Monday, May 21, 2012

Pooled referral gains momentum in Saskatchewan

Specialist "pooled referral" implementation is sweeping the province!  Here's a great story in the Prince Albert Herald about PA's orthopedic surgeons offering pooled access as of March, and general surgeons planning to implement it at the end of May.  The Regina Obstetrics and Gynecology department are also offering this option to their patients.

Pooled referral, also known as centralized referral intake (CRI), involves collecting referrals in a central location and then distributing the referrals so that patients have access to the specialist with the shortest wait time.  When our urology group implemented this system several years ago, the reception from referring physicians was very positive.  (Here's the post looking at wait times for pooled referrals.)  They liked the fact that they didn't need to do the "heavy lifting" of figuring out which urologist had the shortest waiting list, or which one of us subspecializes in a certain problem.  

When I have the chance to share our practice's learning and improvements, the idea of pooled referrals has an immediate appeal to both referring and consulting physicians.  However, physicians do have some trepidation about the system.

First, they're concerned about patients (and referring physicians) having the choice of which consultant they will see.  Our group's philosophy has been that patients and referring physicians have the choice of which urologist they see.  We don't require participation in pooled referrals, however, if someone "opts out" of pooled referrals, they may wait longer to see the urologist of their choice.

Continuity of care is also a consideration.  Physicians recognize that time and effort is wasted, and important clinical details may be overlooked, when patients switch between specialists.  A pooled system should try to maintain any previously-established patient-physician relationships (as long as the patient wishes to do so).

Finally, I'm often asked a very thorny question: How can a pooled referral system ensure that patients will have a consistent experience no matter which specialist they see (AKA not all docs are created equal)?  This applies to the interpersonal, as well as technical, skills of the specialist.  This is very difficult to answer as there is often no formal tracking and reporting of individual surgeon's treatment outcomes and complications.  Communication skills, empathy, and affability may only be judged through word of mouth.

This raises an ethical question: If we promote a new referral management system, and that system has the potential to adversely affect the experience and outcome of some patients, what is our responsibility to assess and improve the abilities of the specialists so that patients receive consistent, competent care that is constantly being improved?  

I think that, by its very existence, a pooled referral/CRI system begins to address this concern.  In order to implement this system, specialists must be prepared to communicate and collaborate, often to a degree that they previously didn't do.  This lets them share information about, and expose differences in, individual practices.  In our urology practice, learning about differences in our practice habits made us curious about what could be considered "best practice" and how we could offer more consistent care.  

Pooled referral/CRI has the potential to improve patients' access to specialist care, and make sure that they receive care from the appropriate practitioner.  However, it's not without drawbacks, and we must proceed with eyes wide open.


  1. Kishore, your experience and observations again confirm the importance of doing all we can to anticipate the intended and unintended consequences of process improvements. Normally, solving one problem merely allows you to focus on solving other problems; it is not a panacea. It's worth thinking hard about the problems that will come into sharper relief when we begin to lift the veil on hoary traditions that made little sense.

    I would take issue with one statement - that communication/empathy and related skills are only available by word of mouth. These things can be measured, and in high performing systems they are measured. At Group Health Cooperative in Seattle, for example, physicians whose communications skills are found wanting by patient evaluation go through an improvement process, which in some cases is as intensive as a 3-day retreat with close to one-on-one coaching.

    And here's the rub: at GHC and other closed systems, if you can't be brought up to standard, you go. Here, pretty much the only way a physician would be asked or required to leave the pool would be serial misconduct identified through the complaints and adjudication processes of the College of Physicians and Surgeons.

    The principle behind risk-free pooled referrals is that everyone is competent, and the difference between the best and the worst is not large enough to make a huge difference to the patient experience or patient outcomes. This implies standardization of competencies across a range of indicators. We can't make that claim now because we do not gather systematic information of this nature. So when patients are in a pooled referral pool, it is basically a lottery or random assignment game.

    But let not perfection be the enemy of better. Word of mouth and well-established doctor-to-doctor referral pipelines are no more accurate at matching patients with the skill sets and personal characteristics they need than random, pooled assignment. So at least the pooled referral system makes access more efficient and arguably fair. But it does highlight why it is important to go to the next evolutionary step, which is gathering and reporting evaluative data that would allow both patients and practitioners to assess "goodness of fit."

    Finally, as you've written about before, there are data on these things, only they're not standardized or statistically robust. They're from Rate My Doctor and similar sites. I think these sites are best at rating physicians' communication and empathy qualities, and the convenience of the care experience. Once you get more than 20 or so ratings, I'm inclined to think that you'll get a reasonably reliable picture on these dimensions.

  2. Steven, we don't disagree on the point about measuring communication/empathy. No question that it can be measured, and improved. But, locally, word of mouth is what we're working with.

    I do wonder, however if, as you suggest, doctor-to-doctor referrals are no more accurate than random, pooled assignment. Many family doctors have considerable insight into the skills and personalities of the specialists to whom they refer, and may be selective in which specialists they choose to provide care for the patients who trust them to make that decision.

    Thanks for relating the GHC story. I like the idea that they provide a remediation process for physicians "found wanting".

  3. I wonder if the "thorny" question is only thorny to physicians, and if patients really care that much. I've never asked to see my physician's credentials or inquired if they've won awards.

    As a patient, what is the criteria for good care? The biggest measure I use to decide if a doctor is a good doctor is based on how that person makes me feel. Were they respectful? Did they listen to my concerns? Of course, I want good technical skills as well, but if I feel disrespected in any way, I'm not going to give that person an opportunity to use their technical skills, if I can help it.

    I've had a couple of bad experiences with specialists in the past. When I told my then-family physician about one of those experiences, she sounded surprised and said, "But he's the number one specialist in the province." My response: "Find me #2."

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