The College of Physicians and Surgeons of Ontario (CPSO) recently released a suite of policy proposals, all with one common goal: to enhance continuity of care for patients. The recommendations are targeted at aspects of continuity that fall under the responsibility of individual physicians rather than the health care system at large, and the College is seeking consultation with Ontario doctors and other stakeholders before enshrining the initiatives into official policy.
Many of the proposed measures are fairly uncontroversial. For example, doctors must ensure that their office telephones are answered consistently during business hours, and that they have a system of after-hours coverage so that critical test results can be responded to appropriately. Hospital physicians will be required to send discharge summaries in a timely manner, and walk-in clinic doctors will need to notify patients’ regular family doctors of any visits to their clinics. Specialists must notify referring doctors of an estimated appointment time within 14 days of receiving the referral.
While I applaud the CPSO for taking these steps, I’m concerned that their recommendations do not go far enough. In my daily practice as a family physician, I have seen far too many examples of patients being overmedicated, undertreated, overtested, or sent home from hospital without an appropriate medical follow-up plan, all because of one thing: lack of real-time, interactive communication between hospital staff and family physicians during an episode of care.
For example, take my patient Connie*, a 95-year-old woman living independently in a seniors’ apartment in Toronto. She has several chronic health conditions which are relatively stable. She also experiences white-coat hypertension: When her blood pressure is measured in a doctor’s office or busy hospital setting, it increases, sometimes dramatically, but only temporarily. Those of us who know Connie, including her cardiologist, are aware of her white-coat hypertension and never panic if her blood pressure is elevated when she is otherwise feeling physically well.
When Connie ended up in the hospital this past winter with a bout of influenza, her blood pressure was understandably high. The constant commotion of alarms, nurses, noisy roommates, and bright lights would be enough to make anyone feel stressed. The well-meaning physician in charge of her care added a new blood pressure medication to her existing regimen, and she was told to keep taking it even when she was discharged from hospital. When I saw her in my office a few days later, she told me that she had fallen and hit her head, having blacked out in her apartment. A quick check of her blood pressure revealed that it was too low to sustain adequate blood flow to her brain. I advised her to stop taking the new medication, and within a few days she was right as rain. Though she thankfully did not have any serious injuries, she did have a completely preventable adverse event.
What could have been done to avert this iatrogenic cascade? A simple phone call or email message from the hospital physician to me would have easily clarified that Connie’s blood pressure was generally well-controlled when she was out of the hospital, and that additional medication would be likely to harm her. Living in a time when instantaneous communication is a routine part of life, there is no longer any excuse for clinicians to depend on 20th-century models of correspondence. Instead of mandating timely discharge summaries, which perpetuate a post facto one-way flow of information, I believe that the CPSO should encourage hospital physicians to interact with family doctors during an inpatient stay, not after. And instead of requiring physicians to make sure their office phones are picked up, I believe that their cellphone numbers and secure email address (which are freely and easily available through the OneID system) should be more widely available to colleagues within our health care communities. One could even imagine using a secure cellphone messaging app to trade messages in real time.
Of course, I understand that all of us deal with incredible demands on our time from the heavy patient loads that we manage: It may sometimes be easier to reflexively order a test, or prescribe a medication, and let someone else deal with the consequences down the road. But when patients’ lives and well-being are at stake, I believe it is incumbent on us to take the extra time to do things right. We already know that the period immediately after discharge from hospital can be perilous for those with chronic health conditions, with up to 10 percent of patients requiring re-admission to hospital within 30 days of discharge. The rate is even higher among those patients who are more frail. Both primary care providers and hospital physicians should be prepared to sacrifice a small amount of their time to ensure that discharges of frail or complex patients proceed smoothly. A financial incentive, such as a billing code for both the hospital and community physician to have this conversation, could help alleviate concerns regarding remuneration.
I encourage all those who agree to respond to the CPSO’s call for comments in an online survey, which is open to everyone, not just physicians and health care professionals. It will take significant momentum to overcome the inertia of our current way of practising—let’s not waste this vital opportunity to make a positive change.
