Daniel Y. Dodek MD CCFP FCFP (biography and disclosures)
What I did before
I practice family medicine in Vancouver and work on a geriatric unit at Mt. St. Joseph Hospital and care for patients at a nursing home. My cardiac, diabetic and other internal medicine patients frequently require specialist consultations. In the past, I would refer the patient and have them wait months for an appointment or search online for the information, never being fully confident of the answer.
In other instances I would play ‘telephone tag’ with a specialist, frequently requiring multiple back and forth faxes in order to get a clinical opinion.
What changed my practice
There is a single telephone advice number that connects family doctors with specialists from a vast array of disciplines, often within an hour. The initiative is called RACE (Rapid Access to Consultative Expertise), a joint partnership among Providence Health Care, the Shared Care Committee (a joint committee of the BCMA and the Ministry of Health), and the Vancouver Coastal Health Authority.
The telephone number is 604-696-2131 or toll free 1-877-696-2131.
Calling the RACE line gives me the ability to talk with a specialist in a timely manner about the care of my patients. It also provides me with the option of continuing education credits (through “Linking Learning to Practice”. The MSP billing code when using the service is G14018 General Practice Urgent Telephone Conference with a Specialist Fee: $40. The link to a billing website is www.sgp.bc.ca.
What I do now
Below are two recent cases where an emergency room visit, and specialist referral were avoided.
CASE #1
A 64 year old woman with hypertension, sleep apnea, and impaired fasting glucose is sent for annual blood tests. I received the results on my EMR the following week. She had a fasting glucose of 18.8, HgA1c of 11.2 and GFR of 66. I called her and she denied a recent infection or symptoms of hyperglycemia, except for increased thirst. I contacted the RACE hotline and spoke to an endocrinologist. We reviewed the case and she asked me if the patient was sick, symptomatic, or well. She suggested I start the patient immediately on Metformin 500mg twice a day. She advised that a dose higher than this would likely cause significant GI side effects. In addition, she suggested a starting dose of glyburide 2.5mg twice a day. I saw the patient two days later to review these recommendations. A visit to the ER was avoided.
CASE #2
A 67 year old patient with a history of mild chronic kidney disease, GFR of 54, impaired fasting glucose and family history of heart disease presented to the clinic with mild chest pain that mostly occurs at night. He reported recent weight gain the past few months with decrease physical activity. His exam was normal and he was sent for an ECG which showed a new Left Bundle Branch Block. This was followed by an exercise treadmill test. The report came back “Non-diagnostic due to LBBB.” I contacted the RACE hotline and a cardiologist reviewed the case with me on the phone. He recommended an echocardiogram to rule out structural heart disease. He also provided some learning points about the treadmill test. The patient and I were both reassured, and a long wait to see a specialist was avoided.
Conclusion:
RACE provides me with specialty advice that I could not previously access. It keeps me in the decision-making loop and improves communication between the family doctor and specialist. It improves patient care, enhances clinical learning, and reduces system costs.
RACE has given me a level of professional satisfaction and empowerment that I did not think was possible.
Resources:
- https://www.bcma.org/rapid-access-consultative-expertise-race-program
- www.sgp.bc.ca
- RACE 604-696-2131 or toll free 1-877-696-2131
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As an internal medicine specialist, I have provided such collegial service for the family doctors who refer to me, but without reimbursement, so I am glad to see some system emerging. Some other places also offer on-call hotlines that are government subsidized on a capitation basis rather than a “fee for service” basis. Given the evidence showing that CME at large conference venues may not be helpful in changing practice, this may also be a more effective method of increasing knowledge (as mentioned in the second case). I do wonder if a forum could be established that would regularly share such vignettes, since these types of questions are very common.
Re: Case #1: Why would a family doctor need to consult an endocrinologist about this?
It is always nice to be able to consult a specialist at any time and this provides information about an easy access. In both cases I think that I would have tried a few things before contacting the race clinic.
Gotta agree with Laura C about case #1, but case #2 shows some of the utility of the hotline.
I like this easy access to advice and hope to be able to use it. I think a forum as mentioned in the first response is a great idea. Regarding the case of hyperglycaemia, I have seen a FP send a similar case to ER. i think we all have our own comfort levels with specific cases, whatever the reason.
I found the RACE hotline very helpful when I had a lab result on a patient with a dramatically elevated CK (around 1000), but everything else normal. He was on Lipitor same dose for many years. His CK was likely elevated d/t doing strenuous home renovations the few days prior. I was concerned if the elevated CK could harm his kidneys. The RACE specialist provided me advice (such as hold the Lipitor, encourage hydration and closely monitor CK and renal function) and we were able to manage his case as outpatient. Thanks RACE!