Coordination of care between oncologists and geriatricians is essential in the care of patients with cancer. Geriatric patients with cancer often have multiple complex comorbidities, making their oncology care more complex as well. Studies have shown that shared care models, where primary care physicians (PCPs) and geriatricians have an active role in the management of geriatric oncology, may improve patient satisfaction. Good communication between geriatricians and oncologists is the key part of this shared care model, but many other disciplines may be involved as well. In this chapter, a case study is presented that illustrates potential pitfalls in communication between the oncologist and the geriatrician during the different stages of cancer care. The chapter will also demonstrate how a shared care model works, the preferred methods of communication in certain circumstances, and how good communication may improve outcomes.
A.G. is an 81-year-old woman with a history of hypertension; a widow, she lived alone and was independent in her daily activities. She had complained about declining memory and family members had become concerned about her ability to continue to live alone and drive a car. She was forgetful about taking medications but her score on the Folstein mini-mental state examination (MMSE) was 28/30 (within normal limits). She declined to have help at home and was considering a move to assisted living. Several months prior to diagnosis she began to lose weight. She later complained of a dry cough. Chest x-ray showed a large (9.5 cm) mass in the right upper lobe of the lung.
Workup
The geriatrician or PCP usually initiates the workup of most cancers. There can be many potential ways to conduct the workup and preliminary consultation with an oncologist at this time can be helpful. For example in the case described above, the PCP may not know whether the patient needs to see a pulmonologist to attempt a diagnosis via bronchoscopy or if it would be more expedient to have an interventional radiologist perform a computed tomography (CT)-guided biopsy. It is preferable that these tests and procedures be ordered prior to the first consultation with the oncologist. There is often an urgency to make a diagnosis, especially if the patient is at a potentially curable stage. The fastest and most efficient way to communicate during this stage of cancer care is directly by phone or via email. Not only can this expedite the workup, but the PCP can also try to set up the initial consultation for the patient with the oncologist, assuming the workup will be completed in 1 to 2 weeks. This can be a critical time for the development of shared care, where the PCP and the oncologist begin to define their respective roles in communicating diagnosis, prognosis, and plans for future care. It is essential to give the patient and family clear information and to establish lines of communication so the family will know how to access care and address problems as they arise.
Often, these impromptu consults are termed “curbside” consults. Studies of “curbside” consultations have shown that advice by means of email, fax, and telephone has been shown to be very useful. They can often be used to determine the need for a more formal consultation. This may be especially true in geriatric oncology. The geriatrician who has a high suspicion of cancer in a patient may be unsure whether to pursue a time-consuming, expensive, and potentially distressing workup for a patient with multiple comorbidities. A “curbside” consultation may help clarify whether or not the patient would be fit enough to tolerate treatment before embarking on the workup. “Curbside” consultations have also been shown to improve or maintain good relationships with other physicians. Interestingly, more subspecialists than primary care physicians felt that “curbside” consultations were important for maintaining good relationships among physicians. However, these types of informal consultations have potential pitfalls. Studies have shown that the information conveyed may be incomplete or inaccurate. Also many physicians, especially subspecialists, may dislike “curbside” consultations because of the potential legal ramifications of giving such informal advice; also, there may be no reimbursement for time spent answering these types of consults.
Another barrier to communication is the preference of the oncologist to have a tissue diagnosis before getting involved in a case. This is more often a problem in the academic setting where physicians tend to be salaried than in community cancer centers where oncologists see patients on a fee-for-service basis and are competing for referrals. However, if the referring physician knows the oncologist and maintains open lines of communication, especially in the academic setting, there is usually more willingness to assist in the workup before the first formal consultation.
Diagnosis and Referral
A.G. failed to keep several appointments for interventional radiology and diagnostic studies. Social services were contacted and the family became more involved. She appeared weaker and more confused. She was brought to appointments by family members but did not always recall the purpose of the visits. With the help and encouragement of her family, she moved into an assisted-living facility. Her lung biopsy revealed well-differentiated squamous cell carcinoma. She and family members met with a geriatric oncologist.
The time between the diagnosis and referral can be crucial. Good communication between the oncologist and the PCP can reduce delays between diagnosis and treatment. The uncertainties of treating geriatric patients with cancer can sometimes exacerbate these delays. In a study of breast cancer patients, the main factors that were independently related to delays in care were older age, lack of Social Security, and advanced stage. Other barriers that may prevent older patients from being referred to an oncologist have been identified. The most common issues cited by PCPs are long waiting lists, mandatory tissue diagnosis before referral, and the belief that oncologists seldom relate to PCPs. In this same study, 86% of PCPs said they would refer an older patient with early-stage, potentially curable cancers, but only 65% would refer those with advanced-stage, potentially incurable cancers. Factors that influence the PCP’s decision to refer were a patient’s desire to be referred, the type of cancer, the stage of the cancer, and the severity of the cancer symptoms. According to this study, age was not a factor in the primary’s decision of whether or not to refer the patient.
