Asking family physicians how we can help them provide care

We've been working on improving patient care and access for over 5 years.  While we continue to improve processes in our practice, it's been frustrating to see that, after our initial success in improving access, patients have been waiting longer over the last 2 years.  This is partly because of reduced manpower in our group (retirements and semi-retirements) and a shift in focus of urologists' time (provincial emphasis on reducing surgical wait times takes urologists away from office consultations and puts them in the operating room).

Wait times have crept up enough that patients and referring physicians are feeling a strain.  We recently received several calls from family physicians commenting on our wait time and the problems it's causing.  Not only do patients have to put up with the anxiety and suffering from their medical condition, but family physicians have to spend more time reassessing patients and then sending "re-referral" letters to us.  Sometimes these letters are indicating a change in the patient's condition and asking for a more urgent appointment.  Sometimes these letters are just checking that our office has actually received the initial referral.  Either way, it's more work for the GP, the urologist (who has to reveiw the second letter) and our respective staffs.

Last week, I visited one of Saskatoon's large family physician group practices.  I attended their regular practice management meetings to acknowledge the difficulty they were having in getting access to urology services and to ask for their advice.  They had some useful suggestions:

While they would prefer to have rapid access for their patients, if there is going to be a wait, they would like to be able to give their patients an accurate idea of how long the wait would be.  They felt that this would reduce anxiety and the number of repeat phone calls from patients wondering when their appointment would be.  One doctor commented that, when our urology clinic had initally improved wait times, family physicians had become used to the rapid access and were still telling patients that "it shouldn't be too long to get in".  Unfortunately, this isn't consistent with our current access, so patients become concerned when they don't get a prompt appointment.

The family physicians were interested in a more collaborative approach to the consultation process.  They asked if we could provide guidelines to help them carry out appropriate investigations prior to their patient seeing the urologist.  I mentioned our hematuria evaluation guidelines (requesting that the GP arrange an ultrasound and certain lab testing, so that we can arrange a "one-stop" consultation for the patient to undergo cystoscopy/bladder examination) and they agreed that more of the same would be useful.  They suggested a urology referral template that would list common conditions and symptoms along with suggested pre-consultation testing and management.  They could load the template onto their EMR for easy access.

One of the senior group members made a frank observation.  He said that, over the years, he's come to rely on our practice to manage his patients' urologic conditions, so much so that he may have become a little "lazy" in managing some of the conditions himself.  He wondered if he could have a "refresher" about common urologic conditions, such as erectile dysfunction and enlarged prostate.   Several of the clinic members agreed that they would like to have guidelines on how to manage these common problems in primary care.  

They also made an interesting observation about the utility of clinical guidelines.  Many guidelines and protocols are available from various sources, including family physician and specialty organizations at both the local and national levels.  The GPs indicated that the multitude of available guidelines becomes confusing for them and their patients.  They were particularly conscious of the fact that if they chose to follow a legitimate national guideline in managing say, bladder infections, and later refer their patient to the local urologist who follows a different guideline, their patient may be distressed and question the GP's aptitude.  For this reason, they preferred that any guidelines bear the "stamp of approval" of local specialists so as to take into consideration local practices and resources.  This doesn't mean that we would have to generate recommendations independent of national standards, but rather that we would review available practice guidelines, and adjust appropriately for local practice before disseminating them.

They also suggested that a variety of continuing professional development tools would be helpful.  In addition to having specialists make presentations at local family practice conferences, opportunistic instruction ("teachable moment") could also be used.  For example, if our urology clinic received a referral regarding a patient with a common condition that can be managed by the primary care practitioner (recurrent bladder infection, for example), rather than making the patient wait to hear the treatment advice from the urologist, we would fax back to the referring practitioner a treatment algorithm, along with an educational module and patient information. 

None of these ideas is earth-shattering, but they demonstrate family physicians' genuine appetite to break out of the current consultation model in which we are stuck, and is not serving our patients well. 

Leaders' work: Removing barriers to success

Don't it always seem to go 

That you don't know what you've got 

'Til its gone

Big Yellow Taxi

Joni Mitchell

This summer, I rediscovered the joy  of cycling.

Last weekend, I went for a long ride with my neighbor, an experienced cyclist. As we were returning home, it began to cloud over and the wind picked up.

"Why don't you try riding about 8 inches behind me," Bruce suggested.

As I experienced drafting for the first time, I immediately found that riding was easier. Because Bruce was blocking the wind for me, I went faster using the same energy.  I realized how much extra effort it had been to fight the head wind.

It was a much more enjoyable ride after that.

This week, I rediscovered the joy of using technology in my work.

Our urology clinic has used electronic medical records (EMR) for many years. Among the many benefits, having remote access to our records is one of the most useful. This is particularly helpful for specialists who split their time between various physical sites such as an office and  the hospital. 

Prior to converting to using an EMR, we would transcribe notes from the paper chart in our office so that we could refer to them the next day at the hospital. (We had a policy prohibiting removal of paper charts from the office, both to maintain chart security and also to give our office staff access to the charts for record keeping and billing purposes.) Not only was this time-consuming, but we had no access to the original chart once we left the office.

Now that we have remote access to our EMR, we can check patient information, lab results and staff communication from any site. We even have access using our smart phones.   This has become such an integral part of our practice that it's hard to imagine what work was like before the EMR. That is, until the technology fails.

Over the last few months, remote access to our EMR has been painfully slow.  At a typical cystoscopy clinic at the hospital, I would see up to 15 patients during the course of a morning, each scheduled in a 15-minute slot.  That 15 minutes includes time for preparing the examination room, greeting the patient, discussing their problem and the cystoscopy procedure, performing the cystoscopy, discussing the results and treatment, dictating a consultation letter to the referring physician, then reviewing the next patient's records.  

My laptop connects to our office via the hospital's wireless network to the internet and then to our office server.  When something is awry in that connection, loading each patient's record can take several minutes.  No amount of hammering on the keyboard changes this.  Many times, the nurse will already have brought the next patient to the cystoscopy room, at which time we all wait for the EMR to work its laborious magic.  At one point, I reverted back to old-fashioned note-making the night before a cystoscopy clinic.  (Blasphemy!)

During the summer, we overhauled our office's computer system with a faster server and upgraded laptops.  This seemed to make a difference initially, but then the problem recurred.  Two weeks ago, in a last ditch effort, we replaced our modem.  Hallelujah!  We now have remote EMR access at almost the same speed as when we're plugged directly into our office network.  Now, I can review my next patient's chart and still have time to review incoming labwork, reports and consultation requests - all while the nurse prepares the cystoscopy room and brings in the next patient.  

Once again, it is a pleasure to let the EMR make my work easier.

On our bike ride, Bruce recognized that, in order to reach our goal (get home before it started raining), we needed to move faster.  He could have encouraged me to work harder and pedal faster, but I was already tired and wouldn't have been able to maintain additional effort.  Also, I would have felt badly for letting him down.  Instead, he found a way to remove the barrier that was preventing me from achieving our mutual goal.

That's great leadership!