Effective, high-quality communication depends mainly on the interlocutors´ prior positions, which in turn depend on their attitudes, beliefs and values. Communication between levels of care is no exception; it is highly influenced by assumptions that form part of each organization's professional culture, in both primary care (PC) and specialized care (SC).
Optimum communication should not depend exclusively on well-designed administrative channels of information, but should also be based on high levels of motivation, which probably arise from knowledge, respect and trust between the parties involved. In our setting, especially in PC, the issue has been of concern for some years,1 although lately it appears to have been pushed aside by other priorities. Perhaps the reason for discouragement is because in daily practice, improvements in communication between different levels of care are terribly slow to appear.2
This slow rate of change is the result, in part, of how hard it is to change ways of thinking and acting that have taken root in the habits of most professionals. For example, simply by talking about communication "between levels," we are implicitly accepting beliefs and images associated with these words. The concept of levels of care brings up, for most of us, the mental image of a pyramid with PC at its base (i.e., at the bottom) and hospitals at its apex (i.e., at the top), or even worse, of hospital care on one level and nonhospital care on a different level. The idea that these levels are arranged vertically (the word itself invokes the notion of a hierarchy) places PC in a position from which effective communication is difficult to achieve. For communication to be truly effective, it must by symmetrical, from peer to peer.
Some convictions that make up an institution's culture, if acquired in an uncritical fashion, strongly influence the entire process. If these convictions are warped, patterns of communication will also be warped. This issue is of crucial importance for understanding the frequent miscommunication between PC and SC.3
The most widely-held opinion among many hospital professionals is that it is in the hospital where the patients' health problems are actually dealt with, where the real experts in all types of diseases are, and where the capacity to resolve the patients' problems is high, to be marred only by an avalanche of people "with nothing seriously wrong with them" who are referred for no justifiable reason by family physicians who are obviously undertrained. On the other hand, primary care physicians generally view specialists (the "other" specialists, that is) as holding a view of medicine that is overly disease-centered, allowing waiting lists to build up needlessly, and undermining strenuous efforts to achieve rational prescribing practices. Furthermore, specialized care does not afford its practitioners a comprehensive vision of the patient's health needs (Table).
The outcome of this scenario can only be a climate of mistrust in which PC, unable to attain the status is deserves, loses out. Despite the enormous changes in PC in recent decades with regard to improved quality of care and enhanced scientific training, many SC physicians continue to perceive PC physicians as "second-class" colleagues. We readily tend to center on the more negative elements in others, neglecting everything that is positive about who they are and what they do. The result, overall, is disparagement, and this has consequences for the quality of communication.
The only things that can lead to respect and the perception of other colleagues as peers are personal acquaintance and frequent contacts, which furthermore allow one to appreciate the value of colleagues´ work. When PC professionals demonstrate their competence and are able to explain the scientific paradigms that guide their practice, the result is enhanced respect and appreciation from their hospital colleagues. Likewise, when PC physicians appreciate the problems faced by their hospital colleagues, their understanding and respect for the work they do increase. This is especially the case in areas where the two types of care come together. The article by María Teresa Cerdán and colleagues shows that collaboration between PC physicians and surgeons leads to a number of interesting results such as improved overall quality of the health care process, as well as an increase in mutual understanding and trust--a valuable commodity. In any experience that involves increased formal or informal contact between different professionals, palpable progress in communication and cooperation is seen.
The reflections offered thus far have been expressed in more or less explicit terms for more than 2 decades.4 A cultural shift in our health care system is needed, but this will take time, because changes of this nature occur in small steps. Time is also needed in day-to-day practice to free practitioners from some tasks so that there is more time for contact with colleagues. The patient load is usually so heavy that no time is left for meetings of this sort--possibly one of the most important reasons why progress in communication between levels of care is so slow. If the health care system is not capable of ensuring enough time for hospital and community professionals to perform their duties with a minimum of rigor, and for periodic contact with their colleagues on the job, the chances of effective communication are remote. Of course improvements in informatics and administrative support are necessary, but they should be accompanied by opportunities to use them effectively. A hastily-written report is a discredit to its author and discourages the person to whom it is addressed from responding to it.5
Therein lies the paradox. We have professionals in both settings with excellent skills despite their chronically heavy work loads, who are unfamiliar with each other's work and thus are unable to recognize good practice, or who ignore each other. In the face of this situation, we have nothing to lose from investigating the benefits of getting to know each other better.
