Speak to any doctor of an older generation and they will tell you the same refrain: doctors in big cities just don’t talk to each other any more. Whether it is because of community doctors becoming increasingly siloed from the hospital, or the increasing use of electronic communication, certainly the telephone is not being picked up as often as in years past.
Is there anything inherently wrong with this? Well if was just a matter of times changing and doctors finding more efficient ways to perform certain processes, then no, there wouldn’t be any problem with this. But I think it’s fair to say that the quality of communication as a whole between hospital physicians and community physicians has declined over time.
Nowhere is this communication more important than in patient transitions between community and acute care. In smaller communities where their primary care physician is also their hospitalist, the transition of the patient from community to acute care and back is seamless. But in larger centres, it is often not practical for primary care physicians to perform this role, leaving it to hospitalists or surgical teams to manage all aspects of patient care.
Let’s start off with the premise that primary care physicians often have invaluable information that would improve the acute care of our patients. Primary care physicians are considered the “quarterback” of a patient’s journey through the health care system, and typically have a great deal of insight into the patient’s medical history, social history, values, and goals. A patient’s admission to hospital is often a stressful event both for the patient, their family, and for hospital staff, who try to piece together fragments of their medical history to provide safe, high-quality care. Important details about a patient’s history may remain hidden from the hospital staff, potentially adding to morbidity and to duration of hospital stay.
Most will point to already-burdened schedules as the main limitation to finding time for this communication to happen. A recent article in the New England Journal of Medicine(http://www.nejm.org/doi/full/10.1056/NEJMp1411416) proposed a system whereby primary care physicians would visit their patients within 12-18 hours of admission to provide support and counselling to the family, consultation to the hospitalist team, and provide direction and scope of the patient’s workup and care. While this is a potentially useful model in some centres, it would be completely impractical in London and at London Health Sciences Centre. The logistics of having a family physician visit all newly-admitted patients within their schedules would be too challenging to overcome in the short-term. The issue of remuneration through OHIP for this would also be a significant barrier.
I recently met with my LHSC Internal Medicine colleague Dr. Andrew Appleton to discuss possible solutions to improve this communication. We weighed the idea of a Quality Improvement Project to look at introducing “mandatory communication”, whereby a trainee or staff physician would initiate a phone call with the primary care physician at admission and discharge to review medication changes, recent diagnostics ordered, recent office visits, previous admissions, previous barriers to discharge, home care, family contacts, values, goals, and follow-up plans.
We came to the conclusion that this type of QIP project would be futile for a couple of reasons. First, it would be difficult to show an improvement in hard outcomes over 6-week period we were proposing in the study. If six weeks went by without significant meaningful information shared, the entire concept of improved communication may be prematurely disregarded as a waste of time. Second, even if we were to show an improvement in hard outcomes, implementing a “mandatory” program hospital-wide would be sure to create resentment in physicians who would have to make calls even in situations where they are certain they don’t need primary care input.
So we’re left with the knowledge that sharing of information would be beneficial, but a mandatory program is not likely the way to go. Our attempt at a solution is to gradually change the culture around this communication.
At the hospital level, educate hospital teams and staff physicians that primary care physicians are generally happy to respond to telephone calls asking specific questions regarding their patient’s history and care. Family physicians are not compensated for phone calls with non-MDs, so if a non-MD is to call, these calls should not be open-ended fishing expeditions, but have a clear focus and short duration. At the beginning of each trainee block, the senior resident should encourage trainees to communicate with family physicians when appropriate, as they may not be used to doing so in other rotations or jurisdictions. (As an aside, there should be a hard look at the physician schedule of benefits in Ontario that limits compensation to 10+ minute conversations between MD and MD. I would propose a separate fee for 5 minute conversations, as well as remuneration for communications with hospital nurse practitioners.)
At the family physician level, let them know to expect a slightly higher volume of calls from hospital physicians, and to try to respond promptly to these calls. Here in London, the London Hospitals Electronic Notification Service (LENS) notifies each family physician daily about any patient admissions, discharges, or ER visits. If a family physician has a patient admitted to hospital and feels they have any relevant information to share, they should be encouraged to call the admitting staff physician directly.
This culture will not change overnight, but our hope is that if a few physicians in each community can take the lead, the lines of communication will re-open and we will see improved patient outcomes and satisfaction.