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In the Loop

Harpham, Wendy S. MD

doi: 10.1097/01.COT.0000358152.58388.e7
View from the Other Side of the Stethoscope

At a recent book-signing event, a local pediatrician asked my final question of the evening: “What can I do if an oncologist leaves me out of the loop?”

Uncharacteristically, I punted: “Maybe one of the oncologists in the audience would like to answer?” I'd never turned a question over to the audience before. But I'd never been asked that question and assumed the practicing oncologists would be happy to respond.

Instead an awkward silence ensued. People looked around and shifted in their seats. After a minute, my husband spoke up, “Come on, now.” He smiled, “I know there are some oncologists in the audience.”

Whispers and chuckles. More shifting in chairs. Finally one oncologist suggested referring to an oncologist known to communicate well with the PCP (primary care physician).

Weeks later, I'm still chewing on the pediatrician's question, imagining his feeling handicapped in his ability to guide, treat, and support his patients. As an internist, I can identify. When I was in practice, occasional patients disappeared into the black hole of oncology, where they stayed for the duration of their treatments. When these patients resurfaced in my office, resuming their routine care was not like flicking a light switch back on: Their needs had changed, and my role was less clear than before.

This sounds like the PCP's problem, not the oncologist's, don't you think? Yes. And no.

For sure, the burden falls on PCPs to recognize and respond to survivors' primary care needs, including late effects. But as a physician/patient I've come to believe that you—the oncologists—have an obligation to help PCPs navigate the survivorship of your shared patients.

Before you make your case about too little time, consider the benefits. For the price of a brief communication (by phone or email, or in person), the insights acquired over the years by your patients' PCPs can help you from the get-go. You may detect physical or emotional problems earlier than otherwise. Details about patients' medical idiosyncrasies and unique psychosocial needs may help you avoid ugly surprises (always a good thing).

Communicating with trusted PCPs can jump-start your new patients' trust in you. On some level, patients feel, “Any friend of my PCP is a friend of mine.” If a patient's confidence in you becomes shaken by a lab goof or delayed report, a string of bad side effects or some other adverse event, the PCP may offer that patient words of reassurance that do more to prevent or heal a rift than anything you could do. Keeping PCPs in the loop helps them advocate for you most effectively.

When I think back on the times my internist helped me through the speed bumps of my survivorship, the benefits of good oncologist-PCP communication become obvious. PCPs can:

  • Clarify and reinforce patients' understanding of the goals of proposed cancer treatment.
  • Integrate information from multiple consultants (including but not limited to oncologists).
  • Oversee the management of chronic non-malignant diseases and thus help optimize patients' overall condition through treatment and recovery.
  • Serve as a safety net by diagnosing and treating non-oncologic medical issues.
  • Ensure that appropriate screening is done for other diseases, including other cancers.
  • Assist with motivating or redirecting patients who skip therapy or checkups, or who take unnecessary risks.
  • Encourage patients in ways friends, family and oncologists can't.

I wish I could provide supportive data for the benefits of updating PCPs, such as fewer hospitalizations or improved disease-free intervals. I can't. But I assure you the rewards for patients are real.

With not one but two portals of entry, it's been easier for me to receive timely attention to problems that are well within the purview of both oncology and internal medicine, such as insomnia and chronic pain.

On rare occasions, two physicians' heads were better than one. Importantly, even when I didn't need two points of view, two explanations, or two voices of hope, the double-dose of care still helped me.

When a worrisome symptom developed, my emotions sometimes led me to contact my internist rather than my oncologist (Note: through absolutely no fault of my oncologist or his office). I suppose this was because my internist's office didn't have any of the sights and smells of chemo. Or because subconsciously I felt going to my internist meant it might be any medical problem, whereas going to my oncologist meant it might be cancer.

Knowing my oncologist and internist communicate regularly, I've never dealt with a sense of competing loyalties by going sometimes to one and other times to the other. As I saw it, they were a team.

On a winning team, everyone is in on the game plan. This brings me back to the pediatrician's question. For our own as well as our patients' sakes, we need to find ways to increase the linkages between oncologists and PCPs.

Once survivorship care plans become institutionalized PCPs will automatically be in the loop regarding patients' oncologic care. Until then, at the risk of stating the obvious, I'll conclude with three simple suggestions:

  1. Give PCPs a heads-up when mutual patients' cases are slated to be presented at tumor boards or oncology Grand Rounds. Even when PCPs can't attend, the invitation fosters teamwork.
  2. When you come across useful articles in the care of specific patients, consider emailing the references to the involved PCPs. This way, PCPs benefit immediately from new information that takes months or years to trickle down to the PCP literature.
  3. Give patients two copies of information-and-instruction sheets, one of which patients can mail or hand-deliver to their PCPs. Alternatively, have patients address an envelope to their PCPs that your staff can use to mail the duplicates.

In the care of the patient, everyone benefits when PCPs are kept in the loop.

© 2009 Lippincott Williams & Wilkins, Inc.
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