Saturday, September 15, 2012

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. 


  1. Hi Kishore,

    Wondering if any of these family physicians work with nurse continence advisors?

  2. Kishore -- we've met before (at the SAHO Quality Summitt & SRMA mtgs) but I always loved your style... just stumbled across your blog and of COURSE i love it! (tho i know very little about urology, a lot of what you say in this article is very relevant in my transfusion medicine world!) See you around.
    -- Karen --

  3. Kishe
    We created a "Shared Care in Urology" program for family physicians here in the Maritimes. We took our top 10 referral diagnosis and offer an annual CME held on a Saturday am from 8-12. 30 Minutes of presentation and 10 minutes of discussion on each of the diagnosis. Have a flow chart approach which tells them when to refer. Great success. Generally do 5 topics one year and 5 the next. Great attendance as no one has to cancel an office and they get to meet their spouse for lunch.

    Dave Bell

    1. Hi Dave,

      Great to hear from you, and thanks for this note! This sounds like a fantastic program and something that we could use here in SK. And by that I mean, can we steal it from you? Will connect with you outside Blogger.

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