Though efficiency in healthcare has improved as a result of communication through electronic health records (EHRs) and hospital mergers that have increased the size of healthcare systems, professional relationships between physicians have suffered, according to a recent editorial from a Northwestern Medicine physician.
In a recent article published in The New England Journal of Medicine, Gregory Brisson, MD, ’94 GME, clinical assistant professor of Medicine in the Division of General Internal Medicine and Geriatrics, discussed how current barriers to interaction between physicians have negatively affected the patient referral process.
“In a fragmented health system, electronic records provide continuity. There is big difference, however, between reading the notes of a consultant, which are often full of pages of imported data that make it hard to find the essential information, and having a collaborative relationship with that consultant,” Brisson said.
Brisson argued that peer evaluations could be a potential solution, helping to strengthen connections and support among physicians that may ultimately improve workflow and patient care.
Read a Q&A with Brisson below.
How has modern medicine affected the referral process for clinicians and patients?
Recent practice trends, such as hospitalist programs and widespread adoption of EHRs, have improved efficiency, but it comes at a cost. Doctors have traded collegiality for clinical productivity. These changes have made the referral process easier in some ways.
For example, I typically refer patients to a department instead of an individual consultant, and the department administrators decide which consultant the patient will see—that’s actually less work for me. But is this arrangement in the best interest of our patients? I’m not sure. Patients often ask me to refer them to a specific doctor, which is tough to do when you don’t know your colleagues. Also, patients think their doctors all know each other and talk about their treatment plan, but that’s not the case.
What motivated you to discuss this topic?
Every day, I collaborate with colleagues I have never met — we communicate through the EHR. This tool is terrific for the transfer of data, but it lacks nuance. This unfamiliarity makes it challenging to select a consultant for my patients based on the interests of the specialist or the particular needs of the patient.
I am fortunate to work at an institution where quality is uniformly high, so consults typically work out fine. Still, I prefer to know my colleagues—having a professional relationship promotes collaboration and strengthens trust. Also, having a strong connection to colleagues makes the practice of medicine more enjoyable. That human element has eroded in modern medicine.
How are patients generally responding to this shift in the referral process? Are patients losing trust in their physicians?
Some have lost trust, of course. But for the most part it seems that patients have become accustomed to having fragmented relationships with their physicians. Many of them now go to urgent care clinics rather than their primary care physician for acute problems. When patients change jobs or their insurance plans change, they often have to find new doctors in a new system. Fragmentation is an unfortunate consequence of our current system. The medical system values efficiency and productivity over continuity. While the impact on quality is unclear, patients and physicians have had to adapt.
What can peer evaluations offer to the referral process and to relationships between clinicians?
Peer evaluation could enable physicians to better understand the clinical interests and personal styles of our colleagues so that we could tailor referrals for our patients. Patients already expect that we do that for them. In a small way, peer evaluation might replicate how physicians used to know each other when we worked in a smaller system. It could actually improve on the old system by providing a large number of data points on each physician.
Doctors are, rightly, wary of evaluations. Medicine is still trying to figure out how to use them in patient care. But if done in a professional way and the results are available only to physicians within the system, I think it could be successful.
I should add that peer evaluation would not increase direct interactions between physicians. As health systems grow, it seems unlikely that we will ever return to system in which everyone knows each other. Peer evaluation is merely one approach to addressing the issue of fragmentation in healthcare.
Where is the patient referral process is headed?
There are opportunities to improve the referral process. If technology is part of the problem, it is also part of the solution. Doctors need to be part of the discussion and must think more broadly—we should not allow the business of medicine to define the practice and culture of medicine. When I wrote the essay, my primary goal was to promote discussion of these concerns and invite innovation. Once we understand the problem and define our goals for improving the system, I am optimistic the profession will find solutions to make the practice of medicine better for patients and physicians.
