• Physician spends enough time with patients to communicate effectively
• Patient care is comprehensive and respects others’ time

• Patients speak highly of physicians’ communication

• Treats too many/too few patients in one day
• Patients complain about physician’s communication
• Several patients transfer care and chose to see another physician
• Physician is blunt, arrogant or rude to patients

• Patient complains that physician never touches them or never talks to them
• Patient comes to specialist office not knowing why they were referred

• Recognizes that illness affects the entire family
• Arranges for spouse of diabetic patient to be present for diabetic counseling session
• Talks to the family and keeps regular contact with the family when patient is in hospital
• Communicates with the family (e.g., by phone or in-person) about the patients’condition

• Visits patient in hospital, makes an effort to be present for the patient’s family

• None reported

• None reported

• Is respectful, polite with nurses and other health professionals
• Works as part of a team rather than individually
• Relays information to nurses
• Charting patients seen on-call
• Involvement of other health professionals such as physiotherapy, diabetes education in patient care
• Involved in discharge planning
• Early consult with discharge planning team
• Shares patient information in a timely manner – is conscious of others’ time
• Supportive of staff when staff are responding to difficult patient conflict/anger
• Explains orders to nurses (e.g. why physician is writing a prescription for antibiotics)
• Involves nurses in decision making such as patient treatment; asks for others’ opinion (e.g., what do you suggest for this patient?)

• Sends patient chart records with patient to specialist appointment
• Provides enough information on consult to explain urgency of patient problem
• Contacts specialist about patient medications and other important information before referral
• Describes patient symptoms, family history on consult
• Does not hesitate to call specialist with legitimate concern (i.e., not delaying contact)

• Condescends to or insults nurses
• Corrects other health professional/nurse errors in front of patient

• None reported

• Contacted by other physicians in the community for advice on patients

• None reported

• Overuse/under use of antibiotics
• Orders too many CAT scans
• Prescribes outdated medications
• Frequently orders unnecessary battery of tests for patients

• Makes referral without consideration of other factors (e.g., age-risk factors, societal factors)

• Uses clinical practice guidelines
• Female patients get regular mammograms/pap smears

• Doesn’t over or under test depending on the condition
• Test choice agrees with specialist test choice
• Selects tests according to standards of care (i.e., national guidelines)

• Orders inappropriate tests based on patient history
• Orders too many diagnostic tests
• Orders tests but fails to follow-up with patient
• In group practice, other physician reads patient history and finds patient had not been called-in to discuss test results

• None reported

• Documents thought process (e.g. differential diagnoses) in medical records/referrals
• Monitors patient INR levels

• Conducts appropriate history and physical
• Takes the time to assess the significance of diagnostic information and follows through with treatment
• Follows guidelines for INRs or platelets

• Emergency department hospital chart shows recommended follow-up on CAT scan that was not done

• Patient arrives at specialist office and has not had history and physical
• Patient with low hemoglobin from macrocytic anemia is put on iron

• None reported

• None reported

• Patient test results indicate a medical problem and patient is not called-in for an appointment
• Patients are in hospital for a longer period of time than is typically expected for patients with similar concerns
• Consistently behind schedule, leaves work late

• Frequently misdiagnoses patients
• Patient unnecessarily admitted to hospital when patient required only a simple treatment

• None reported

• Considers age and mental health factors in treatment plan (e.g., does not send demented patient with poor chances of remobilization for knee replacement)

• Prescribes inappropriate medication combinations
• Prescribes outdated medications
• Prescribes inappropriate medication dosage
• Neglected INR patient admitted to emergency with bleed
• High percentage of patients on short acting narcotics and benzodiazepines combined

• None reported

• Self-evident

• Self-evident

• None reported

• None reported

• Calling out, signing out the call schedules when transferring patient out of unit
• Transfer notes are easy to read, clear and concise
• Takes responsibility for patient transfer of care
• Takes responsibility for patients in critical care
• When going on vacation or end of shift, transfers patient history and advises colleague(s) of at-risk patients (e.g., monitoring of patient international normalized ratios (INRs))
• When going on vacation or end of shift, gives colleague short to-do list (e.g., pick up mail, watch out for this fax)

• During follow-up, it is evident that the physician accepted and reinforced specialist treatment plan and was willing to take the patient back
• Takes responsibility to phone specialist when feeling uncomfortable with some aspect of patient care

• Overlooks/ignores test results at end of hospital shift (e.g., nurse asks replacement physician about a blood test and previous physician on shift did not provide information)
• Transfer of knowledge about patient situation is inadequate (e.g., leaves hospital shift and does not inform replacement physician about a jaundiced baby)

• Specialist writes good consult letter explaining in great detail precisely what needs to be done and care is not followed-up

• Provides clear and concise information when communicating patient condition to the on-call surgeon
• Provides adequate information on consult letter referring patients
• Is assertive with specialist in getting help for patient in-need
• In managing complex patients, writes notes such as “what am I supposed to do now”? on abnormal test results and faxes to the case consultant for advice
• In consults with specialist, provides information such as basic investigation results, patient history, differential diagnosis, treatment possibilities

