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.

Thursday, April 01, 2010

It Happened Again, Dammit!

Why do people keep doing this?!?

I got a call from the cheerful chippy at the cardiologist's office:

CCCO: Your patient, 28-year-old Joe Bloe, has an appointment to see us tomorrow. Would you please fax over any recent blood work or EKGs he's had at your office?

Me (after pulling chart from cold storage): We haven't seen this patient since 2002, so we don't have anything "recent" on him. But I do see that he saw you for palpitations in the past. Don't you have that information in your records?

CCCO: No, I'm afraid I don't. Could you please fax them over?

Me: Um, I guess so. What is he coming to see you for anyway?

CCCO: I don't know.

Me: What?

CCCO: There's no Presenting Complaint written down.

Let me get this straight: a patient calls up and says, "I'd like to see a cardiologist," and you say, "Sure, come on in," WITHOUT EVEN DETERMINING THAT HE ACTUALLY NEEDS A CARDIOLOGIST?!? What the fuck! Whatever his complaint actually turns out to be, you'd better believe that these idiots cardiologists are going to do a bunch of "screening" tests (blood, EKG, echocardiogram, probably a stress test) on him because, well, because they can. Because they're cardiologists.

And if they don't find anything (as they're perilously unlikely to on a 24-year-old guy who hasn't seen a doctor in eight years), they'll ship him off to at least three other specialists; probably a gastroenterologist to see if his chest pain is GERD, a pulmonologist to evaluate his lungs, and an allergist because, well, he may have allergies. The GI will do an endoscopy and give him Nexium, the pulmonologist will order a chest x-ray and pulmonary function tests (probably before even seeing him), and the allergist will skin test him. By the time all is said and done (and the patient winds up with a diagnosis of anxiety) he will have generated thousands of dollars in medical care for literally no reason at all.

No wonder medical care in this country is so fucking expensive.


At Thu Apr 01, 01:36:00 PM, Anonymous Anonymous said...

Hmm. This hits a little too close to home. As you know, dear Dr. Dino, I (a 49 yo F) was in the ER for chest pain a month ago. All labs turned out to be negative; X-ray negative; nuclear stress test later that day at the cardiologist's negative; previously scheduled heart scan (for calcifications) resulted in a "0". Turns out that the chest pain I was experiencing was muscular, b/c I'd re-started an exercise program the day before.

Go figure.

At least I don't get a mammogram every 3 weeks -- once a year plus a twice-a-year visit to the breast surgeon is good enuf for me.

Good luck w/ your B&B this weekend. Remember, I like 'em w/ lots of cream cheese! (Yes, would you still love me if....)


Kensington MD

At Thu Apr 01, 01:39:00 PM, Anonymous Anonymous said...

And, of course, when the patient follows up on the referral to gastro, his insurance company will demand that you initiate the referral (without knowing anything about what is going on), and similarly with the pulmonologist, the allergist, and so on. So it will go on your profile, looking like you were the one who felt he needed to see all the specialists.

And, also, all the other docs will expect you to be the one to provide them with records of what the other docs have done.

Isn't it great being a PCMH (and you're doing it all for free)!

At Thu Apr 01, 03:38:00 PM, Anonymous Anonymous said...

A while back, after I underwent a certain episode which caused me to be subjected to a number of tests including several heart tests, all of which turned out negative, I was told by the cardilologist that I should schedule myself for a several additional heart tests, including a stress test. It seemed to me, and to other docs to whom I spoke, that those additional tests appeared to be unnecessary so I called the cardiologist to ask why those tests were needed. He wasn't available and I asked for a callback. I never got the callback so I never scheduled myself for those additional tests, and I have lived happily ever after.

At Thu Apr 01, 04:30:00 PM, Blogger Unknown said...

Perfect example of why people need to start of with their Primary Care doc.

At Thu Apr 01, 11:04:00 PM, Blogger Amy said...

So I guess the conclusion here is that patients are not the *ONLY* Americans who are the "real problem with American health care" ;)

I agree with your previous post that so many want so much for so little. But let's face it. Most patients would not even know how to pronounce the latest, greatest, gee-whiz wowza medical test if some doc somewhere had not ordered it in the past.

More than one doc has suggested I get an intestinal biopsy so I can have a 'definite diagnosis' for my issues with gluten. Apparently my own observations that eating the stuff makes me feel like sh*t on toast, and avoiding it makes me healthy, are simply not good enough. Really, there are lots of us out here that are perfectly happy using a lot of common sense and seeing our GP every so often for a chat and a check out of anything that is a bit more off than normal...


At Fri Apr 02, 07:03:00 AM, Blogger medstudentitis said...

Interesting. Here in Canada patients can't self refer to a specialist. They must have a referral from their primary care physician or the emergency room to be seen. They can't even go back after more than a year has passed (unless it's a scheduled follow up) without another referral. The cardiologists need the referring physician's billing number to even bill for the visit. How different things would be if they could just call up any specialist they like and ask for an appointment. Very interesting.

