Thursday, February 17, 2011

Listening to my FP colleagues - Part 2

Last month, I heard from family practitioners (FP) from across Canada about what they thought was lacking in the FP-specialist referral process. Last week, I had another opportunity to learn what’s on the minds of my FP colleagues.

As part of the Sask Surgical Initiative (SkSI), care pathways are being created for conditions like back pain or hip problems. I’m participating in developing a prostate cancer pathway. Our working group has mapped out the current state in the province, that is what path men currently follow when diagnosed and treated for prostate cancer. Now we want to explore changes that could make the journey quicker, smoother and more effective, or as SkSI puts it “Sooner, safer, smarter”.

An important part of the working group’s next step is broad representation of interested parties, and FPs play a central role in the process. They do the initial testing that raises suspicion that a man may have prostate cancer. They make the referral to a specialist. They provide education, support and ongoing care as a man has treatment. They are often responsible for long-term follow-up after the man’s treatment.

We need the perspective of an FP on our working group, so I met with the executive council of Saskatchewan’s section of family practice to ask for their help in recruiting one of their members. While supportive of the prostate cancer pathway, they made a couple of pointed comments.

Make our work simpler. Many well-intentioned groups are developing guidelines, checklists, templates and standardized forms to help manage specific conditions. While each of these efforts makes sense in the context of that condition, when FPs are bombarded by dozens of documents, it’s bewildering. Without consistent design, the learning curve starts anew when completing each form.

Perhaps the end users of these documents (in this case, FPs) should insist that any new forms adhere to a common template. If a template is too restrictive, then a set of design principles such as font size, page layout and completion instructions could be used. As one of the FPs pointed out, “Poorly designed forms may only take me an extra 30 seconds to fill out, but that adds up over the course of a day.”

Ultimately, an electronic medical record would solve these problems by “imposing” a style template and virtually filing all documents in one location.

Compensate us appropriately. There were strong feelings about this one. Because of their central role in patient care, FPs are asked to participate on a multitude of committees, boards, and working groups. This work often happens outside of regular work hours and so interferes with family life. When the meetings occur during regular work hours, fee-for-service FPs are often asked to sacrifice practice income.

One of the FPs pointed out that when committees didn’t pay him for his attendance, they undervalued his time. He had been asked to sit for hours through deliberations that didn’t involve him, just so he could participate in discussion of a single relevant issue. He felt that if he were being reimbursed at the same hourly rate he could earn working in his office, the committee would be more careful to schedule the meetings so he was present only when truly necessary.

Others pointed out that most administrators sitting on health-related committees are salaried employees, and so don’t pay any financial penalty for the time they spend at meetings.

I’ve been relatively insulated from the financial burden imposed by participating in administrative work. The pooled revenue-sharing nature of our urology practice means that our group can support one or more individuals taking on non-clinical work that we see as important for advancing patient care. However, if I were a solo, fee-for-service practitioner, taking a day away from my practice could end up costing over $1000 in lost income, with overhead expenses continuing to mount in my absence.

The executive committee indicated they would support our effort to recruit FP representatives for our prostate cancer pathway initiative if our recruiting message included the offer of a stipend. To be fair, I think that stipend should be offered to all non-salaried participants, including specialists and community representatives.

That puts the ball squarely back into the government/SkSI’s court. What other consultants provide their expertise for free?

P.S. I received a stipend for attending the CMA meeting last month...


  1. Hi Kishore, thanks for continuing to highlight important issues that prevent us back from improving our health system. It's the kind of open and honest conversations we all need to be having as we continue to work on transforming our health system.

    I've been in a number of meetings recently that have been focused on physician compensation for participating in QI activities. Interestingly, I have also been helping my family, who are located in a rural area, deal with a number of health issues as well.

    With that, I'd like to consider looking at it from a different perspective - who compensates those who receive poorly coordinated care? Who pays for the hotel, gas, food, time away from work, family and other commitments when you drive 3 hours to hear "everything's fine" or "oops! You should have had that test before I saw you - can't do anything to help you at this appointment - can you come back in 3 weeks?". For rural residents, I would suspect the personal costs of poorly coordinated care is far beyond the cost it takes to help revamp a consultation form.

    I believe everyone's time is valuable. Maybe we should consider a different approach - what if a physician had to reimburse the costs their patients incur every time they had poorly coordinated care. Could my family then invoice the system for the costs of travel, lost time with family, restaurants, hotels, etc?

    I wonder, how much compensation should be required for 3 days away from your child due to canceled surgery....

    Food for thought!

  2. Thanks, Anonymous. Very tasty comment!

    Your suggestion sounds similar to some of the pay-for-performance (or don't pay-for-defects) initiatives in the US. I understand that hospitals/doctors don't receive insurance payments if apatient suffers preventable errors (wound infections, venous thrombosis) while receiving care. Apparently, it focusses attention on reducing those defects...

    If we were to implement a system of "pay back for defects", I think we would first need providers to recognize that poorly coordinated care is a defect! Right now, it's accepted as standard operating procedure. And, we have brainwashed the rest of the public into believing that too.

    It's tempting to want to punish (financially or otherwise) someone when we get bad service, but I wonder if there is another approach that would emphasize partnership and involvement in our own care. Could we foment a grassroots movement to make patients more active/responsible in coordinating their own care? How about a checklist to go through before you go to see the specialist? Do I have, for example, my medical history with medications and allergies in writing (on a form downloadable from this new patient movement's website). Have all the necessary tests been sent to the specialist (check with GP's staff)? What tests would usually be requested by this specialist for someone with my problem (again, check the list on the website)? Could they be arranged ahead of time or on the same visit? Why am I travelling 3 hours to see this specialist - is there an alternative to a face-to-face visit (telehealth)? Why isn't that being used? Could my GP solve my problem with a phone call to the specialist?

    I agree that poorly coordinated care wastes time, money and resources. Providers should be taking the lead on improving this care. But, patients and their families don't need to be passive victims here. Come on, grassroots!

  3. I'm keeping out the compensation debate - however, the making things simpler is interesting to me. From a patient's perspective the processes and pathway (and guidelines etc) can be horrifically complicated as well. I often wonder if simplification from the patient view can contribute to simplification from the doc's point of view.

  4. I would just like to thank you for providing me with such thought provoking blogs to read. You are a great inspiration to those of us who are trying to be champions in the healthcare sector. I think we have for far too long focused on the convenience of those working in the sector versus those USING the services. Having had a few experiences with poorly managed healthcare, and having been an advocate for my families health, it is refreshing to see a physician out there, identifying that changes need to happen, as you are right, we have everyone so convinced that there is nothing we can do to change healthcare, that they just accept things the way they are. Thank you for highlighting these things, that a lot of us see, but don't shine the light on!

  5. Sarah, thanks for the comment. Please see the post "Simplicity is its own reward." (March 5, 2011)

  6. Anonymous, thanks for your kind words and encouragement. Please keep commenting - I'm very interested to hear about what is on your mind, and what issues are important to you.