(UC) "Dr. Blahblah wants you to order a blah."

[Febrifuge]

As some of you know, I solo-cover a suburban Urgent Care, attached to a big health system. about 2/3 of the people I see have their PCP in this same building, during sensible business hours; about 1/3 are completely new, and for all I know they have never seen a doctor in their lives. There are some overlaps, like people who tend to use the UC instead of their PCP, but in general it works fairly well.

 

We also have a nurse line people can call, and in typical fashion I see a few people who only came in because of they way they answered a question on the phone. That doesn't bug me too much; better safe than sorry, right?

 

The issue that does grind my gears is when a patient calls the nurse line - or their PCP's office - and some doc on call says "go to the UC, have them order such-and-such a test, and then based on that result we can do x or y."

 

I'm a team player, truly. I make big speeches about how important it is to see your PCP, how they can watch out for you in ways we can't, how the UC is a poor substitute for continuity of care. I talk them up, I respect their wishes, I don't monkey with people's BP or DM meds unless something is obviously really wrong.

 

But dammit, either log in and put the damn orders in the damn system your own damn self, or else just tell people to come see me, and let me decide what to do. Even when I would do the exact same thing you just said, I feel like you're using me as a satellite office because you don't want to go to some effort, either big or small.

 

Maybe I'm just ranting, I dunno. Maybe these people - who aren't even in the same division as my SP - really do respect my clinical acumen, and they're just looking out for their patient the best they can. But it bugs the crap out of me, especially when Dr. Smartypants just tells the LPN all this, and doesn't even bother to speak with me on the phone.

 

This is why the term "physician extender" makes me grind my teeth.

 

Thoughts? Horror stories?

[KMD16]

I quickly glance your point. I get your point. I provide solo coverage at UC Ctr not affiliated to major hospital etc + ED coverage and share in your concerns. I listen but don't yield to pts PMD request. I examine pt & provide appropriate tx. I'm only responsible to discuss/review pt w/ my SP if I see the need to. Don't be push around.

[ventana]

Call the PCP

 

Ask if they are just ordering the test - if so don't see the patient - refer the PCP to the scheduling department to get set up for the test....

If the PCP is not just ordering a test - and wants the patient examined, explain to the PCP that it would be best to let the person evaluating the patient decide what is the best test to order, and at the same time ask if there is any particular reason (specific to this one patient) to order a certain test. 

[True Anomaly]

Agreed Febrifuge- the way I see it, you send someone to the ER because you have a concern and want a second opinion from someone who's specialty is emergency medicine- no different than sending to another specialist to get their expert opinion on a patient's complaint.  Many times when these patients are referred to the ED for testing that the PCP should've ordered in the first place, I try to contact them directly (if they don't call in first) and ask what their concern is.  If my exam does not jive with what they're seeing, I will get my attending involved to see the patient and see if they agree with me.  There are times, though, that even after this and myself and the ER attending both agree on the exam, the attending will end up doing the test as requested so as not to ruffle feathers.  At which point I just document everything thoroughly.

 

There are times when I feel the PCP utilizes the ER because they either don't want to or feel they don't have time to do the legwork to hunt down the cause of a patient's symptoms and if it actually needs any follow up.  Case in point- a couple years ago I saw a woman come in for what her PCP said was "CSF rhinorrhea".  It was definitely more watery than the fluid associated with a more allergic rhinitis, but thicker than plain water.  It had been going on for about a month- not sure if the patient actually had some trauma which started it, but she believed so after a ground-level fall.  Target test was negative (there was no blood anyway), so we did a CT of head and facial bones- no obvious break.  We send the patient home to follow up with PCP after calling and discussing with a colleague of the PCP who agreed.  I come back to work the next day- guess what, the patient is back!  She said her PCP was not satisfied with our decision so she sent the pt back to the ER again.  So I research as thoroughly as a I can what available text there is, and I call both an ENT and a neurosurgeon to discuss, and they both agree- nothing to do at this point, to even TEST the fluid to see if it's CSF takes about a week to confirm, and even if it is the treatment is outpatient- there's no reason to have her in the ED, and they're certainly not going to come in at night to evaluate this.  I call the original PCP who seemed a bit incredulous at this, but I explain it as simply as I can, and after a few tries it finally sinks in.  

 

I get family practice is a tough, high-volume environment...but so is our ER.  And if they don't have an acute fracture in the facial bones, no signs of acute intracranial pathology, no signs of meningitis/encephalitis or some focal neuro deficit that needs immediate attention....they don't need to be here.  And the PCP taking the time to do the calling that I did in the ER saves the patient from TWO TRIPS to the hospital that weren't necessary.