• Describes the clinical question, explains what has been done, provides copy of tests and current situation, asks “where do I go from here?”
• Sends patient chart records with patient to specialist appointment
• Patient chart provides adequate information about patient concerns (e.g.,  patient symptoms, family history)
• Notifies specialist about patient (e.g., medications) before the referral
• Does not hesitate to call specialist with legitimate concern about a patient
• Refers patients with identified, unanswered questions
• Specialist knows exactly why the patient is being referred, the expectations of the physician and what has been done to reach a diagnosis, or therapy that has been prescribed 
• Conducts physical exam (e.g., pelvic exam, patient history) before referral
• States urgency of problem on consult , but is selective in what problems are ‘urgent’
• Provides concise instructions about intended involvement in continuing patient care
• Notifies specialist of request to conduct follow-up with patient on referral (e.g., will say “diagnosis and on-going care”) and explains why (i.e., lacks skills)

• Physician on-call at hospital sees patient who is at emergency because they were not appropriately referred earlier in the week
• Provides inadequate referral information (e.g. “re: rash”, “re: chest pain”)

• Reason for referral is obvious misdiagnosis (e.g., refers chest pain and patient has Parkinson’s)
• Does not indicate urgency of problem to specialist (e.g., chronic bowel pain)
• Provides inadequate referral information (e.g., “refers a patient with the name of a patient at the top of their prescription sheet and the word ‘hypertension’, and they sign it” )
• Sends all patient tests and information to specialist even those that don’t pertain to problem
• Sends referral without prior investigation (e.g., doesn’t take personal history, no physical exam, no rectal exam, no pelvic exam)
• Gives little information (e.g., X and Y) and says “please assess”

• None reported

• During follow-up with patient it is evident that the physician was attentive to specialist recommendations and takes responsibility for continuing patient care

• Discontinues hospital involvement and patient care is transferred to hospital physicians

• Doesn’t follow-up with patient

• In transfer of care, provides enough information to ensure good patient care in their absence
• When taking time off, leaves a note and calls to advise: (1) dates away; (2) who is covering; (3) list of patients

• Communicates referral information to patient, follows treatment plan prescribed by specialist

• None reported

• None reported

• Difficult to assess

• Explains to patient why they are being referred (i.e., patient arrives at specialists office understanding why they have been referred)

• None reported

• Patient does not understand reason for consultation (e.g., patient asks specialist, “what kind of doctor are you?”)

• Encourages other family members to attend treatment counseling (e.g., diabetes education)
• Visits patient in hospital, drops-in to say ‘hi’
• Calls family to give update on patient in hospital
• Attends CME on psychosocial aspects of care
• Takes the time to ask patient questions about home/work life.
• Patient sees physician regularly

• Considers the contribution of anxiety and depression in medical problems before refers patients
• Considers lifestyle options in treatment plan before referral (e.g., 375-pound patient is referred for knee pain with consult letter that describes previous attempts at weight loss)
• Has samples of medications on supply for low socioeconomic status patients
• Knows the family members and is able to direct placement issues such as home care
• Considers issues of compliance when discussing treatment options including referrals with patients
• Considers issues of cost when discussing treatment options for patients

• Refers patient with high liver enzymes to specialist without consideration of alcohol treatment options
• Refers patient with shortness of breath to specialist without consideration of lifestyle treatment options (e.g., smoking cessation)
• Patient comes into specialist office with emotional health-related ‘baggage’

• Refers diabetic patients to Diabetic Education Centre
• Refers patient to community resources that are known to be helpful, trusted, current

• Informs specialist of efforts to improve care through community resources, even if unsuccessful 
• Is aware of resources available and refers patients to groups such as hearts in motion, diabetes care

• None reported

• None reported

• Difficult to assess

• Refers patient to appropriate services such as alcohol abuse clinics or advises specialist of problem at time of referral and does not ask specialist to manage this aspect of care.

• None reported

• None reported

• Manages patients with depression well
• Refers patients to psychotherapy
• Prescribes antidepressants
• Refers patients to psychiatrist

• Specialist does not have to address patient psychosocial concerns because physician has already done this
• Encourages patient with ongoing chest pain that is not responding to cardiac treatment, to consider other treatment options for improving quality of life

• Does not manage patient psychosocial concerns; has attitude:  “if you have mental problems, go see a psychiatrist”

• None reported

• Writes a note on abnormal test result when unsure of treatment and faxes it to the consultant involved in the case, and asks “what to do?”
• Acts promptly on results that suggest medical problems (e.g., INR management – sign of lab work)
• Follows clinical practice guidelines (e.g., diabetic patients are on statins and ACE inhibitors)
• Management of diabetic patients – has a flowchart, monitors blood work, patient has annual flu shot, weight loss counseling/efforts 
• Takes the time to explain treatment to patient

