CSHM Response to CFP Article (April 2017)

Recently there was an editorial opinion in the April 2017 edition of the CFP. Attached is the article for those who have not read it: ​http://www.cfp.ca/content/63/4/264

This article was addressed by the CSHM Board and we felt very strongly that a response was needed by this society, along with many of the board members individually, to advocate on behalf of all hospitalists. Below is the formal CSHM response which was sent to the CFP and we have requested be printed. 

As a key representative of Canadian hospitalists, I felt it important to respond to an opinion recently published in the Canadian Family Physician in April of 2017*. Dr. Roger Ladouceur’s recently penned an editorial article / letter addressing what he felt to be an extremely important issue; that of safe and effective care transitions for hospitalized patients. He references a recent JAMA study* that associates end-of-rotation care transitions and increased mortality rates, Dr. Ladouceur draws upon an instinct that many of us share; MRP care transitions can be hazardous.

However, there were many other issues raised in the letter. Besides the issues of transitions of care, he also raised concerns about the model of care currently in place, residency training programs and the previous and current work of family physicians in community and hospital based environments. 

The editorial lead to a significant response in many circles of hospital medicine. For some, it raised concerns that there was a lack of respect of the work that many of the hospitalists perform here in Canada. For others it was an affirmation of the difficulties faced in the current system. 

It was felt that it is important to put into context the issues raised in the opinion by Dr. Roger Ladouceur so that those who do not work in the hospital system clearly understand the reality of the current system and how many of us who are working there feel.

Firstly it should be noted that the article he referred to is based on works from 10 hospitals in the northeastern United States. It is also based on a very particular organization - the veterans affairs system. This may easily have a strong bias to its applicability to the Canadian system. One could judge independently why this may be so.  

No matter what country, unfortunately, the risk associated with most responsible physician (MRP) transition is not exclusively tied to any model of inpatient care. Rotational models of care assume this risk when patients are transferred on a scheduled basis. Traditional family medicine models of care assume the same risk on weekends and during peak holiday times.

Regardless of the model of inpatient care, we in the medical community are obliged to devise and implement strategies that will mitigate the transition-associated hazards. The Canadian medical protective agency has identified this as one of the most critical and sensitive times in a patient’s care cycle during their hospital stay. Many hospital medicine programs now insist upon templated and typed handover notes as well as a mandatory verbal dialogue between departing and incoming MRPs.

Such initiatives are rapidly becoming standard quality measures in the hospital environment. The Canadian Society of Hospital Medicine and other organizations have strongly endorsed and promoted these efforts in recent years.

Dr. Ladouceur’s reflections touch upon another key challenge that we face. How do we best preserve care continuity when patients transition from hospital to home? Short of asking every community-based family physician to follow her/his patient continuously while in hospital, there are other ways of proceeding.  Social/supportive family medicine visits to hospitalized patients are enormously welcome and effective. In addition, timely and efficient discharge summaries as well as brief telephone conversations between providers should be a part and parcel of our routine care.

But, given the trending increase in volume and complexity of in-patient care, it is significantly more difficult to ‘dabble’ in the practice of hospital medicine. This has lead to a devoted group, primarily Family Physicians who are residency trained and members of the Canadian Society of Family Medicine, to assist and care for those patients who need hospital care - hospitalists. Dedicating their practice to the special focus, Hospitalists are able to provide inpatient care for those who need it because of their increased skills, abilities and knowledge of the system in which they work while still maintaining the overall mentality of patient centered care. It has been confirmed recently that this is an increasing effective, safe and fiscally responsible model for inpatient care. ( reference recent phd thesis from ontario)

There is increasing demands and specialized knowledge / information in primary care and hospital medicine and it is becoming increasingly difficult to know it all. Many have chosen to limit their practice to one area or another. It is important be equally supportive of the two groups who participate in the care of patients in these situations. 

Canadian-based hospital care will remain critically dependent upon family medicine-trained experts; whether primarily hospital-based or predominantly community-focused. Their skills, work and dedication bodes well for all of us as we evolve to deliver optimal quality care for the patients that they serve in whatever locale they are working for them. Although the Canadian system still has it challenges around the time of handover, there is an increased awareness and there is a strong push to optimize communication and minimize risk during this time.  

Serge Soolsma BSc, MSc. MD, CCFP, FCFP

Calgary, Alta

President, Canadian Society of Hospital Medicine

*Ledouceur R, Are attending physician rotations costing hospitalized patients their lives? Canadian Family Physician April 2017, 63(4) 264;

*Denson JL., Jensen A, Saag HS, Wang B, Fang Y, Horwitz Ll, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA 2016;316(21);2204-13.

*White, H.L. (2016). Assessing the Prevalance, Penetration and Performance of Hospital Physicians in Ontario: Implications for the Quality and Efficiency of Inpatient Care (Doctoral Theses). Retrieved from https://tspace.library.utoronto.ca/bitstream/1807/75996/1/White_Heather_L_201603_PhD_thesis.pdf