[EMEDPA]

I will consider their request and if it's fairly benign( do a cbc to check for anemia) I will go ahead and do it.

if I don't think they need the test they don't get it. my least favorites are go to the ER to get a ct scan after a minimal injury without loc or n/v or go to the er for an LP because you have a h/a with your cold. not gonna happen. I don't work for them and could really care less what the docs in the community think about the way I practice. like Feb said, if the really want the test they can order it themselves.

[Febrifuge]

Thanks, guys. Nice to know it's not just me.

 

I have spoken with the Nurse Line people, and will be talking with my SP as well. There may be some systemic/ procedural ways to address the problem. Also, someone may have messed up today under existing rules, so there's that.

[Febrifuge]

It's worth pointing out that the consultant on call might have said "yeah, I bet they could use [test], so the UC is the place to go. Oh, and I'm concerned about [infection] in this one, so if the UC is concerned too, make sure they know to send the patient to [specialty clinic] and not the ER, okay?" ... or they may have actually said "tell the UC to order [test] and then if it's abnormal, have them send the patient to [specialty clinic]. I didn't speak to anybody else with a medical license, so I have no idea.

 

It's the "telephone tag" nature of the thing that bugs me so much. The LPN who works with me told me what the nurse line nurse told her, which was supposedly what the on-call specialist said. Uh-huh, sure. Can't see how that could possibly be messed up.

[EMEDPA]

nurse phone triage has to be the easiest job ever.

they have one script. it goes like this:

1. listen to pt complaint

2. send all pts directly to the ER immediately regardless of #1

 

I'm serious. the ridiculous stuff they send in to the ER at 3 am blows the mind.

Tiny splinter in thumb x 15 min. td utd. that couldn't wait 5 hrs to see the pcp in clinic? you needed to spend 750 dollars of someones money to do an intervention your mom could have done at home?

Runny nose tonight. no fever. healthy 21 yr old male college student with no pmh. alert the media.

 

what has happened to common sense?

[PACdan]

Runny nose tonight. no fever. healthy 21 yr old male college student with no pmh. alert the media.

Can't believe you missed that diagnosis.

 

It was clearly a case of 8AM Orgo Exam-itis.

 

"uh...I can get a note for school, right?"

 

 

Sent from the Satellite of Love using Tapatalk

 

[rev ronin]

what has happened to common sense?

 

It's been sued out of existence.

[Emerson]

I will always take into consideration requests by the patients PCP. Difference being, I work in an emergency department and my job is determine whether or not their patient is having an emergency. But, I am not ordering an MRI of the Lumbar Spine to r/o Cauda Equina when their patient presents with no cord deficits. I understand they may have a radiculopathy secondary to a root compression from a disc protrusion, but that doesn't justify an emergent MRI in the ED that will be 10x the cost for outpatient imaging.  Unless they lack sphincter tone, US demonstrates >120 post-void residual, areflexic, muscle atrophy, no bulbocavernousus reflex, diminished sensation while sticking an 18g needled into their dermatome then I call the PCP and request they schedule this as an outpatient procedure. We used to be able to call the hospitalists and admit for 'intractable back pain' knowing they would get the MRI, but we are getting push backs now on the validity of an admission. This will be the future of ED where we absorb all the risk!

[ventana]

what has happened to common sense?

 

 

It's been sued out of existence.

 

 

Not entirely true

 

Having worked in a high volume PCP office it was not that the doc's were getting sued, but instead that their schedules were jam packed and they honestly did not want to see any add ons.  They (IM Doc's) feel the need to maintain their 200k+/yr income and the only way to do this is to have a jammed packed scheduled of routine followups.  The one acute visit that requires ongoing thought and management (or heaven forbid suturing) is just a time looser so - punt to ER.....

 

In my personal opinion this is very short sighted and not good for revenue - they lost all procedures (where the $$ is) and just became outpatient visit machines....

Starting such things as an acute care schedule, simple ortho management, joint injections......  all help the patient and the bottom line.

[skyblu]

Depends on the test. And the PCP!

 

There are a few around me who are notorious for abusing the resources. It is frustrating for the patient, for me, and ultimately for the whole system when we are used as the "convenience room" instead of the emergency room.

 

A couple of examples from this last week:

 

Woman with chronic back pain, no neuro deficits/red flags, no new features to her pain. PCP sends her to the ED "to get an x-Ray to see if you have arthritis." Lady waited 5 hours for this "emergent" film. And yes, of course, she had arthritis. Don't we all?

