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Trust, Communication Vital to Community Physician-Transplant Center ‘Marriage’
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In reading this month’s cover story, I found myself looking at what could be an ideal ‘marriage’ between the community practice and liver transplant centers. In an ideal world, this goes as well as it has for experts like Mitchell L. Shiffman, MD, but not all marriages can be considered a success.
If you, as a community physician, intend to keep and co-manage the liver transplant patient population, you must be honest about what you can and cannot do. You must come up with an efficient means of communication with the entire transplant team and understand the limitations on both sides.
Community practices must understand when their technology is not up to par for reporting into a transplant center and when the transplant center may be the best place for their shared patients. Transplant centers may be better equipped to handle many listed patients but it can be hard to admit when you need to rely on your partner.
The most important factors for success are to understand what you can do well in both places and to establish a line of communication that works. If a patient comes in with newly developed ascites, for example, that needs to be a call to the transplant center. Say, “Our patient came in with a big change. Do you want me to shift them?”
Communication is Key
Some community physicians are educated and know their limitations and they know how to communicate with those of us in transplant. They call and say, “This is what I’m doing. Is this ok?” They aren’t asking permission, but they are communicating. That builds trust.
You can never hold a patient or monitor a status change without letting a transplant center know. Conversely, taking a critical view of the transplant center, most of us are bad at letting the community or referring physician know what’s happening in real-time. If you’re not in the same EMR, that level of how you communicate needs to be refined and agreed upon. You have to establish the line of communication very early in these relationships.
In outreach-oriented transplant centers, there is a greater understanding of this communication. I am fortunate to have clinic in several outreach locations; I know which of the community doctors don’t mind handling the acuity of my patients.
There was a recent publication from AGA on transplant management because we must have help. Patients referred by a trusted physician still like that physician, often more than the transplant center.
The Importance of MELD
You can earn MELD points in two ways: your labs can get bad or you can get prioritization points for things like cancer. Your earned MELD reflects patient acuity. The higher your MELD, the more likely you are to be transplanted but the more likely you are to die.
Trying to hold on to high MELD patients in a community setting can be dangerous. They can lose their transplant window very quickly. A low MELD patient is less likely to die and less likely to be transplanted.
If you see that MELD ratcheting up, call the transplant center for transfer. I recommend using the online MELD calculator provided by the Organ Procurement and Transplantation Network and understanding the importance of correctly using that barometer. The MELD is a surrogate marker for what their risk is, not only for when to transplant but also for complications they may not survive.
If you have a listed patient that comes in or has a change, it’s rare that a transplant center will want the community practice to do a procedure like TIPS or do locoregional therapy for cancer. If the patient gets sick from the procedure, it’s on us. It helps us better control the outcomes for these patients. If I have a non-listed liver patient, community centers work within their skill set to care for that patient.
Mutual Need
In the end, it is a marriage and sometimes the co-management is like parenting. It’s difficult for those of us in transplant centers to let others take care of our most fragile patients. Once you’ve referred several patients and you’ve co-managed them effectively, then the transplant center begins to trust that your level of decision-making is in line with theirs.
And the need is mutual. We have to lean heavily on our referral base. Sometimes insurance mandates things happen outside the transplant center. Whether we want to or not, we must go with these communication processes. Our patients will get co-management.
You might be in a community with little to no liver knowledge or interest, but you still must build a relationship with that community because the patients are coming from there. You may not always have an ombudsman as Shiffman has been in his community.
Do you serve as that ombudsman? Do you have tips for improving communication between transplant and community physicians? If so, please share with @HealioGastro and me @NancyReau.
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- Nancy S. Reau, MD, FAASLD, AGAF, is The Richard B. Capps Chair of Hepatology, Division of Digestive Diseases and Nutrition, Rush Medical College, Associate Director of Organ Transplantation.
Disclosure: Reau reports no relevant financial relationships.