At Fri Apr 02, 09:40:00 AM, Anonymous Anonymous said...

For someone who's clueless about medicine: any chance you could explain how starting with a primary care doctor would be different?

At Fri Apr 02, 11:28:00 AM, Blogger Unknown said...

OK - This is weird. I was at my allergist's office yesterday and someone came in for their appointment. The receptionist told him that when they called the primary's office that she gave for a referral they were told she had not been in for 2 years and would not give the referral because of that. So the patient was given a choice - a) pay out of pocket or b) go see her primary for a checkup and then see if a referral was indeed in order... Gee - isn't that how it should be?

At Fri Apr 02, 12:33:00 PM, Anonymous Anonymous said...

Before I start, I am a co-founder of Qliance (monthly-fee) primary care in Seattle. However, I am also a "patient" in the health care system like everyone else - here is my story about chest pain...

Regarding the first comment about the individual who had chest pain, four years ago I started working-out (again) and as a part of my routine did some bench presses. Two days later, I was running and had to stop as a result of excruciating chest pain.

I got home and called Dr. Garrison Bliss (my monthly fee doctor at the time, co-founder at Qliance with me today). He was able to see me that afternoon (with only 800 patients to take care of he had the time).

I went to his office, he listened to my heart, performed an EKG and a quick test to see if I had heart attack enzymes in my blood. All were negative. We then talked (what a concept). In our discussion he asked what "other" things had I done lately. In the end, we concluded that I probably tore the muscles that connect my ribs (or something like that) and when I ran the muscles were agitated with the arm movement and bouncing. The entire visit was just over 1/2 hour. It cost me nothing (I already paid my $65 monthly fee to see him) and I went home a happy camper.

Affordable monthly fee primary care IS the solution to this mess because the doctor had only one incentive and that was to be available and take care of me. His income is consistent, he knows who his patients are and he has no incentive to do more or do less than what is truly needed. If he fails to follow-through on these promises, I fire him.
I am a “healthy” 40 year old, ex-collegiate rower however I have been to the doctor probably five times this year for little things - odds and ends. The reason I go is because I can and for that reason I value the service and keep ahead of the curve. I also have a high deductible insurance plan but rarely need to use because I can get so much done at Qliance.

At Sat Apr 03, 01:23:00 AM, Blogger ray said...

wow! Truth hurts to hear but I guess this happens all the time. Now isn't the new health reform going o weed such fraud and abuse ??? I thought PCP has to refer if the specialist did not see the patient in more than a year.

At Sat Apr 03, 01:23:00 PM, Blogger Tris said...

Dr. Dino, how do you know that this patient wasn't referred by another primary care doctor for something that really does need a cardiology workup? And an overzealous intake process asked what doctors he had seen in the past eight years, requesting records from all of them?

Or maybe he seldom goes to the doc at all, but did go to a primary recently whom he had never seen before, and therefore prior records were requested.

Or he presented to the ER with chest pain, the basics were done, and he was referred to a cardiologist by the ER. Being an apparently healthy 28 year old man, he has had few if any doctor visits since seeing you in 2002.

Don't jump to conclusions.

At Sat Apr 03, 02:45:00 PM, Anonymous Anonymous said...

Tris -
In Dr.Dino's defense I must say that in every situation where I've had to have a referral the offices are quite clear that they will only take a referral from a PCP that is your current one. Assuming that this is an office that has dealt w/Dr. Dino or any of his area associates in the past (and you have to assume that is the case in most places) then if it were the cardiologists office's fault every doctor in the area would know that by now and would have talked to the cardiologist to tell him to clean up his office's act. I will stick the blame entirely on the patient. I've just finished a series of treatments at my local hospital. There are many people who show up there for the same thing. Amazing how many of them show up late instead of at their appointed time and then get all upset that they cannot be seen. Many doctors and specialists in my area have put up signs that explain that if you don't show up you will be liable for a cancellation fee of $25 and/or if you miss or cancel 3 appointments with less than 24 hours notice you will be dismissed. Astonishingly the no-show rates at those offices have dropped amazingly and only a few patients have been dismissed. Tris - a couple of other things - I've never seen a form at a doctor's office that did not ask for one's PRIMARY care physician and every person - healthy or not should see their primary once a year for an annual checkup. This helps to establish a baseline and also might prevent other issues going forward. Nope - it's that patient's fault for being stupid and Dr. Dino - I hope you did not give him/her a referral without he/she coming in to see you first.

At Sun Apr 04, 10:34:00 AM, Anonymous Anonymous said...

As you quite rightly say, there is no cure for stupid.... Doctors or patients. Fossil

At Wed Apr 07, 02:17:00 AM, Blogger HMS said...

Great blog, first of all.

Have been contemplating how to draw a line between [medical] wasteful practice and that of necessity. Here is a recent NYT article that goes along the same topic:

"In Medicine, the Power of No"

If the reform were to succeed (5-10 years down the road), our understanding, expectation and routine/status quo/practice would have to fundamentally change. Just saying.


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