• Does not ask specialist to address issues out of their specialty (e.g., physician makes chest pain referral to cardiologist and takes responsibility to address patients’ diabetes)
• Does appropriate history, appropriate physical, appropriate lab investigations
• Does not refer patients with “chronic bowel pain” before taking a complete patient history, physical, rectal exam and basic investigations
• Allows enough time for the appropriate assessment
• Follows clinical practice guidelines

• Physician’s patients often come into emergency or readmitted to hospital 
• Overbooks number of patients with complex problems in one day
• Works primarily in walk-in clinic with few to no patients with complex medical problems

• Does not provide care for patients with complex problems (e.g., elderly patient)
• Physician has “one problem per visit” sign in waiting room (e.g., make an appointment and come back next week)

• Explains to nursing staff reasons for changes in treatment (e.g., rationale for switching antibiotics)

• Patient with knee pain has been referred to physiotherapist as well as specialist
• Helps to coordinate palliative care for patient
• Helps to coordinate care for multi-symptom problems such as an ophthalmology consult, rheumatology, psychiatrist, social worker, home care
• Continues to be involved in care after the patient has been referred
• Refers to diabetic education, asthma clinics

• None reported

• Specialist recommends hypertensive treatment and it is evident that patients’ hypertension has not been well-managed in a follow-up visit

• Offers house calls to a palliative care patient
• Is on call 24 hours, visits patient when they are dying
• If patient is in ICU, stops in to say ‘hi, glad you made it through that’
• For those who don’t do obstetrics, drop-in to visit new moms

•  None reported

• Does not greet patient in a pleasant way
• Lectures patients who are late or missed appointment

• Does not spend enough time with patients (e.g., patient shares that her husband is dying of cancer, and physician suggests that patient schedules an appointment to talk about it next time)

• Ensures conversations are private with other physicians about their patients
• Doesn’t talk to patient about health problems until patient is in office and door is closed

• None reported

• Betrays patients’ confidentiality

• Openly talks about their patient(s) while out in the community (e.g., at local grocery store, on the golf course)

High-scoring behaviours reported by family physicians.

High-scoring behaviours reported by specialists.

• None reported

• Respects patient decision to refuse treatment

• Speaks poorly about patient(s) in casual conversations with other family physicians

• None reported

• Exchanges information about patient diagnosis/treatment plan with colleagues
• Participates in monthly medical team meetings
• Participates in informal lunch room discussions
• Uses fax rather than phone communication (i.e., fax is more timely and respects others’ time)

• Asks specialist for input with written request such as, “what do you think we should do?” or asks them to make an appropriate judgment

• None reported

• None reported

• Attends CME, rounds
• Talks about journal articles

• Attends CME

• None reported

• None reported

• When corrected by nurses, expresses gratitude and is able to accept feedback and admit mistakes

• Admits errors in referral choice with patient and explains reasons for error 

• Does not accept responsibility for medical errors (i.e., makes excuses for error) and/or blames others for error (e.g., patients, nurses)

• Patient is referred for same problem multiple times

• Makes appropriate use of Diabetic Education Centre
• Hires a family practice nurse

• Does not over-utilize the system
• Is not influenced by fear of lawsuits in choosing appropriate care
• Orders appropriate tests

• None reported

• Orders a CT when a chest x-ray would be fine

• Takes the time to discuss a difficult day with others to de-stress
• Is aware and respects personal boundaries
• Is aware and seeks balance between personal and professional life
• Goes into work with a smile on their face and leaves work with a smile on their face
• Recognizes need to set boundaries such as “no house calls, limit hours with patients”
• Takes time off (i.e., vacation)

• None reported

• Not taking care of themselves: not eating right, working right through lunch
• Appears ‘frazzled’
• Doesn’t pull own weight in a group practice
• Is often ill
• Has overextended themselves into the community (e.g., member of many committees, walk-in clinics)
• Frequently cancels their office

• Deterioration in their practice
• Patient comments that GP doesn’t look well, lost weight, is rushed, forgets things, or does  not listen to patients

• Able to ask for help when appropriate
• Shows humility
• Able to recognize areas of medicine in which they are uncomfortable/lack skill and refers to medical colleague

• Recognizes own limitations in performing clinical procedures (e.g. cortisone injections) and refers to colleagues

• Frequently blames others for their mistakes
• Easily become defensive when questioned about their actions
• Complains on a regular basis
• Blaming mistakes, poor outcomes on nurses, patients, colleagues – does not accept responsibility for actions

• Physician tries to do procedure and does it incorrectly even when aware that he/she lacks the skill to do it well
• Patient seeks treatment elsewhere; such as ER or walk-in clinic

• None reported

• None reported

• Doesn’t sign out appropriately
• Difficult to contact when on call (e.g., patient INRs are 7, and the physician cannot be reached)
• Doesn’t arrange for coverage – leaves it up to colleagues to cover patient care

• Physician is on-call, but is frequently unavailable (e.g., out of the city/province/country, or frequently refuses to come in)