# Trends and Challenges in Orthopedic Referrals Following the Development of a General Medicine Department in a Community Hospital: A Mixed-Methods Study

## TL;DR

This study examines how a general medicine department in a community hospital affects collaboration with orthopedics and identifies challenges in improving patient care.

## Contribution

The study provides insights into interdepartmental collaboration challenges and opportunities in community hospitals with multimorbid older patients.

## Key findings

- General medicine referrals for orthopedic inpatients were common, with high patient age and varied referral reasons.
- Qualitative analysis revealed themes of role ambiguity, workload imbalance, and the need for standardized referral processes.
- Early general medicine involvement was seen as beneficial for comprehensive care and patient safety.

## Abstract

Background

In community hospitals, an increasing number of older patients with multimorbidity are being admitted to orthopedic wards. Although general medicine departments are expected to contribute to comprehensive inpatient management, their roles in orthopedic ward care and interdepartmental collaboration remain insufficiently defined. This study aimed to explore how the establishment of a general medicine department influenced collaboration with orthopedics, and to identify challenges and opportunities for improving inpatient care in a community hospital setting.

Methods

We conducted an explanatory sequential mixed-methods study at a community hospital in rural Japan. First, a retrospective review of electronic medical records was performed to analyze referral patterns from orthopedics to general medicine between April 2016 and March 2024. Descriptive statistics were used to examine patient characteristics, referral timing, and reasons for consultation. Subsequently, semi-structured interviews were conducted with 11 general medicine physicians, and qualitative data were analyzed using thematic analysis to explore perceptions of collaboration, roles, and system-level challenges.

Results

A total of 530 orthopedic inpatients were referred to general medicine during the study period, with consistently high mean patient age. Referrals varied widely in timing and content, with symptoms, laboratory abnormalities, and vital sign abnormalities being the most common reasons. Qualitative analysis identified four themes: (i) awkwardness in the referral process arising from differences in professional values; (ii) building bridges toward effective collaboration; (iii) mutual collaboration grounded in an appropriate sense of responsibility; and (iv) the importance of mutual understanding for sustainable collaboration. Participants emphasized the benefits of early general medicine involvement for comprehensive management and patient safety, while highlighting challenges related to role ambiguity, workload imbalance, and lack of standardized referral criteria.

Conclusions

In community hospitals, general medicine departments can play a critical role in improving comprehensive care and safety for orthopedic inpatients. However, sustainable collaboration requires clearer role definition, standardized referral processes, and organizational support. Redefining general medicine as a core component of inpatient care may enhance interdepartmental collaboration and improve overall quality of care in community hospital settings.