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  1. John Bamford
  1. Dr John Bamford, Department of Neurology, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK j.m.bamford{at}

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Any discussion of the diagnosis and investigation of stroke and transient ischaemic attack (TIA) must keep in mind the convincing evidence of the benefits of organised stroke care to patients of all ages,1 the availability of evidence based guidelines for management of patients with stroke,2 3 and the evidence that the management of substantial numbers of patients does not reach these standards.4 As a consequence of the above, purchasers of health care are increasingly demanding that there is a coherent strategy for stroke care in their area, and current patterns of referral will undoubtedly change. As an individual practitioner you need to be aware how and where your skills will contribute to the overall multidisciplinary team approach to stroke care. Will you be assessing patients hyperacutely in the emergency room (minutes to hours after onset), subacutely as inpatient referrals or rapid access outpatient clinic (hours to days after onset), or will it only be the occasional, unusual patient referred for a tertiary opinion? You will also need to be conversant with the skills of other multidisciplinary team members, something that lies outside the traditional repertoire of many clinical neurologists.

Despite both technological and therapeutic advances, the clinical history and examination remain central to making an accurate, prompt, complete diagnosis. Additionally, the manner of the personal contact with a doctor at a time when patients are feeling particularly vulnerable should not be underestimated—there are few things that people fear more than serious disability from a stroke. However, you must remember that the priorities of patients and carers may differ from those of professionals, and while they clearly value being treated by knowledgeable staff, this knowledge has to be communicated in a consistent and appropriate way that allows them to participate in shared decision making.1


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