Reviewing Patient Access to After Hours Care

College of Physicians and Surgeons of Alberta Messenger, Standards, Trevor's Take On 6 Comments

In the next few weeks the College will be seeking feedback on some of our Standards of Practice, one of which is the After Hours Access Standard.

The College has espoused the principles behind this standard for a couple of decades, initially as a College policy and then (under the HPA) as a Standard of Practice.

We know by experience that some practices adhere to the standard and some don’t. I suspect most physicians have tried calling a colleague’s office after regular working hours only to get the generic voice mail that says “if this is a medical emergency go to the nearest Emergency Department” and, by the way, “this phone does not accept messages”. Not only is this not very helpful for us, it’s not good patient care and not consistent, I believe, with our professional obligation to our patients.

The challenges that non-adherence to this standard raise came out poignantly in the Health Quality Council of Alberta’s report on Continuity of Care late in 2013, the tragic story of Greg Price. I continue to hear from our members, from medical leaders, and from laboratory and diagnostic imaging physicians that some of our members are difficult or impossible to reach after hours. This is not good for patient care.

I have to admit that the CPSA has been complicit in this behavior. While we don’t know the extent of the problem (we’ve never systematically checked up on physicians to learn how well they adhere to the standard), we know there is a problem, and we haven’t addressed it properly. By not taking on the problem we’ve essentially said it’s OK not to provide access to your patients after normal working hours. We’ve allowed the behavior to continue, and that is not a good message to the public and to the many physicians who take this responsibility seriously. They may ask “why bother providing continuity of care and after-hours access?” as the College doesn’t seem to care whether they do so or not. Well, that has to change. We’ve had intensive discussions internally about this topic and agree we need to take a measured and rational approach.

The first step will be to survey practices to quantify the magnitude of the problem. The consultation on the standard will inform Council and staff as to possible changes.

When the revised standard is approved we will notify the profession and indicate as clearly as possible what is expected of our members. We’ll help those practices that are experiencing difficulty meeting the new standard’s requirements but we won’t tolerate ignorance of the standard or willful non-compliance.

This standard, like all of them, is about good medical practice. That should be everyone’s goal, and doing so is not voluntary.

So you can expect that we will, in the next few weeks, call many physician offices after hours to learn:

Do you provide an after-hours emergency contact number for yourself?

Do you identify another physician who is covering your practice and provide a phone number to call?

Do you direct your patients to go to the nearest Emergency Department or walk-in clinic, or do you direct them to call Health Link?

Please provide your feedback on the current standard and please also use this as an opportunity to consider how well your practice meets the current standard.

Medicine is about service; making sure that somebody (or some mechanism) is in place to ensure care and follow-up after hours is part of our commitment to our patients and the public.

The College responded to all of the recommendations from the HQCA report on Continuity of Care via a letter to the Minister of Health, copied to interested parties. One of the recommendations was specific to the role of radiologists in expediting the care of patients with “time-sensitive conditions”, as follows:

Recommendation #3: The Alberta Society of Radiologists (ASR) work with CPSA and AHS to develop policies and procedures to support radiologists expediting the care of patients with “time-sensitive” health conditions to directly order the next logical DI test and/or directly refer the patient to a clinical service when that expertise is needed.

In our letter to Minister Horne we wrote:

The College has concerns about this recommendation, especially the part about radiologists initiating the next referral for care (as differentiated from initiating the next diagnostic imaging step) in the absence of a discussion with the primary provider. In short, the CPSA does not condone radiologists proceeding to order or initiate further treatment for a patient without consulting with the physician who ordered the diagnostic imaging consultation.

Council questioned whether radiologists are always sufficiently aware of a patient’s clinical circumstances to proceed without consultation with the next appropriate diagnostic test, recognizing that there are some situations (e.g., a woman with an abnormal mammogram for whom the next test should be an US) which are obviously in the patient’s best interest (low cost; low risk) and should be done. We recognize that our position places an onus on the radiologist to consult with the ordering physician that can only be realized when there is ready and easy access to the ordering physician. The CPSA will continue its discussions with the ASR, AHS and others towards the goal of a provider registry to address that solution to the problem.

Recently I wrote to the Alberta Society of Radiologists (link here) clarifying the College’s position on this recommendation and addressing the concern that radiologists might be seen as in conflict of interest if they expedite the next appropriate step, especially if that is another diagnostic imaging procedure.

The reason to share this letter with the whole profession is that there are implications and reminders for all physicians who refer their patients for diagnostic imaging:

Make sure you’re ordering the correct (best test) for good clinical reasons

Recognize your diagnostic imaging colleague as a consultant and use his/her expertise to help determine what the “best” test might be

Be available to speak with your DI consultant to help clarify the patient’s underlying personal and clinical circumstances and the agreed goals of care, and to discuss appropriate next steps – whether further diagnostics or referral for a therapeutic intervention – depending on the patient’s situation, needs and wishes

To reiterate what I wrote in the letter, no guidance document can cover all possible situations, and physicians will always have to use their clinical judgment in the best interests of their patients. Be assured that the College will look favorably on efforts made by our members that are clearly in the best interest of the patient should those efforts be questioned.

As always, I welcome your feedback below or by email.

Trevor Theman

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I would tend to agree with the sentiment in the comments posted below. I am in a group practice with after hours call access 24/7 as required by the CPSA. Also, we have same day access, most times with the patient’s own physician. We do not offer evening or weekend hours. From my experience the calls we receive are few and far between so the actual burden of “call” is not that onerous – certainly I don’t think that one would close his or her practice because of it. That being said, there is not a single time I can… Read more »

Miloslav Bozdech

I find that practicing medicine is becoming increasingly more difficult as time goes by. It is challenging enough trying to keep up with advances in medicine with endless conferences and journal readings, not to mention high standards of professionalism expected in dealing with difficult patients and sometimes their unrealistic expectations, challenges with hospital administration and health care cutbacks limiting resources, as well as a “priesthood” standard of benevolence and behavior expectations. Since I started practicing medicine I had seen CPSA Standards of care mushrooming to the point that it is becoming a major source of stress trying to meet them.… Read more »

Dr. Trevor Theman, CPSA Registrar

I appreciate the feedback and hope that Iris, Brad, and Meghan all respond to the formal consultation on this standard coming in the New Year. The College’s goal is not to place an unreasonable burden on physicians but to remind members of their professional obligations. One of my goals in writing this piece was to encourage physicians to consider their options if they are not currently providing after hours access – to join a call group; to explore a partnership with a PCN; to see what options Health Link may be able to offer. If providing afterhours access is good… Read more »


What this unattainable standard has me thinking of doing is:
a) turning my lovely family clinic where I know patients well, have same day access, and have happy patients, to a walk in clinic where I pack people through, am unhappy with unhappy patients, so I don’t have he obligation as a continuity family physician to provide after hours information or
b) close my family practice which I love and excel at and become a ‘niche’ physician where I don’t have this obligation.

Iris Kumpula

Calling my office after hours will not reflect my coverage after hours. I discuss with my patients individually the options after hours. They could call me at home–my phone number is listed in the phone book.

Brad Martin

I have difficulty agreeing with all of aspects of the current College Standard on After Hours Access. I am a general practitioner, providing care for patients in my office, the hospital, and a variety of long-term care facilities. I do daily rounds at the hospital, and see patients daily at the office on weekdays. With very few exceptions, I am able to see patients with urgent problems on the day that they phone. I carry a pager seven-days-a-week, and respond to urgent calls from the hospital, emergency department, nursing home, homecare, pharmacy, or laboratory. When I am unavailable, I either… Read more »