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