Friday, September 5, 2008

Isn't That Special?

In "Bang for your Buck," I reported our urologists' recall rates. The variation among urologists was striking. Some rarely recall anyone, while others recall nearly a quarter of their patients. Here are the rates (thanks, Amanda) for May to July:

Two of the docs have zero monthly recall stats because they were away for those months. But another doc, who was working during this period, also had no recalls. I asked both of the low-recall docs why they are so different from the rest of the group. One didn't know why there was such a discrepancy, but commented that maybe he wasn't recalling often enough!

In the previous post, I made the same observation. I meant it slightly tongue-in-cheek, but there is a kernel of truth in that comment. We want to reduce unnecessary recalls (internal demand), but not at the expense of compromising patient care.

So, what is the magic number of recalls to balance optimum care with acceptable access? I don't think a single number could apply to our entire group. Most of us have similar practice profiles, but there are some differences that account in part for the recall variation we've noted. However, speaking for myself (a sneaky way of saying I think everyone does the same thing…), my recall practices are based on habits accumulated over the past 20 years. There are very few evidence-based guidelines for following patients with chronic diseases, so physicians are left to make up their own protocols. Kudos to organizations like the Canadian Urological Association that are developing standardized follow-up protocols for conditions like kidney cancer and hematuria.

In our group, we rarely compare notes about our office-based practices. We regularly share war stories about difficult operations or complicated management problems. As with many professions, it's the way we learn from each other's experiences. But, you don't hear many yarns spun in the surgeons' lounge about best practices for long-term follow-up of kidney stones. There aren't a lot of heated debates about how often to recall men with enlarged prostates. Consequently, most of us aren't aware of each other's recall practices.

So, if we're overdoing patient recall, how will we make changes? Back to the other low-recall urologist: When I talked to him about his recall practices, he said that his philosophy is to return all care back to the referring physician or nurse practitioner, unless the follow-up care cannot reasonably be completed by that primary care practitioner (PCP). He leaves specific recommendations for the follow-up, and details the situations that he wants to be notified about so he can reassess the patient. Finally, he lets the patient decide where they want to have their follow-up carried out. As many Saskatchewan patients have to travel significant distances to visit us, he finds that people are usually very satisfied to be followed by their PCP.

He's got a lot of ideas going there. I like the notion of patient choice in follow-up. If we want to promote follow-up by PCPs, we have to "market" the idea to patients: Explain the follow-up we recommend; provide patients with written surveillance plans on which they can record test results; list test results or symptoms that warrant review by the specialist; and, improve access so that patients are confident they can see us promptly, when necessary. Our patient advisor, Stephen's take on follow-up is this: I don't need to see you regularly, but when I do need to see you, I want to see you right away.

The main issue my partner raises is: What care can only be provided by specialists? What stuff can only my super-mega-specialist brain (no, really, you should see it) figure out? When will only my incredibly delicate, yet immensely dexterous, hands suffice? This is the essence of what it means to be a specialist.

Consider specialist skills as either cognitive or technical. You certainly want a certified specialist to use her technical expertise to remove your kidney. But, do you need the specialist's cognitive skills to interpret the kidney blood tests after the surgery? Couldn't the specialist dump her brain onto paper in the form of an algorithm? The algorithm could list the type and frequency of testing along with triggers for further specialist review. If the algorithm were clear enough, the PCP could carry it out. Or the patient could do it!

Some conditions are so complicated or uncommon that developing an algorithm would be difficult or impractical. We'd leave those conditions to the specialist. But the bread-and-butter problems could be returned to the PCP's care. So, what's a urologist's bread-and-butter?

I reviewed all my office visits from April 21 to June 27 and recorded the frequency of recall for certain diagnoses.

I learned that, in my practice, the 3 biggest indications for recall are: prostate cancer, stones, and renal cancer. That's my bread-and-butter, and that's where I should concentrate efforts to outsource follow-up.

I also learned that a review like this is very labor-intensive. It took me about 90 minutes to complete this. It would be nice to have an electronic medical record (EMR) that would automate this type of analysis. Our office EMR doesn't have that capability, but just the fact that all charts are available for review in our EMR made the process many times faster than it would be using paper charts. Also, my habit is to document all intended recalls in my consultation letter, so it's easy to find the information. If I tried to do a similar review for one of my partners who doesn't include these details in his letter… forget it!

If I don't do it, it won't get done! A couple of my partners have raised this concern when we've discussed how to reduce our recall rates. They say this with the welfare of their patients in mind. They sincerely feel that no one else can be trusted to complete needed follow-up. There's probably some truth to this, in a limited number of cases - perhaps a patient who is mentally handicapped, or someone who doesn't have a PCP. But, in most cases, I suspect that patients would be quite vigilant in their own surveillance.

Our challenge is to identify which patients truly need the specialist's hands or brain. And, when we're not essential, we need to put the follow-up algorithm into the hands of our competent, motivated patients, and their PCP.

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