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.

Wednesday, June 03, 2009

Why I Do Blood Draws

From the comments:
Do you really do lab draws for other (i.e., lazy) docs?

You're taking on all the responsibility for handling, tracking, follow-up, and payment just to make life a little easier for those over-worked specialists?

Please explain!
Okay, I will.

I don't do it primarily to make life easier for those other lazy docs, but for my patients and myself. For patients who still insist on galivanting about to all the various partialists, coming to me for all their blood work has significant advantages:

1. I can avoid duplicate testing.

This happens all the time. I recently had a patient with newly diagnosed celiac disease whose gastroenterologist wanted several tests. I was able to send only half the ones he'd ordered, because the others had been done two weeks earlier. I copy the endocrinologists on lipid panels ordered by cardiologists, and grab a PSA for the urologist while I'm at it. All told, I would say this is the single greatest advantage to sending the lab work myself.

2. I can add other tests that are due or indicated.

If it's been more than three months since an uncontrolled diabetic's last A1C and he comes from the urologist for a PSA, it's as easy as checking off a box on a requisition and drawing an extra tube. I once had a patient come in for an electrolyte panel and noticed that he was jaundiced as all hell! I added appropriate liver function tests, and drew an extra tube for hepatitis serologies. Not infrequently, a patient will ask me to add other tests, as in, "Could you just check my cholesterol while you're at it?" Assuming they haven't just had it done within the last six months, I'm happy to oblige. A lab tech doesn't have that option.

3. It keeps me in the loop.

As I may have mentioned a thousand times once or twice, I can't always count on specialists letting me know what's going on with my patients. When I send the lab, I know I'm going to get a copy of the results. Although my policy is to tell the patient the specialist is responsible for letting them know about the results, I know I'm going to get a copy if I'm the one sending it. That way, if the patient calls and complains that the specialist never got back to them, at the very least I know whether or not there's anything to worry about. This is also why I don't mind being in charge of the tracking process. If the specialist lets something fall between the cracks, it will be the patient who suffers for it, and who may decide it was my fault for sending him to that particular doc in the first place.

4. It's an opportunity to review the chart and see if the patient needs anything else while they're in the office.

Usually I scan the inside front cover of the chart, which is where I keep my preventive care flowsheets. Flu shot? Tdap due? Do they need prescriptions refilled? Note for a mammogram? Phone number to schedule a colonoscopy? Time to schedule a pap or physical? There's a reason I code these as Level 1 visits, since I can almost always get in at least 5 minutes of discussion or counseling of some kind.

5. I'm a really good stick.

I have patients who go to what might be considered ridiculous extremes to let me -- and only me -- draw their blood. A bad experience at a lab can be traumatic. I have some tricks that result in large proportions of surprised and grateful patients.

And that's why I send labs from my office.


At Wed Jun 03, 07:20:00 AM, Anonymous Dano said...

I'd like to add one more : sometimes the office can't do it (as a method to ensure that they are not fudging numbers to get a procedure done).

At Wed Jun 03, 08:05:00 AM, Anonymous Anonymous said...

The WORST when in the ER is when a patient would come in with bloods results from somewhere in their hand from the same day or the day before and they draw the exact same ones in the ER (when there's no reason to suspect any change).

At Wed Jun 03, 08:22:00 AM, Anonymous SHG said...

Please make sure you don't forget your tricks between now and 7:30 tomorrow ("It's not easy being green" Source: Frog KT, Sesame Street, volume and year unknown.)

At Wed Jun 03, 08:23:00 AM, Anonymous family doc said...

Thanks for the reply.

A couple thoughts:

"1. I can avoid duplicate testing."

I guess the virtue here is that you save a few bucks for the starving insurance companies, but then you add on an E&M code, so it's pretty much a wash, isn't it?

"3. It keeps me in the loop."

Actually, it does more than that: it puts you in the hot seat. If you're the one requesting the studies from the reference lab, no matter what some specialist has scribbled on the back of a prescription, you're the doc who is ethically and legally responsible for notifying the patient of the results and making sure that any abnormalities are followed up on appropriately. Just telling the patient to get the results from the other doc doesn't get you off the hook: YOU'RE the one who ordered the test.

This has been an issue in our office for years. Two MDs, two PAs, one lab tech, dozens of patients showing up daily with requests for extensive and obscure tests, no diagnosis indicated, ordered by other lazy docs (who also want to make their profiles look more cost effective to the third party payers by having us do all their lab work for them). We finally came to the decision not to do any lab for other docs, and life is better.

My motto: act like a scut monkey, get treated like a scut monkey.

Thanks for a great blog!

At Wed Jun 03, 09:00:00 AM, Blogger #1 Dinosaur said...

First, thanks for the props. Next: I completely see your point about lazy docs ordering extensive obscure testing for questionable dx. I've even picked up wrong tests (coagulopathy w/u for slight bleeding gums ordered by Gyn). I've either called the partialist on it, or changed (well, added) the right test(s) if indicated. In the process, more than one patient has decided not to bother going back to that particular doctor.

In the situation you describe, though (busy practice; much abuse by others) I agree that your decision to opt out is well advised. For me, though, the pros still outweigh the cons.

At Wed Jun 03, 10:51:00 AM, Blogger Jon said...

Can you tell me why, when my doc orders 10 tests, they must draw 10 tubes of blood? I mean, seriously, not all tests require 5ml of serum or a whole purple top tube! I sometimes feel like why not just take a whole pint, then, and donate what they don't use. Sheesh.

At Wed Jun 03, 02:07:00 PM, Blogger Ambulance Driver said...

Heh. Great minds think alike.

I was taught the bevel-down IV technique fifteen years ago in a PALS class, and I've been using and teaching it even since.

I even use the same diagram you use in your post.

It's a lot harder to do with shielded IV catheters, but it can be done.

At Wed Jun 03, 02:34:00 PM, Anonymous Anonymous said...

I do the same thing...not for any of your reasons... I just like stickin people with needles...thats why I went into anesthesia...
Gets a little uncomfortable at cocktail parties...

At Wed Jun 03, 03:05:00 PM, Blogger #1 Dinosaur said...

Great minds think alike.
Yeah, but so do we.

@Frank Drackman:
You can just poke them with toothpicks (the ones with the colored cellophane ruffles) at cocktail parties instead. (Actually, it's been shown that poking people with toothpicks is just as effective as acupuncture.)

At Wed Jun 03, 11:09:00 PM, Anonymous Anonymous said...

In out office we do lab for outside docs only if it's one of our patients, there is a written order, and they include a diagnosis code. And even then not all the time.

At Thu Jun 04, 08:14:00 AM, Anonymous William the Coroner said...

Funny-on my patients I am considered good at getting the blood. But I use an 2" 16 ga needle and go straight for the femoral. If that doesn't work, I can always get it out of the aorta.

At Thu Jun 04, 08:56:00 AM, Blogger #1 Dinosaur said...

@WTC: And you don't even have the pulse to help you locate it.


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