Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, November 30, 2007

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.


At Thu Nov 29, 08:32:00 PM, Anonymous Anonymous said...

How about the specialist whom you consult for a legitimate specialty complaint who notice a mild primary-care-appropriate medical problem and inappropriately refer to a specialist? I've had specialists refer my patients to cardiologists for their stage I hypertension. Aargh!

At Thu Nov 29, 08:38:00 PM, Blogger #1 Dinosaur said...

I just had a (non-board certified) "rheumatologist" refer a patient to a cardiolist "for BP control." Her BP: 134/86. I agree: it's a huge problem.

But I really like the term "ricochet referrals." Don't you?

At Fri Nov 30, 07:34:00 AM, Blogger MedStudentGod (MSG) said...

Sorry about getting a little heated regarding the surgeon/ anesthesiologist issue. It just makes the blood boil a bit to hear people spout out untruths.

At Fri Nov 30, 09:53:00 AM, Blogger Dreaming again said...

You've got to be kidding Dr. Dino ... I'm sorry. As a patient who has to have a Rheumy (but doesn't ..long story) anyone who needs a rheumy, neuro, or similar specialist ... does not need to have the burden of a referral to a CARDIOLOGIST for control of BLOOD PRESSURE

IMHO ..even really high blood pressure, without other complications should be managed by a PCP ... unless the PCP says it should go to the cardio.

a Cardio is a scary referral for most patients ... it in and of itself causes stress. To add to the patient the burden of another specialist, to a patient with a chronic health condition is irresponsible!!! EGADS that's cruel!


At Fri Nov 30, 12:14:00 PM, Blogger mark's tails said...

great post and I'm glad to know this happens everywhere. I saw a consult yesterday who was also seeing Dermatology the same day. I saw the patient first and made my recommendations. Derm saw the patient and had the "Balls" to write in their note (we have an EMR here) "saw allergy, no skin testing performed" and they proceeded to order RAST testing for inhalants and foods.


Seriously!? WTF

At Fri Nov 30, 01:17:00 PM, Anonymous Anonymous said...

i'm a cardiologist. patient asked for a referral to endocrinologist. i referred her to the endocrinologist for diabeters management. patient was in on sq insulin and oral hypoglycemics and a1c>9. the endocrine clinic apparently only accepts referrals from primary care docs. uh okay, why would that be, i asked? the receptionist kindly answered because otherwise they would have to manage the primary care problems.

anyways, not really related to the conversation, but i wanted to play.

At Fri Nov 30, 03:36:00 PM, Anonymous Anonymous said...

Isn't this really an issue about getting paid (or not)? If I were paid appropriately for these "pre-op physicals" or could collect payment from the patient, I would be glad to do them. Sooner or later the patients would get wise and ask why the surgeon would force them to incur the extra expense of going to the PCP for this service. However being forced to do these for an office visit fee (Medicare) or a $5.00 co-payment (managed care) is the real ball buster here. This is another reason why PCP's need to opt out of the increasingly ridiculous payment system for the sake of their financial, professional, and mental health.

At Sat Dec 01, 08:08:00 AM, Blogger #1 Dinosaur said...

Anon 1:17: If a patient is asking you (a specialist) for a referral to another specialist it means that either:
1) She thinks of you as her primary (a problem)
2) She isn't comfortable with her primary (a different problem)
3) She doesn't have a *real* primary (a different problem altogether.)

These problems are the direct results of the shameful state of primary care reimbursements in this country.

Anon 3:36: Of course getting paid is the issue. It's the root issue that leads to all these problems, and more.

At Sun Dec 02, 06:38:00 PM, Blogger Dreaming again said...

#4) she doesn't understand the roles of specialists and PCP's ...another problem altogether.

At Thu Dec 06, 06:07:00 PM, Anonymous Anonymous said...

As to residents being there to please their superiors:
I had an implant placed in the dorsal column (for pain). The wound area became red and oozy. On the phone the resident told me that this was normal healing.
It turned out to be a raving infection that resulted in my losing the implant.
When I told the attending, my eeurosurgeon, that Dr. ( ) ignored my cmplaints before the infection required the hospitalization and removal, he ignored me.
And this was a surgeon for whom I had the utmost respect.
In a separate incident, during the same hospitalization, another resident ignored my repeated "No's" about putting an IV line back in. He grabbed my arm and put it in anyway.
Again, when I told my surgeon, he said "You should talk to him about it." as though it was my job to teach him medical ethics.
Thank you


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