 

Healthy 38 yo guy with no comorbidities has cough and fever. Sees PCP, who runs a flu swab and gets an x-Ray right at their facility. Flu is positive, CXR shows small PNA. Guy is totally stable, normal sats, etc. PCP puts him on Tamiflu and amoxicillin, but also sends him to the ED "so they can run more tests." Mystified as to what other tests he meant, I called him. He asked me to check a CBC to see if he has a white count. Um, why? I didn't. I told him I didn't think there was an indication for emergent testing since the presence or absence of leukocytosis would not change our treatment. And then I changed the antibiotic.

 

PCP sends a guy to the ER "to be seen by a hand surgeon" for a small piece of glass embedded in his finger for 6 months. Guy waits 3 hours to be seen, then I tell him the surgeon will not come to the ED for this, guy stomps out in a huff and likely skewed our Press Ganey.

 

It drives me a bit mental when PCP's do this. If there is a reasonable concern, or even less reasonable but at least somewhat urgent, I'll play ball. But don't waste my time and the patient's time with the chronic stuff!

[True Anomaly]

Depends on the test. And the PCP! There are a few around me who are notorious for abusing the resources. It is frustrating for the patient, for me, and ultimately for the whole system when we are used as the "convenience room" instead of the emergency room. A couple of examples from this last week: Woman with chronic back pain, no neuro deficits/red flags, no new features to her pain. PCP sends her to the ED "to get an x-Ray to see if you have arthritis." Lady waited 5 hours for this "emergent" film. And yes, of course, she had arthritis. Don't we all? Healthy 38 yo guy with no comorbidities has cough and fever. Sees PCP, who runs a flu swab and gets an x-Ray right at their facility. Flu is positive, CXR shows small PNA. Guy is totally stable, normal sats, etc. PCP puts him on Tamiflu and amoxicillin, but also sends him to the ED "so they can run more tests." Mystified as to what other tests he meant, I called him. He asked me to check a CBC to see if he has a white count. Um, why? I didn't. I told him I didn't think there was an indication for emergent testing since the presence or absence of leukocytosis would not change our treatment. And then I changed the antibiotic. PCP sends a guy to the ER "to be seen by a hand surgeon" for a small piece of glass embedded in his finger for 6 months. Guy waits 3 hours to be seen, then I tell him the surgeon will not come to the ED for this, guy stomps out in a huff and likely skewed our Press Ganey. It drives me a bit mental when PCP's do this. If there is a reasonable concern, or even less reasonable but at least somewhat urgent, I'll play ball. But don't waste my time and the patient's time with the chronic stuff!

 

It's become such a part of the routine now that I didn't even blink when reading this.  If you (not you, skyblu, the general "you") haven't experienced situations such as the above, you haven't worked the ER long enough

[GetMeOuttaThisMess]

Depends on the test. And the PCP! There are a few around me who are notorious for abusing the resources. It is frustrating for the patient, for me, and ultimately for the whole system when we are used as the "convenience room" instead of the emergency room. A couple of examples from this last week: Woman with chronic back pain, no neuro deficits/red flags, no new features to her pain. PCP sends her to the ED "to get an x-Ray to see if you have arthritis." Lady waited 5 hours for this "emergent" film. And yes, of course, she had arthritis. Don't we all? Healthy 38 yo guy with no comorbidities has cough and fever. Sees PCP, who runs a flu swab and gets an x-Ray right at their facility. Flu is positive, CXR shows small PNA. Guy is totally stable, normal sats, etc. PCP puts him on Tamiflu and amoxicillin, but also sends him to the ED "so they can run more tests." Mystified as to what other tests he meant, I called him. He asked me to check a CBC to see if he has a white count. Um, why? I didn't. I told him I didn't think there was an indication for emergent testing since the presence or absence of leukocytosis would not change our treatment. And then I changed the antibiotic. PCP sends a guy to the ER "to be seen by a hand surgeon" for a small piece of glass embedded in his finger for 6 months. Guy waits 3 hours to be seen, then I tell him the surgeon will not come to the ED for this, guy stomps out in a huff and likely skewed our Press Ganey. It drives me a bit mental when PCP's do this. If there is a reasonable concern, or even less reasonable but at least somewhat urgent, I'll play ball. But don't waste my time and the patient's time with the chronic stuff!

 

Another group of examples where we let common sense once again enter the picture and it makes life difficult for us.  I wonder if the physician even knew what form of pneumonia that they were most likely treating, and why?  Don't worry sky, if we see only tourists we're only going to be dealing with sunburns and sealife bites/stings.  Just keep mai-tai's handy for anesthesia.  All kidding aside, this is one of the reasons that EM in the ED was left in the rearview mirror for myself.