If the secret to successful real estate investing is “location, location, location,” the key to maintaining good relationships with referring physicians is “communication, communication, communication.” While this may seem simplistic, the complexities of interpersonal communications can pose challenges even in the most straightforward of physician interchanges.
Recent studies and hospitalists consulted for this report maintain that hospitalists’ communications with referring physicians must be examined, practiced, and fine-tuned continually to ensure satisfaction for doctors—and their patients.
“It’s all about the communication,” says Bruce Becker, MD, chief medical officer at Medical Center Hospital in Odessa, Texas, and a family physician and professor of medicine for more than 20 years. “It’s sometimes not what you say, but how you say it.”
According to John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, Wash., a consultant for hospital medicine groups with Nelson/Flores Associates and a columnist for The Hospitalist (“Practice Management”), it is key for hospitalists to examine and revise oral and written communication processes—especially at critical points during patient handoffs—rather than to assume that good communication will just happen naturally.
Some primary care physicians (PCPs) are more willing than others to refer patients to a hospitalist. Initially, new programs may have to work hard to gain acceptance with referring physicians. Some referring physicians may not be ready to give up hospital visits and may want to maintain collegiality and control. On the other hand, some family physicians are “ready to step away from hospital practice,” says Dr. Becker, citing diminishing reimbursements due to diagnosis-related groups (DRGs) and managed care.
John A. Bolinger, DO, FACP, medical director of the Hospitalist Program at Terre Haute (Ind.) Regional Hospital, believes that one way to promote a hospitalist program to PCPs is to emphasize hospitalists’ levels of training and efficiency.
“I try to make them aware of how [our hospitalist program] can be advantageous to them,” he explains. “Even if they have only one patient in the hospital, by the time they drive there, get the chart, make the rounds, make their notes, and do the required paperwork, it may take them an hour to see one patient. It makes good economic sense for them to stay in their offices, where they can see a minimum of four patients in the same amount of time for equal or better reimbursements.”
When primary care physicians voice resistance to using a hospitalist program, Dr. Bolinger says he tries to impress upon them the fact that hospitalists do not have outside practices, they will “never try to steal patients,” they stay within referral patterns, and they will make sure that PCPs get pertinent records as soon as possible. Dr. Bolinger believes referring physicians’ biggest concern when dealing with hospitalists is that they “don’t want to lose control.” The way to address those fears is to make sure referring physicians are always kept in the communications loop regarding their patients’ progress.
The policy for Dr. Bolinger’s hospitalist program is to make sure all dictated reports are transcribed and faxed immediately to the referring physician’s office. All scheduled follow-up appointments and medication changes are included in discharge summaries. “If need be,” says Dr. Bolinger, “we will even hand deliver information to physicians’ offices, which we have done multiple times.”
The methods Dr. Bolinger describes often result in referring physicians’ satisfaction with hospitalist services, followed by increased referrals. Hospitalists can ensure continued referrals from their PCPs if they remember hospital medicine’s cardinal rules of availability and prompt, thorough reporting, says Dr. Nelson. It can help to view the interface with the hospitalist service from the PCP’s point of view.
For instance, how can physicians quickly reach the hospitalist service? “If you’re a referring doctor and you’ve got a patient in your office whom you think should be admitted today, who do you call? This can actually be a little tricky for most practices,” says Dr. Nelson. “Every practice should give some thought to making that contact as easy for the referring doctors as possible.”
Some important questions to ask: When trying to reach a hospitalist, is it best to call the group’s main number? Will a voicemail message be returned within an hour? Two hours? Is it better to call the hospital operator and have the hospitalist paged? Or do PCPs have access to hospitalists’ cell phone numbers?
Dr. Nelson suggests that hospitalist groups also give thought to standardizing admission and discharge reports, as well as other forms. Often, individual members of a hospitalist group use slightly different formats for reporting to referring physicians. He points out that this can be less user friendly for the reader, who may have a harder time scanning the document quickly to find a particular piece of important information. Other useful suggestions for making reports user friendly: Use similar headings on all reports; avoid dense text; list pending tests in a prominent place in the report document; and consider highlighting or underlining key words.
Preference for In-Person Contact
For a new hospitalist practice, telephone communication between the hospitalist and the primary physician is valuable, and the hospitalist should “pick up the phone liberally,” says Dr. Nelson.
Dr. Becker believes the best way for physicians to communicate is one on one—in person. “Too often,” he says, “we get used to communicating through a third party—usually a unit clerk, a nurse, or a resident. I believe that physician-to-physician communication is the ideal. If the attending physician and the consultant [hospitalist or subspecialist] speak in person, they can explain their thinking to each other, and “within one minute of precious time, figure out which way to go.”
In this way, without wasting time, the physician gives the consultant guidance as to the appropriate track to take and can also listen to the consultant’s suggestions.
“I feel that medicine has perhaps gotten a little bit away from that communication link,” continues Dr. Becker. “When we get further away from that direct communication—whether it is between doctors and consultants, nurses and doctors, or doctors and family members—you take that little bit of risk that there will be a missed step, either on the part of the communicator or on the receiving end as the listener.”