*Name has been changed to protect privacy
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You state “Many of the proposed measures are fairly uncontroversial” and then go on to list as one of those uncontroversial measures…”walk-in clinic doctors will need to notify patients’ regular family doctors of any visits to their clinics.”
This is anything but uncontroversial. I own and work exclusively in a walk-in clinic. My default is to copy family physicians on all test results of investigations that I order. I suspect that you would be stunned at how many people refuse this and demand that their family physician NOT be copied on these results. Is this not their right to refuse this? Are you suggesting that a CPSO policy should override the basic principles of informed consent? Really? Uncontroversial? Hardly…
Paul,
I don’t think anyone, the CPSO included (though I can’t speak for them), is suggesting that we should override a patient’s explicit request to keep medical information private, and I’m not sure why you’re reading that into the CPSO’s policy. What’s uncontroversial, in my opinion, is the requirement to notify the patient’s primary care provider of the encounter and any associated diagnostic results, assuming that the patient consents to this. You may run a top-notch and highly responsible walk-in clinic, but many other clinics do not have the same strong commitment to information sharing; I often have to chase walk-in clinics for information and test results in order to properly follow up on patients’ concerns.
Put the actual policy in the College survey to make it easier to complete and so I don’t have to open up two separate documents.
Thanks Ed. When I worked as a hospitalist, I used to tell our house staff that the most under-utilized diagnostic test was a call to the patient’s family physician. Unfortunately, we didn’t make one often enough, and sometimes when we did, we’d get an answering machine that said “We are not here. Please don’t leave a message – call back at 2pm”. I agree that in 2018 there should be more effective ways of timely communication.
That all sounds good but leaves me wondering about the old saying that many hands make lighter work. Isn’t a big part of the work load problem a lack of a sufficient number of Drs etc…
This is a nice opinion piece, but not a lot more than that.
While the CPSO continuity of care policy seems reasonable on the surface (but it’s not on deeper dive), it is simply an end-around to impose accountability and work on physicians without any pay. Regulation is not the way to improve quality of care in any working environment. That is a doomed to fail strategy. Taking some time to understand WHY continuity of care is fragmented and addressing those systemic issues would be a far more effective strategy.
As for the anecdote, there is so much missing information, that it is impossible to know if it was a preventable patient safety incident.
Very good article. Just wondering who’s educating, informing, supporting, mentoring, coaching the doctors on these expectations?
An excellent article. While we need pillory the ER physician, we should not praise him or her as “well-meaning”: based on a high-stress, one-off experience, he/she prescribed a medication for high blood pressure and told the patient to keep on taking it. White-coat hypertension is a well-known phenomenon and physicians aren’t to blame for that: it’s just human nature. But the ER physician did not take that into account, and did not consider the experience the patient was actually having. We all know that blood pressure can fluctuate significantly, especially in a stressful medical setting. We all know that blood pressure medication is dangerous because people’s pressure fluctuates. Prescribing such a medication from a one-off, very stressful experience completely is myopic at best. This was a medical error by the ER physician that fortunately did not have any long-term impact, but it could easily have done so (if she had fallen and broken a major bone or suffered a head injury, she would have likely died quickly thanks to the ER physician). Has the ER physician been informed of this mistake?
Hi Adam,
It may not have been completely clear in the piece, but it was actually an attending physician in hospital after the patient was admitted, not the ER physician. I did provide feedback to him but nothing much came of it. Unfortunately this has been the trend in several such instances in my experience.
Thanks for that clarification that the issue was with the attending physician, not the ER physician. Sadly that makes it even more frightening!
Dr . Weiss ,
Please help i am a patient of yours. I saw you out of a clinic at parklawn and queensway some time back.
I am looking to see you once again I am in need of your expertise.
I left a msg at queens family health in Kingston with my name and number.
My name is David. Please help me. I am willing to Drive to Kingston just to see you.
I apologize if this is out of line ising this forum to reach you Dr, but I am desperately trying to reach you. I have been referred to other Dr’s but havent meet any yet that I feel comfortable with or trust.
You are by far one of the best Dr’s I have ever meet or seen.