More Clarification on "Balls"

I'd like to further clarify some of the details of my complaints about surgeons who try to get me to do their work. Some of the comments to the previous clarifying post began to get into a pissing match between surgeons and anesthesiologists, which was not the issue. Here's why:

Out here in the real world, things work somewhat differently from in a teaching hospital. The usual protocol is for the patient to have a separate anesthesia consult, often several days prior to the surgery, where the anesthesiologists do their own evaluation. They have their own patient questionnaire; they review the pre-op labs and EKGs, and they will often contact me independently if they have a concern about the patient's medical status. I have no problem with this. (Except when they call the morning of surgery with a 50 y/o diabetic's creatinine of 2.7 that's been stable for years, insisting that "she needs to see a nephrologist" before surgery. I call my nephrology colleague, am reassured that he is as incensed as I, and recite the magic words to Anesthesia, "Nephrology says it's ok.")

It is the surgical history and physical of which I speak. As my (good) surgical colleagues have explained to me, the surgical H&P goes over the surgical problem and physical findings, along with the surgical diagnosis and plan; including, of course, the informed consent and an assessment of whether or not a separate medical consultation is required. This is what the (lazy) surgeons are trying to foist off on me.

I would also like to point out something poorly understood (or ignored) by so many, from various commenters to Medical Economics magazine itself: the idea that I, as a primary care physician, can express my displeasure with a specialist by withholding future referrals is NONSENSE! In the sub-specialist-saturated area in which I practice, patients are referred willy-nilly from one specialist to another with no input from me at all. In the case that initiated the original diatribe, for example, the patient was referred by her ophthalmologist to a plastic surgeon who sub-specialized in ocular plastic surgery. And of course once a specialist says, "You need to go see this other doctor," no one cares about my opinion.

As if that weren't bad enough, in this age of information overload, patients often select their own specialists -- either from the internet or word-of-mouth referral -- and take themselves off to see them without even telling me. Worse, there are times when they do ask and I say, "I prefer Dr. A or Dr. B, but I've had some problems with Dr. C, so I don't recommend him," and sure enough, the letter comes back from Dr. C (that invariably begins, "Thank you for asking me to consult on Mr. Moron," thus insuring he can bill the visit as a consult for higher reimbursement.) Until (unless?) primary care in this country is strengthened to at least allow me to stay in the loop, this shit will go on. Obviously the strict gatekeeper concept failed miserably, but there ought to be some kind of middle ground; otherwise these ricochet referrals will only get worse.

Bottom line is that I have no power in these situations. As previously discussed, standing my ground too often means alienating the patient; another issue that only takes on real meaning after graduation from residency. Think about it: there's plenty of lip service paid to the importance of patients in the teaching hospital, but as a trainee, the people you really have to please are your superiors. Sad as it may seem, it doesn't matter if patients don't like you. They don't get a say in your evaluations. (Hmm: maybe they should.) The flow of patients is independent of your actions or behavior. They keep on coming, whether you're the nicest guy on the planet or a raving lunatic. It's only later that reality intrudes to the point of realizing that you have to play well with others if you want to eat. (Perhaps those who never learn this are the ones who remain as academic/teaching hospitalists.)

So thanks for the positive feedback. I just wanted to point out that it's not an anesthesia issue, and that all those textbook suggestions about "Don't refer to them in the future" are unhelpful in the real world.