All the GPs indicated that shared responsibility and care for the patient are essential elements of the collaborative relationship with the medical specialist. Extending the degree of collaboration would serve the patient's best interests, particularly for seriously ill patients and the elderly. An increased degree of collaboration would also speed up the referral process and facilitate the communicative pathways between the GP and the medical specialist.
Experiences from the regular care setting which may affect the development of new collaboration models
Personal relationships
Most of the interviewees indicated that collaboration is facilitated when the physicians involved know each other on a more personal level. This makes collaboration more enjoyable, more candid, and easier. A number of GPs stated that they are more inclined to use the telephone to discuss patient related issues when they are acquainted with the specialist involved. Additionally, they said that knowing each other personally also leads to a better understanding of each other's working method. The relevant medical competencies are better understood and there is increased insight in physician's behaviour with respect to the patient. This helps the GP choose the appropriate specialist for a specific patient.
"Knowing each other personally is what makes or breaks successful collaboration with specialists."
"You know how they are, how they treat their patients. It's important to have some idea of their professional knowledge, and they should have some idea of what a GP does."
Perception and status
GPs generally want to be regarded as competent colleagues by the specialists who take the patient's environment into account and who do not make unnecessary referrals. Many GPs would like to be accorded the same level of respect that specialists show each other.
"That the specialist values the GP as an academically trained professional who has his own expert knowledge of patients and an expertise which reflects the generalistic outlook of the GP."
Almost all of the GPs did not claim to experience any difference in status with the specialists, although such a difference is sometimes perceived in society.
They simply also earn more [...] and people naturally regard them differently. But I disagree."
The older GPs noticed a clear difference between present day practices and the past. As they age they experience less difference in status because they become more self-confident and they perceive less arrogance on the part of the specialists. Some did state however, that residents were sometimes prone to displaying arrogance.
"As the years go by, you attach less and less importance to status.
"The arrogant specialists have all retired by now anyway."
Most of the respondents stated that they did not perceive a difference in status. Contrary to this claim, we did find indications of an implicitly stated difference in status in the transcripts. Many GPs look up to specialists. This was evident in the answers pertaining to perception as well as in the arguments for changing the collaborative process.
"So, if I'm walking down the hallway, and a specialist pats me on the shoulder, it just makes me feel good."
Positive factors for developing new models of collaboration
Increasing medical knowledge
All of the GPs considered the increase of medical knowledge as a reason for participating in new models of collaboration. They enjoyed being able to subsequently use this knowledge for the benefit of their patients. They considered evidence based knowledge an important source of knowledge next to knowledge gained from experience.
Understanding each other's methods of working and professional competencies
All the interviewees considered it important for the specialists to increase and improve their understanding of the GPs' working method and the competencies associated with the profession of family medicine. The specialist should gain a better understanding of the conditions under which GPs work, their basis for making decisions, and the way that time is factored into patient management. Additionally, specialists could be made aware of the non-medical circumstances of a patient that often play a role in treatment decisions.
"As resident, I have occasionally had thought: how can a GP have missed that in such an abdomen? You work in this nice little cubicle, under the bright examining lights, neat examining cot. And once in a while you are called out to someone's house, and they have a waterbed [...] you should try to do a proper examination of the abdomen in those conditions!"
Some GPs find it sensible to improve their understanding of the specialists' working methods but do not consider this a primary goal. They said that, after all, they have been acquainted with the hospital setting since their undergraduate training period.
Reciprocal inspiration
Many GPs indicated that they found it stimulating when new joint initiatives were developed and that they felt more energetic when such initiatives were conducted properly. This leads to a more pleasant working environment. A number of GPs expressed the opinion that sharing the responsibility for patient care gives them a good feeling.
"It is so inspiring, not so much to learn, but simply to experience the feeling, enthusiasm and zest for work."
Impediments to the development of new models of collaboration
The respondents gave three main reasons for not changing the current level of collaboration.
Some GPs felt no change was needed as they considered the present level of collaboration to be excellent. Another objection to the development of new collaborative practices was grounded in the time commitment that would be necessary. Personal and work related issues were seen as more important. Finally, some of the GPs claimed that they had had negative past experiences with new models of collaboration. For example, they felt that there had been too much of a rush during the initiation phase of some project without adequate preparation taking place. On the other hand, other collaboration projects were organized to such an extent that they were too demanding with overly extensive protocols requiring excessive paperwork.
"At the time, transmural care consisted of an office with all kinds of employees, a nurse who took care of discharging the patient from the hospital home with all manner of bells and whistles. Well, that's how it was presented. If I think back to that, I see red."
"Such a fancy professional – a Jack-of-all-trades and master of none – corrupting the issue and hiring an expensive consultation firm, these are all insurance premiums."
Some projects involved patient categories rarely seen in daily family practice, causing the protocol and any accompanying information to be misplaced and forgotten.
In some projects either the GPs or the specialists did not comply with the agreements that were made and it was not clear who was responsible. Some GPs reported negative experiences with specialists because of their cynical attitude.
Many interviewees stated that projects should be developed to meet a common need. Some initiatives appeared to stem only from specialist needs and seemed to address only those tasks that the specialists wanted to move out of the hospital setting.
"Then he's developed an entire form, and it was sent to all of us, and then I get very nervous, because that form has to be put somewhere, and of course it takes another two months before I see someone like that, and he then wants to go to a different hospital. Well, fine. Things don't work that way, so I think it's all nonsense really."
"And then you suddenly get a patient who brings with him a schedule from the hospital, and he says: 'Doctor, you have to come now, because that's what the protocol says.' And then I think to myself #$%^%$, why don't you go fly a kite?"
Most GPs did not find it important to be compensated during the developmental stages of a project, though they did feel compensation was justified once the collaborative project was up and running.
"If you take it seriously, there will be a price tag attached."