The trend toward increased specialization and sub-specialization in medicine has led to a number of wonderful advances in the delivery of health care. Patients benefit from the skills of surgeons and procedurists who do high volumes of a small variety of procedures; as well as from the wisdom of experts who have highly specialized experience in the diagnosis and treatment of uncommon diseases. Canadians can be reassured that for pretty much any disease or condition, “x”, there is an “x-ologist” somewhere in the country who will be able to provide state-of-the-art care.
As a cardiac electrophysiologist with a particular interest in inherited heart rhythm diseases, sudden death in the young and cardiac resynchronization therapy, I am one of those sub-specialists who routinely sees patients who have been filtered through 2, 3, or even 4 or more other physicians before they appear in my clinic. I am the “end of the line” – I provide the definitive diagnosis; the definitive therapy. I enjoy my role; I know that our work is important and that we help many patients to lead longer, better lives.
But there is a significant downside to the specialization of medicine – the increased fragmentation of care that has resulted. As we busied ourselves setting up all of this specialized infrastructure (granted, with the best of intentions) we somehow failed to notice that we were building silos of care. It is true that within each silo, there is excellence. But looked at collectively, it is now quite apparent that we have unwittingly contributed to the creation of an “un-system” that is characterized by excellence in episodes of care, but which fails patients’ longitudinal experience by performing inadequately at the transition points. Our un-system also serves to sometimes undervalue the critical, essential, and highly central role of the family physician and the primary care community in general.
Today, we speak of patients navigating the health care system. We speak of the patient journey. Patients are shuffled from venue to venue; provider to provider; consultation to test to procedure to follow-up. It’s complicated, it’s inefficient, it’s costly, and it is a source of great anxiety for patients who find themselves at a vulnerable point in their lives. They don’t want to have to navigate anything. They want our help.
These multiple transition points have created a health care environment that is predisposed to preventable medical error. It is also at these transition points where negative perceptions are spawned, where inefficiencies, waste and excessive wait times are generated and where suboptimal outcomes are born.
Creating a seamless, efficient, error-free patient journey will not be an easy task. Slow progress is being made on the adoption of electronic medical records, medication reconciliation, adherence to guidelines-based care, wait list management and accountability, and (importantly) patient empowerment – putting information and solutions in patients’ hands. All of these efforts are moving us slowly in the right direction.
But these are system-level solutions. What can we, as individual doctors, do better?
My recent work with Health Canada and the CMA on the development of referral pathways has helped me to see where some quick gains can be made at the individual physician level.
It was a fantastic experience. Five family physicians and five cardiologists sat down together and we simply asked the question, “How can we improve the referral process?”
“When I refer a patient, the paper goes into the fax machine and then into the ether. I never know if it’s been received or acted upon. My patient asks me when the appointment will be and I can’t tell them,” said one family doc.
“I got this referral the other day that said, ‘Please see re: HF'”, said one cardiologist. “How can I triage that? Is it urgent? Has the family doc done any testing? What meds are they on? I couldn’t tell from the referral note.”
“My patient got this automated note back saying that they’d see the patient in 6 months,” said another family physician. “Six months! My patient will be dead by then! I tried to call the cardiologists’ office, but couldn’t reach her. Am I supposed to keep chasing her down?”
“I get referrals sometimes that are completely illegible. On one referral, the letterhead listed 9 family doctors and I can’t even tell which one sent the referral!”
“My patient got their appointment with the cardiologist in 2 months, but what can I do in the interim? Isn’t there some way that I can get some early direction? Are there any tests I can arrange or any treatments I could get started on?” said one family physician.
The discussion was rich and peppered with anecdotes about bad referral experiences. Everyone in the room nodded knowingly as each story was told, and excitement started to build as it became apparent that some of the solutions are tantalizingly simple.
A referral pathway for congestive heart failure was developed that day. (http://ccs.ca/advocacy/HF-Pathway_en.pdf). When family physicians and cardiologists all understood where they were failing each other (and therefore, failing their patients), the product took shape quickly.
It’s just a tool. It will certainly help, and I am very pleased to see it being implemented in numerous places across the country. But there are even bigger lessons that came out of this exercise.
Our discussions that day allowed a common understanding that in turn led to a harnessing of the power of professionalism. Collegiality goes a long way, and there is nothing like face-to-face communication to facilitate this.
Canada’s primary care/community-based care physicians are increasingly isolated from the consultant/hospital-based community, and this has served to perpetuate and reinforce the silos.
Every doctor can help to reverse this trend by embracing the power of professionalism and collegiality. We should foster personal relationships and friendships with other doctors in our communities. Every consultant should examine his/her practice and fix simple issues like acknowledgment of receipt of the referral, and by being readily available to referring docs for questions and advice. Every family physician can work to enhance their referral notes with pertinent information that allows the consultant to triage effectively and so duplicate testing can be avoided. Finally, we can all ensure that patients are kept in the loop along the way, so they don’t feel abandoned or uncertain while waiting for their visit with the consultant specialist.
All of this is achievable and it doesn’t have to cost a cent. Patients’ confidence in us will increase when we show that we understand and are interested in the integration of our contribution to their care with their overall journey.
Every physician can make a difference. I strongly believe in the capacity of Canada’s physicians to provide meaningful solutions. Let’s embrace these professional principles as a key component of our path forward.