In a study exploring barriers to effective patient handoffs, Solet and colleagues focused on the communication between physicians as a vital link in patient care continuity. The authors concluded that, regardless of the method of managing patient handoffs (e.g., computer-assisted or paper-based), the best way to ensure effective handoffs of hospitalized patients was “precise, unambiguous, face-to-face communication.”1
In a 2001 study by Hruby, Pantilat, and colleagues at UCSF, the authors found that, for the most part, hospitalized patients with PCPs wanted contact with their primary physicians even while in the hospital. Approximately half of the surveyed patients also believed that the PCP, rather than an inpatient physician, should be the first to discuss with them serious diagnoses or disease management choices.2 Preferences such as those expressed in this study may play into referring physicians’ reluctance to make use of hospitalist services, says Dr. Bolinger. They may fear that patients will feel abandoned by the primary physician. Dr. Bolinger’s response to those sentiments: “Initially, some patients [in our hospital] were a little guarded and were not sure what to expect. But after a day or two of having us there, they are generally very, very pleased to have us on board. We are part of their medical team now.”
A Need for Marketing?
Dr. Becker has been actively developing a hospital medicine program at Medical Center Hospital for the past two years and joined SHM as part of that effort. Familiarizing himself with the tenets of hospital medicine, he discovered that, as a family doctor, “unknowingly, I was actually practicing hospital medicine for 20 years!”
As part of the hospital medicine program development process, he has solicited input from local physicians as well as patients. A simple survey to assess interest in a hospitalist program asked potential referring physicians, Would you use a hospitalist? Would you use a hospitalist after waiting a while to see how the process goes? Or, would you not consider using a hospitalist?
In two years, says Dr. Becker, response from the referring physician community has changed from “bah, humbug” to one of readiness for the program.
A mass mailing can serve to introduce a hospital medicine program in a community. Dr. Bolinger’s group used this method and, in his experience, local subspecialists—orthopedists, cardiologists, endocrinologists, pulmonologists—have proved the biggest source of referrals to their program. But PCPs are starting to use the hospitalist service for vacations and call-coverage issues and are beginning to value hospitalists’ services. “Physicians like coming to the hospital, but they’re starting to realize that the hospitalist program is a better system,” says Dr. Bolinger.
Dr. Nelson has been a hospitalist for 18 years. For most of that time he has had no shortage of referred patients. In fact, the bigger problem has been finding enough doctors to join the group and handle the existing referral volume. In that situation, it has not made sense to undertake marketing with the goal of increasing referrals. However, he advises, “It is always worth spending time and energy trying to maintain good relationships with physicians with whom you regularly share patients, and perhaps this could be called ‘marketing.’”
To maintain good relationships with referring physicians, his group conducts a survey on a yearly basis. A survey, he suggests, should be very short, consisting of only a few key questions, such as:
- Do we send reports promptly to your practice?
- Are your patients satisfied with the care they receive from us?
- Do you have any comments or feedback for our group?
Although his group gains information from these surveys, Dr. Nelson notes that the greater value of conducting such surveys may be in building public relations capital. By conducting a survey, hospitalists demonstrate that they care enough to ask for their referring physicians’ input.
Another good marketing tool is a patient education brochure, given to referring physicians, that explains hospitalists and hospitalist care. These brochures can help referring physicians prepare their patients for seeing a hospitalist in the inpatient setting, thus easing the initial reluctance patients sometimes experience when encountering a new physician.
On the cusp of launching his medical center’s hospital medicine program, Dr. Becker sees that good communication between referring physicians and hospitalists will ensure the program’s success. He advises physicians to remember their classes in communication as third-year medical students, when most participate in videotaped patient encounters. It’s always instructive, he says, to see how we come across to others in conversation.
Both verbal and nonverbal cues play a part in good communication. A 2003 study by Griffith and colleagues concluded that better nonverbal communication skills are associated with greater patient satisfaction, and that formal instruction in nonverbal communication can be a good addition to residency training.3
“I find that doctors talk to each other, in general, very easily,” says Dr. Becker. Sometimes [good communication] is just a matter of opening that door and essentially keeping the former attending, the PCP, apprised of what is going on.”
When hospitalists attend to thorough communication and promptly deliver complete discharge summaries, family physicians can report to their patients that they know what happened in the hospital and poll their patients about their experiences in the hospital. In this way, hospitalists and referring physicians can cement their relationship as team members for the patient. The success of any hospitalist program, Dr. Becker believes, lies in “making sure you fulfill the promise of what hospital medicine generates, and that is a continuity of care … , obtaining front-end communication so that patients get the best care throughout their [hospital] stay, and then follow up with discharge summaries to the primary physician’s office.” TH
Gretchen Henkel is a regular contributor to The Hospitalist.
- Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12): 1094-1099.
- Hruby M, Pantilat SZ, Lo B. How do patients view the role of the primary care physician in inpatient care? Am J Med. 2001;21;111(9B):21S-25S.
- Griffith CH III, Wilson JF, Langer S, et al. House staff nonverbal communication skills and standardized patient satisfaction. J Gen Intern Med. 2003 Mar;18(3):170-174.