When the decision to refer the patient is made, what is the best way to refer? This depends on the urgency of the referral. Someone with life-threatening disease is usually hospitalized where multiple subspecialists can be consulted simultaneously and a treatment plan can be made together. In patients who have rapidly progressive disease but are medically stable, coordination of care usually occurs in the outpatient setting. These urgent consults are best communicated by phone. As electronic medical records and resources become more frequently used, email may also be an effective way of communicating an urgent consult. A study of an email consultation service at the Walter Reed Army Medical Center showed that this could be a viable option. In a 20-month period, 3121 consultations were logged. The average time to response was approximately 12 hours. The implementation of the system required little extra training on the part of the users. In general, the use of this system mirrored the usual clinical practice of consultation and response. However, the study did identify potential barriers, such as a lack of secure communication and difficulty assigning workload credit for the participants, which may limit the use of this system in a broader setting. Other reasons to refer by phone or email, as opposed to sending a letter, are to convey sensitive information, to relate any psychosocial problems that may affect treatment, or to convey information that may be too complex to communicate through a letter ( Table 27-1 ).
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Although telephone consultations seem to be the quickest and most direct way to initiate a consultation, some potential pitfalls of using this method of communication have been studied. A qualitative study of telephone consults between physicians identified five sources of tension: presentation, context, fragmented clinical process, reason for call, and responsibility. Consultants complained that the pace of conversation was too fast or too slow. Sometimes information was not conveyed because of the accent of the caller or because the caller was disorganized when describing the case. A case that may be extremely urgent from the perspective of the caller, may be just one of 10 phone consults that an oncologist receives during a day in which he is seeing 20 other patients in the office. The clinical process in phone consultations is fragmented and information passed from caller to consultant can be inaccurate or incomplete. A PCP may call a consultant for reassurance about a case; the consultant may view this as inappropriate, especially if his or her opinion is different from the caller’s. Responsibility for a case may cause tensions in both directions. A caller may be trying to pass the responsibility of a complex case on to a consultant; alternatively, a consultant may find it easier to have a patient transferred to his or her hospital so as to see the patient in person, while the caller is reluctant to release the patient from his or her own care. All of these tensions tend to undermine the quality of care. ( Table 27-2 .)
| Tension | Examples |
|---|---|
| Presentation | The pace, accent, organization, and tone of the caller or consultant may make it difficult for the other to understand or may create emotional tension. |
| Context | An urgent and important case to the caller may be just one of 10 telephone calls the consultant receives while rounding on other patients. |
| Fragmented Information | The consultant has to rely on observations and knowledge of the caller and information may be inaccurate or incomplete. |
| Responsibility | It may be easier for the consultant to take over the care of the patient, while the caller is only asking for advice and is not willing to give up the responsibility of the patient’s care. |
| Reason for Call | The consultant may be asked to provide information that the caller could find in the medical literature, but may not have time to search for. |
In the same study, the caller’s and consultant’s strategies for averting these tensions were reported. In some instances, the strategies used by the consultant to abate tension were seen by the caller as exacerbating tension. An example that was cited was a case where a consultant asked for the patient’s laboratory results and the caller reported them as “all normal.” The consultant then asked for the specific values of certain tests and the caller felt he was “being talked down to.” Although they didn’t offer specific strategies to avoid these circumstances, the authors of this study felt that it was important for both callers and consultants to recognize these tensions. They concluded that many physicians are poorly trained in professional communication skills and recommend that this be given greater importance in medical school curricula.
In some circumstances, consults are made by means of a referral letter. A study of referral letters from PCPs to oncologists showed that the amount of information contained in the letters was quite variable. The key pieces of information for the PCP to convey to the oncologist are outlined in Table 27-3 . As illustrated in the case above, the patient’s “back story” can often be as important as the diagnosis and comorbidities. As pertains specifically to geriatric patients, a knowledge of geriatric syndromes such as cognitive impairment, history of falls, or other signs of frailty can strongly impact the oncologist’s treatment plan. If this information has not been passed on from a physician who knows the patient well, it can sometimes be missed in an initial visit with the oncologist, who usually does not have the time to do a complete geriatric assessment.
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