Hi Ben.
As you probably know, a form of integrated practice is emerging (primarily in integrated health systems) in which care processes are cooperatively designed by, e.g., generalists, specialists, nurses, and case managers. In these care processes, evidence-based (modifiable) care plans include the typical situations that make referral appropriate or automatic. In such processes, patients are more likely to get care from the most appropriate professional and less likely to be referred simply as way to manage patient flow.
Jim
James M. Walker, MD, FACP
Chief Medical Information Officer
Geisinger Health System
The best way to predict the future is to invent it.
- Alan Kay
>>> "Djulbegovic, Benjamin" <[log in to unmask]> 08/31/09 8:20 AM >>>
No doubt what you described is likely one of the reasons for increasing use of referrals. However, our (educational) organizational structure is such that we are still insisting on individual physicians proficiency (e.g. typically in the US you need at least 30-50 annual CME, take your specialty exam every 7-10 years depending on your specialty etc). So, tremendous effort goes into building your individual knowledge base in order to refer your patient to a number of other consultants?
ben
-----Original Message-----
From: Piersante Sestini [mailto:[log in to unmask]]
Sent: Monday, August 31, 2009 2:41 AM
To: Djulbegovic, Benjamin
Cc: [log in to unmask]
Subject: Re: EBM and increasing requests for the use of consultants...
I am not sure whether the number of referrals did increase in Italy over
the last 10 years, but they certainly did enormously over the last 20 or
30 years.
As you suggests, this has more to do with the way the health industry
works that with the availability of systematic reviews and guidelines.
Medicine is less and less seen as an individual business and more as a
collective, interprofessional teamwork.
The reason is probably the same that lead to the success of EBM: the
enormous increase in information to be managed and of needed skills.
If a physician has to care for many patients with a large variety of
possible disorders, she cannot get enough expertise on most of them to
be confident to treat them, even if she has the time of reading some
relevant guidelines: you don't get skills by reading a guideline. Of
course, no conscientious physician would treat a patient just based on a
quick browsing through a guideline and a few checklists, without having
a good confidence of her skills and understanding of the underlying
condition.
Thus, IMHO guidelines are more likely to be useful to improve the
practice of different teams, than to be used by every single physician
of each team.
regards,
Piersante Sestini
Djulbegovic, Benjamin wrote:
>
> Dear all
>
> It has been my impression that the rise of EBM (along with
> proliferation of systematic reviews (SR) and guidelines, critical
> attitudes toward health care claims etc) has not reduced the requests
> for the use of experts (consultants). Paradoxically, the last decade
> has seen ever increasing use of consultants. In the US, at least, an
> explanation for this trend in ever increasing requests for "consults"
> is related to the incentives to see more and more patients with the
> consequence that doctors do not have time to look up the guidelines,
> SRs etc. As a result, doctors just ask for yet another consult. I
> wonder what has been trend in other countries? Do physicians elsewhere
> also consult more often than, say, 10 years ago? If yes, why is this
> so? What is the purpose of developing all these guidelines if only
> experts will use them (and who will typically deviate from the
> guidelines)? What is an average number of physicians that the patients
> typically see?
>
> I would appreciate some thoughts on this issue, which is actually not
> a trivial one as it may appear on the first blush.
>
> Thanks
>
> ben
>
> Benjamin Djulbegovic, MD, PhD
>
> Professor of Medicine and Oncology
>
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