (1) and they introduced diagnostic terms along with the use of ‘red flags’ as part of this guidance.  They also introduced recommendations for clinical practice, some of which remain relevant with the increased understanding we have today.