Reinforcing Outpatient Care

Today a preceptor shared with me an innovation at Toronto Western Hospital that I was previously completely unaware of.  One of the internists spends a half day per week on “consult” service in the family health team aiding primary care physicians who have questions about puzzling or complex patients.  This doctor is modifying his availability to these primary care physicians in order to work around the constraints of our current medical system which puts much pressure on primary care physicians to manage complexity in an out-patient setting.

As anybody working in healthcare knows, hospital admissions are shorter now (sometimes drastically so) than when my preceptors were medical students and residents.  A logical extension of this is that patients are leaving the hospital in a more fragile state and needing close and effective follow-up with their regular primary care physician to maintain and improve their health status post-discharge.  Furthermore patients are also living longer with more medical conditions that need to be managed both in and out of hospital.  Consequently complex patients are often being managed in the out-patient setting, often by family physicians that have little support from specialists, except through formal consultation.  You can’t just meander down to the doctor’s lounge or to the specialist’s office to ask a question when you are out in the community. 

You can learn lots of medicine on any inpatient rotation, but one of the more interesting things I observed throughout my clerkship is how good, available primary care is essential to discharge planning and managing complex patients in an outpatient setting.  It is surprising how much better you can feel about discharging a patient with multiple active issues when you are sure that they have good follow-up and that the care plan enacted during a hospitalization will be able to be followed to completion.  Team-based care works great on an inpatient unit but is much harder to orchestrate and enact in the community.  It can also be difficult to rapidly access the same services that a patient can rapidly access within hospital.  We expect so much from primary care physicians when we discharge our patients and we are giving them very little support in many cases.  

The healthcare system has started to change around us, with a heavier role on outpatient management than on inpatient. I think it behooves us to consider ways that we can change our outpatient management to provide the best outcomes for our patients.  I believe that more integration between general internists and family physicians, such as the initiative at TWH, is one way to reinforce our healthcare system for outpatient complexity in the present and in the future.

-Julia