It’s a knee-jerk default discharge phrase. It’s a catchall punt of responsibility and liability. And dear colleagues, we need you to think twice before ever saying it again.

It’s true, we family physicians are quite competent and have “capable hands” as many consult letters nicely acknowledge (whilst dumping on family medicine).

Patients trust us. We know our patients the best. And continuity of care is especially important.

But something has to give.

Family doctors are burning out. They’re retiring early or pivoting career paths. There are not enough medical student recruits to fill the ever-growing void. Look no further than the daily news headlines about the Family Medicine Crisis and over 2 million Ontarians without a Family Doctor.

Family Medicine has become an unattractive option for medical students. A recent study showed Family Doctors theoretically need 27 hours per day to fulfill their expected duties. (That’s 27 work hours per day, not just 27 hours per day).

To relieve some of the burden, family medicine needs to stop being a dumping ground for other people’s work. All too often, the advice to “follow up with your family doctor” is part of that dumping.

Can someone explain to me why surgical patients are advised to “follow up with your family doctor” after surgeries?

Maybe I’m just overly pragmatic, but this makes zero logical sense when you think about it.

Take, for example, a patient who I saw in my clinic last week. He just had his gangrenous gallbladder removed.

Then comes the common, yet backwards, discharge advice:

• Follow up with your family doctor within one week.
• Then follow up with the surgeon is six weeks.

Can people not see the illogicalness of this!? And yet this is the ubiquitous discharge advice given every day.

This is all not to mention the logistical nightmare and administrative burden required by family doctors and their staff to then coordinate unforeseen urgent specialist appointments when needed.

Related: perhaps scheduling patients to see their surgeons post-operatively would be an ideal time for them to remove those sutures they put in?

Let’s imagine another relatable scenario. A patient is hospitalized for new atrial fibrillation compounded by congestive heart failure and acute renal failure. The patient is started on a multitude of new medications.

Quite a complex patient. She understandably needed the ICU and the expertise of internal medicine specialists throughout her hospital stay. A few of the medications she has now started are beyond the scope and expertise of most family doctors.

And yet here come those discharge instructions again:

• Follow up with your family doctor within one week.
• Then follow up with your cardiologist in 6 weeks.

How backwards is this?

Would it not be in the best interests of this patient to see her specialists for immediate follow up?

Some ailments can be expected to resolve on their own, and that’s okay. Hospitals and emergency departments can indeed provide definitive care and advice.

A sprained ankle with a negative x-ray does not necessarily need to “follow up with your family doctor” in one to two weeks, at least not by default.

And neither does routine mechanical back pain.

A standard mild exacerbation of COPD that has been appropriately treated with antibiotics and steroids may well be expected to simply recover back to baseline without any further intervention.

I get it. We want patients to be safe.

It would be ideal for all patients to always follow up with their family doctors just to ensure there is no fever, no infection, no shortness of breath, no pain, and so forth.

But family doctors, and the medical system in general, frankly do not have the capacity for such ideals any longer.

Is it callous and unreasonable to believe that patients could actually be empowered and given some responsibility in their care? Could patients not be given clear discharge advice that includes what worrisome things they should watch for? and then seek medical attention if those things occur?

Instead of simply advising patients to:

“follow up with your family doctor”

What about:

“follow up with your family doctor

*if* you experience any fever, infection, or severe pain”

?

I’d still point out, though, that if a post-operative patient develops any of those red flags, it’s the surgeon she needs to be seeing immediately, not the family doctor. And if the ultra complex medical patient runs into complications, it’s the specialists she most appropriately needs to see.

If the patient recovers as expected without complication, as many do, then that saves the entire system a visit and some capacity.

If you still feel it’s appropriate to advise a patient to follow up with her family physician, then please be explicitly clear why – both to the patient and the family doctor.

Just the act of self-reflection will help.

Be precise with discharge instructions:

• Are there specific vital signs that need rechecked? And why?
• Are there blood tests that need rechecked? Which ones? And why?
• Are there specific symptoms you need rechecked? Which ones? And why?
• Are there specific physical exam findings you need rechecked? Which ones? And why?
• Will medication doses need adjusted? Which ones? And why?

Related, are there tests or things that you could (and should) be arranging prior to the patient seeing the family doctor?

• Have you equipped the patient with the required bloodwork requisition?
• Have you pre-emptively ordered any follow up imaging the family doctor will need?
• Have you made the parallel referrals to specialists that you’ve recommended?

As family doctors, having all of this information up front will help us appropriately triage and schedule the patient.

In fairness, I’ve seen some excellent discharge summaries from certain hospitals. They have clear, specific instructions to the patient. And they have an itemized list of things for the family doctor.

If we start to second guess the knee-jerk phrase, “follow up with your family doctor”, it will save capacity in primary care and our overall healthcare system.

This may just be a small part of the solution. In the bigger picture, though, it’s part of a much needed culture shift. We need to reduce inappropriate overuse of family physicians.

Because what will happen if there are no family doctors with which to follow up?

 

by Dr. Adam Stewart

April 16th, 2023