| Macro or meso (system-level issues) |
Delays in medical transcription |
“Dictations are usually done in a timely fashion from the person-dictating-them point of view; however, transcription sometimes becomes an issue. And if you don’t have access to a dictation from the [hospital name] for 2 months and a person comes in and you don’t know at all where they are at, even in terms of treatment cycle or what they are doing, or what the plan is, it’s very hard. You feel like you are totally out in the dark dealing with a patient who is fairly complicated and you feel like you are not giving them the quality service that you should be able to give them” (Male FP, interview 34)
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| Difficulties accessing patient information |
“Sometimes I find that there’s a big delay in written documents being transferred …. There [are] the hospital-based electronic files, and then there is the clinic-based electronic medical record and they don’t always talk to each other, or [it] seems like things are either delayed or lost in the shuffle. So there is a lot of tracking down on the part of me and my staff here to see the most up-to-date information. It can be very frustrating” (Female FP, interview 47) “I use one software program in the acute care hospital, a different program in the cancer agency that does not communicate with the one in the hospital, and a third program in the radiation oncology department … then primary care providers use 1 [of] 6 different software programs” (Male GP in oncology, interview 9) “Unfortunately the electronic chart system we use [in the cancer centre] is not the same as that of our regional health authority …. It’s a sort of permanent state of inefficiency, miscommunication, and duplication” (Female medical oncologist, interview 38)
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| Physicians not copied on all reports |
“Communication [with the cancer centre] is average at best …. Consult letters come unreliably; biopsy reports come back to me unreliably. Generally, it’s about 60% I get and 40% I never see” (Male FP, interview 56) “I would recommend that oncologists start dictating notes every time they see a patient and make sure a copy goes to all of the individuals that are taking care of that patient so that (a) there’s no duplication of investigations and (b) everybody know[s] where they stand in terms of people’s thoughts and treatments … and what kind of follow-up investigations … and examinations are going to be ongoing, so that the patient doesn’t see 3 doctors in 1 month and then nobody for a year” (Male general surgeon, interview 2)
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| Micro (individual- or practice-level issues) |
Lack of rapport between FPs and cancer specialists |
“It should be our responsibility as medical oncologists …. We need to invite them [FPs] for at least a meeting, at least to get together to know each other even just to say ‘Hello, how are you.’ The problem is, which is no excuse, we are so busy …. At least, if you meet people face to face, it makes it much easier for family physicians to pick up the phone and call you” (Male medical oncologist, interview 32) “I haven’t even physically met a lot of the oncologists so I find that’s a bit of a barrier because you don’t create those working relationships and they can’t just drop by and say ‘Oh, you know, I saw your patients, they are doing better’ or ‘They are doing worse; I’m going to do this’” (Male FP, interview 51)
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| Lack of clearly defined and broadly communicated roles |
“They [the cancer specialists] will send out a letter to me, the referring surgeon, and to the family doctor and they give general guidelines about what to do for the next 5 years …. I always call the patient back in because I operated on them, then I’ll find out they’ve already had a CT [computed tomography] organized by their family doctor and so we get some duplicate testing going on …. They [cancer specialists] give recommendations but don’t say … ‘General surgeon should do this,’ or ‘GP should do it.’ They say ‘either-or’ and then there is a bit of confusion” (Male general surgeon, interview 23) “I do feel kind of lost about who exactly is following up with the patient …. I sometimes wonder if there is not duplication of care. You know, for patients post-care, they are very compliant with coming back. They want to make sure that they are OK, so if you ask them to come back they will come back, but I’m not sure I’m doing much more for them than with the oncologist or the family physician. So maybe they’re seeing me unnecessarily or seeing the oncologist or family physician unnecessarily, and it just seems like a lot of duplication. It’s just not always clear” (Female general surgeon, interview 52)
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