General internists are often the unsung heroes in a hospital setting. When patients suffer medical complications or exacerbations of pre-existing conditions, it is the medical consultants that other specialists rely on to diagnose and manage complex, potentially life-threatening events, often in challenging circumstances.
The College is concerned by the recent emergence of a pattern of practice in a number of hospitals that puts patients at risk—the apparent inclination of some internists and other specialists (in hospitals with subspecialty departments) to attempt to limit their involvement in the care of in-patients to a single consultative visit. Surgeons, family physicians, ER physicians, GP hospitalists, medical staff leaders and even other internists have contacted the College with disappointing accounts of evolving serious medical conditions and internists declining to cover beyond the day they were on call, directing callers (generally a nurse, primary care physician or surgeon) to check the schedule and summon the specialist designated for that day.
Last year the Inquiry Committee was highly critical of an internist for instructing a nurse to call the surgeon after-hours to assess an evolving coronary syndrome in a post-operative patient that the internist had earlier seen in consultation for the same problem.
More recently a worried surgeon wrote:
“I think it inappropriate that I am asked to provide primary care for internal medicine problems. I would ask that my colleagues follow internal medicine problems for which they have been consulted until the problem is resolved, or the patient is discharged. I do not think that I should have to find a new consultant for the same problem daily to secure appropriate follow-up for my patient.”
The College agrees. The surgeon is paraphrasing article 19 of the CMA Code of Ethics:
“Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient; or until the patient has been given reasonable notice that you intend to terminate the relationship.”
The College does not have a professional standard that addresses this issue directly as it is a relatively new problem. Nor does the College have authority to be prescriptive for the unique context of each BC hospital. Some employ GP hospitalists and/or clinical associates who are expected to function much like internists for many conditions. Some are extensively subspecialized, while others depend on a small group of general internists. Some have surgical special care units, while others rely on a general ward, minimally staffed. In some communities, family physicians provide primary in-patient care.
The historical roots of this problem also vary between medical communities. Combinations of inadequate support from other disciplines, perceived lack of respect, unrealistic expectations for teaching and administrative contributions, flaws in the payment system and, occasionally, deficient performance on the part of another member of the team may have strained collegial relationships.
Whatever its origins, fragmented care is suboptimal care. Patients requiring medical consultations will frequently require a series of reassessments and may need to be seen urgently if they deteriorate. If the original internist expects to be temporarily unavailable, s/he must arrange coverage and document it in the patient’s chart. If medical consultants work shifts, a formal system of handover may be required.
This issue won’t be solved by individual physicians or departments. It requires collaboration by internists, surgeons, primary care providers and the medical staff leadership to formulate an approach that is effective in their hospital. At this stage, the role of the College is to flag the issue in the expectation that hospital-based physicians will find a solution.
Physicians are individually accountable to their medical staff organization, the College and the civil courts for their conduct and clinical performance. Consultants who see patients once, then decline to follow-up and/or return when asked may anticipate criticism in the event of a College complaint. The College encourages physicians with questions in this regard to consult the CMPA or call the College. While physicians’ autonomy is respected, it is limited by ethical, professional, and legal obligations to contribute to a system of care that gives priority to the safety and well-being of patients.