This is How "Balls" Works
I'd like to expand on my previous post about surgeons abdicating their medical responsibilities by explaining what happens out here in the real world when surgeons (some; not all by any means) try to get other docs (cough*me*cough) to do their work for them.
First of all, to elaborate on the specifics of the incident discussed, which is quite typical:
Yes, it was a "standard" H&P form from the facility. Surgeons -- or, more specifically, their "surgery coordinators" -- tell me that it's the hospital or outpatient surgery center that "requires" them to use the form, and that it must be completed by the patient's PCP. That is, they claim that someone other than the surgeon is insisting on my involvement. Frankly, if I were a surgeon I'd be insulted that my facility didn't allow me to do my own H&Ps or trust my judgment about whether or not I need a second opinion about my patient's fitness for surgery (if it were really the case that the hospital is requiring the PCP to complete the forms, of course.)
Here's what's really happening, though: the surgeon -- or more likely an office staffer -- says to the patient, "You need to have your doctor fill out this History and Physical form." No difference between a 75-year-old on a dozen meds or a 22-year-old having pins removed from an old fracture. No hint that the surgeon is requesting anything specific of me. No indication that I'm to do anything other than fill out a form. It's just another piece of necessary paperwork (totally glossing over the importance of evaluating a patient preoperatively) that they can foist off on someone else, because otherwise the surgeon would have to do it. And so the patient is left with the impression that "this is how it's done," which is how he comes to my office.
The problem is that when I throw a hissy fit, the patient has no idea what's going on. I'm stuck in the middle as the bad guy who won't cooperate with dear Dr. Surgeon to help the patient get the care they need. And how can I explain the problem to the patient without bad-mouthing the surgeon?
The real problem is that it's the patient who is inconvenienced when I try to stand my ground. I've tried calling surgery offices, rarely getting to talk to the actual surgeon. ("He's way too busy.") The surgeries tend to be technically "elective", but they're things the patients need; things that having to re-schedule wouldn't be fair to the patient. Of course the offices that do this sort of thing are the ones that tend to be the least cooperative, telling me the patients can't have the surgery if I don't do it, and that I have to explain it to them; basically playing a nasty little game of chicken. They know that I have more to lose by pissing off the patients than they do. That's why I often end up going ahead and just filling out the damn forms.
Besides, as is so often the case, there's the issue of money.
If a surgeon wants my opinion about a patient's fitness to undergo surgery, that is called a "Consultation." It requires several things, including:
- A written request for my opinion, and
- My written report back to the surgeon containing my opinion and recommendations.
Regarding that line of text about having discussed the surgery with the patient -- which I had not seen on other forms: I don't really think the surgeons are expecting me to obtain Informed Consent. I believe it's there as a backup in the event of a lawsuit if the issue of consent should come up. If the patient complains that the surgeon's informed consent was defective, they've got that line to fall back on: "Blame Dr. Dino. See; that signature right here says that everything was discussed with the patient."
(More later on how I try to get what I need to code these as Consults, if anyone's interested.)