Continuity of Care
On May 22 and 23, 68 board members and senior officials from three professions and five organizations joined together to consider two broad questions:
Question 1: What are the key issues facing the professions with respect to continuity of care? How do changes in our healthcare systems and the roles of the professions affect patient care and how can the professions work together to improve continuity of care and overall care delivery?
Question 2: What is our preferred vision of healthcare delivery that improves the continuity of care for patients and contributes to personal and professional satisfaction for our various members?
The impetus for nursing, pharmacy and medicine (and our respective associations and colleges) to get together began some years ago, leading initially to the Tri-professional Conferences on Interprofessional Collaboration. The HQCA report on Continuity of Care gave us a common platform on which to focus our discussions. All health professionals recognize the challenges in ensuring continuity of care, especially during hand-offs and transitions in care, made sometimes even trickier when the hand-off is to a healthcare worker from another profession.
Issues of communication and silos and teams – or the lack thereof – were identified by all the participants. We all want to do better in the interests of patient care. We all recognize that at times we are influenced by external factors to practise in ways that do not enhance the patient experience – changes in scopes of practice and changes in funding, to name just two. While this group wasn’t able to get to the details of its preferred future, it did come up with a list of significant requests or intentions of which this is a sample:
- We need to understand each other’s work issues, including standards and scopes of practice.
- How can we effectively speak with one voice? Can we learn to disagree in private and yet present one voice in public? Can we agree (on some things) to jointly lobby government?
- How to effectively focus on and engage patients?
- How do we challenge our members to change what they can change, in the interests of better continuity of care, and not wait for system change? Can we be grass root level revolutionaries?
- How do we as three professions work effectively with Alberta Health for system change?
- How do we increase trust between all three professions, at the board level and at the front line?
- Can we develop a common vision for what the health system should look like in the future?
We have experience working together, enhanced by the trust and respect gained during this forum. The CEOs of our five organizations – Mary-Anne Robinson (College and Association of Registered Nurses of Alberta), Margaret Wing (Pharmacists Association of Alberta), Greg Eberhart (Alberta College of Pharmacists), Mike Gormley (Alberta Medical Association) and me – have been tasked with identifying next steps and looking for opportunities for cooperation in the interests of better patient care. We’re certainly going to try. We’ve got momentum; we have to maintain it. No one is happy with the status quo.
If our three professions can’t identify and promote a better future for health care, who can?
Moral or Religious Beliefs Affecting Medical Care
This past week there was a story in the Calgary Herald that caught a lot of attention – a physician who put up a sign in the clinic where she was working indicating the physician on duty that day would not prescribe the birth control pill.
The day after the story broke, over 250 responses had been posted on the Herald website, most critical of the physician.
The College has a standard of practice that addresses moral or religious beliefs that affect the delivery of medical care:
- A physician must communicate clearly and promptly about any treatments or procedures the physician chooses not to provide because of his or her moral or religious beliefs.
- A physician must not withhold information about the existence of a procedure or treatment because providing that procedure or giving advice about it conflicts with their moral or religious beliefs.
- A physician must not promote their own moral or religious beliefs when interacting with patients.
- When moral or religious beliefs prevent a physician from providing or offering access to information about a legally available medical or surgical treatment or service, that physician must ensure that the patient who seeks such advice or medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options.
The first point I wish to make is that patients shouldn’t be denied access to a medically necessary service. Numbers 2 and 4 (especially #4) of the standard emphasize that point. The physician in this case responded by altering her sign, giving prospective patients specific information as to where (and from whom) they could receive information about birth control including, if appropriate, a prescription for oral contraceptive pills.
While there are many elements to this story, I want to focus on the assertion of some of the respondents that patients have a right to the medication they believe they need, in this case the oral contraceptive pill (OCP).
I believe patients have a right to good medical care, guided by sound medical ethics. Patients have the right to accept or refuse treatment (patient autonomy) while physicians have the duty to act in the patient’s best interests (beneficence).
What do I mean by good medical care? The patient who presents with a clinical problem has the right to expect the physician will take a focused history and perform a physical examination relevant to the patient’s problem. Depending on the clinical issue, other testing or steps (such as investigations, a consultation or a procedure) may prove necessary. A diagnosis is made. The patient has the right to learn about the natural history of the condition, the treatment options, and the potential risks and benefits of each. A form of treatment – often a prescription – is offered, and the patient exercises his/her autonomy and chooses whether or not to accept it.
The physician’s job is not to issue a prescription “on demand” for any condition or presentation but to provide information to the patient and to help the patient make a decision about treatment that is, in the physician’s judgment, in the patient’s best interests.
Sometimes the physician and the patient will disagree. Sometimes a patient will refuse the physician’s recommendation and sometimes the patient will request therapy that the physician believes is not indicated or is not in the patient’s best interests.
I’m certain every physician has faced that situation. When I was in surgical practice I’d occasionally see a patient with gallstones whose symptoms were, in my judgment, not in keeping with gallbladder disease. I would give the patient advice about the natural history of gallstones and the pros and cons of removing the gallbladder. In the situation I’ve described I’d tell the patient that I was not willing to subject him or her to an operation that carried all the risks associated with the procedure but offered, in my best judgment, no benefit. While some patients were quite insistent that I remove their gallbladders, if I was convinced that surgery would not alleviate the patient’s symptoms, I’d refuse to operate. I’d sometimes say that accessing medical care was not like buying an article of clothing. If an individual wants to buy a shirt that is too large, that’s his choice. But if the individual wants to undergo a procedure – or be issued a prescription – that is not going to help and will only subject him/her to potential harm, then that is not consistent with the ethic of acting in the patient’s best interests.
I recognize there are a number of differences between what I’ve described and the situation that caught the public’s attention. My point is that patients deserve much better than treatment on demand. Not only is treatment on demand not good medical care, it removes the necessary dialogue and understanding – and consent discussion – between the patient and the physician that is essential to finding the solution (treatment) that best meets the needs of the patient. Patients deserve better; so do doctors.
Here is a link to Council’s response to the HQCA Continuity of Care recommendations. I want to emphasize Council’s position that continuing competence will include knowledge of and adherence to the CPSA Standards of Practice. While the mechanism to ensure that members have appropriately adopted the standards into their practices has yet to be determined, I fully expect some form of monitoring or inspection to be part of that process.
Council adopted a couple of other important positions at its June meeting. One was to seek more integration of our competence programs, like PAR, IPAC and CPD. In future, physicians should expect to receive more comprehensive feedback at defined intervals, rather than a PAR review every 5 years followed by an IPAC inspection at some other interval.
Finally, Council took the position that every patient in Alberta should have an integrated electronic record that is accessible to all healthcare workers involved in the patient’s care, and to the patient as well. While Council has not determined that every physician in Alberta must have an electronic medical record (EMR) as a requirement for practice, I think it’s only a matter of time before that position is taken. To practise without access to Netcare and the Pharmaceutical Information Network (PIN) – which are only two advantages of electronic connectivity – is becoming less and less acceptable.
Finally, it is summer in Alberta. While not all our days in July and August are long and warm, there are many that are indeed glorious and worthy of celebration. Enjoy the summer!
If you have any comments or questions, leave them below or email me at firstname.lastname@example.org
Trevor Theman, Registar