OB/GYN scope of practice

[tygerli11y]

In the past two weeks I have received two separate cases from OB that confused me a little bit.

 

Case 1: 14 week pregnant female with hypothyroidism. CNM sent her to family practice to make sure that thyroid levels were stable.

 

Case 2: 35 week pregnant female sent by OB to family practice to be evaluated for back pain and sciatica.

 

Common sense tells me that these cases could have been been handled by OB directly,but being a new grad I figured I would ask. Am I missing something here?

[primadonna22274]

Back in the mid-90s before I went to PA school it seemed every OB/GYN wanted to be considered a PCP...and I knew several who would handle primary care things, and many of them quite well.

 

Then I graduated from PA school in 2000 and worked 3 days a week in family medicine, 1 day/week in OB/GYN. About half of the OBs would treat primary care issues. Half would send them back to IM or FP (or ask me to see them if I was in the dept that day). But ALL of them would treat their pregnant patient's cold or mild asthma exacerbation or otitis or simple eczema, etc., etc. Most would punt the more complex stuff back to primary care.

 

Then I came to the southeast where (at least in my strange little microcosm) it seemed the OBs treated absolutely NOTHING but PREGNANCY. So if their pregnant patient had a sore throat or a UTI or an asthma exacerbation or an earache or God forbid a hangnail they sent them to...you guessed it...their primary care provider. Often on the same day. So very silly. Drove me nuts.

 

I'm not sure if it's a comfort zone thing, or a reimbursement thing, or a liability thing, or what. I'm also curious how widespread this odd phenomenon is of not touching primary care issues when you work in a very primary-care specialty like OB. :rolleyes:

[dfwpa]

You'll find lots of specialist don't want to do anything beyond their specialty at all. In this economic environment, I'd say don't look a gift horse in the mouth....a copay is a copay and you'll get the chance to bring revenue into the clinic by working these women up.

 

And personally, I prefer the specialists to whom I refer my patients to just take care of the problems in their specialty....nothing irks me more than referring a patient for palpitations/presyncope to a cardiologist only to find out the cardiologist is now managing their lipids and had added an SSRI to their med list because they feel the patient might be depressed or anxious. And the ones who start acting like internists when I could be managing those issues never get a second referral from me again......and given the area in which I practice, there's lots of competition to go around for specialists, so I have that luxury............Sorry, what was the question again? LOL. (I'm a notorious threadjacker!)

[primadonna22274]

Umm...a cardiologist IS an internist...newsflash! :rolleyes:

But I hear ya. Honestly, if I refer a patient to cards for a cardiology evaluation, I expect a thorough cardiology evaluation. Lipids & HTN and all that good stuff is the cardiologist's domain, so it wouldn't offend me in the least if the cardiologist worked it up/made recommendations etc. IME most of the time they treat the immediate problem and, unless patient is in need of a long-term cardiologist, they send them back to primary care with recommendations for the PCP (which the PCP may choose to ignore and often does....)

 

....nothing irks me more than referring a patient for palpitations/presyncope to a cardiologist only to find out the cardiologist is now managing their lipids and had added an SSRI to their med list because they feel the patient might be depressed or anxious. And the ones who start acting like internists when I could be managing those issues never get a second referral from me again......

[dfwpa]

Oh, I'm quite aware they're internests, but 99% of the ones around here eval the pt for the problem they were referred for and send 'em back to us for HTN and lipids....unless there's an arrhythmia or something like that where the HTN and antiarrhythmic meds over lap.....see there are 2 local cardiologists who have basically stolen patients I've sent over to them for something as simple as stress testing due to risk factors....next thing I know it's time for Mr. S's 6 month fasting labs and f/u visit, our office calls him to remind him and he replies that Dr. Miller is prescribing those meds for me now, and by the way he's refilling my thyroid medicine and this and that as well. I get to talking to other providers and they're noticing the same thing happening....turns out the cardioloigst has hired a couple of mid-levels and is running an IM practice under the same roof as his cardiology practice.

 

Needless to say, I only refer my patients to specialists who "mind their business", for lack of a better term.....but yes you're technically correct that a cardiologist is capapble of doing IM....doesn't mean he/she should though.

[primadonna22274]

Well, that I understand. Patient-stealing is not cool.

But I'm still baffled by OB/GYNs who won't treat their pregnant patient's URI or otitis...or COME ON, their UTI?! Isn't that what OB/GYNs should be pretty darn comfortable doing?!

:p

 

Oh, I'm quite aware they're internests, but 99% of the ones around here eval the pt for the problem they were referred for and send 'em back to us for HTN and lipids....unless there's an arrhythmia or something like that where the HTN and antiarrhythmic meds over lap.....see there are 2 local cardiologists who have basically stolen patients I've sent over to them for something as simple as stress testing due to risk factors....next thing I know it's time for Mr. S's 6 month fasting labs and f/u visit, our office calls him to remind him and he replies that Dr. Miller is prescribing those meds for me now, and by the way he's refilling my thyroid medicine and this and that as well. I get to talking to other providers and they're noticing the same thing happening....turns out the cardioloigst has hired a couple of mid-levels and is running an IM practice under the same roof as his cardiology practice.

 

Needless to say, I only refer my patients to specialists who "mind their business", for lack of a better term.....but yes you're technically correct that a cardiologist is capapble of doing IM....doesn't mean he/she should though.

[dfwpa]

yeah, it's strange, but I get a lot of pregos who come in because their OB told them to see us about their colds or whatever.....maybe they're too busy to deal with such mundane stuff as URIs, tinnitis, and folliculitis.

[tygerli11y]

I understand maybe sending over a toe nail removal or even cold/flu's, but 5/10 back pain? That is something very common when you are 35 weeks pregnant. To make things even more annoying patient gets mad and calls OB to complain about not being given something other than tylenol.

[intrauma]

But I'm still baffled by OB/GYNs who won't treat their pregnant patient's URI or otitis...or COME ON, their UTI?! Isn't that what OB/GYNs should be pretty darn comfortable doing?!

:p

 

I had a preceptor who said this very same thing (just not as nice as you). He was a true physician "generalist" who owned a large family practice organization where he worked 6 days a week while delivering 8-14 babies/week. He also performed minor surgeries at an affiliate hospital in between.

 

He claimed that OB/GYN's only know what lies between the belly button and the arse. The only people he would ever send his high risk pts to were the perinatologists. None of OB's in that particular area would touch a hypertensive or a diabetic OB pt. Hummm, PIH, GDM, pre/eclampsia, ect... isn't his part of the gig?? :rolleyes:

[bcstout]

Sounds more like midwifery than OB care.

[caldje]

we have a couple of good OB/GYN docs in our clinic system so that is nice. But I have been getting patients left and right from the other OB/GYNs in the vicinity for UTIs. I'm even getting 36 weekers coming in saying "my doctor stopped seeing me because I'm on Medi-cal."

 

So yeah, I feel the pain too.

 

Chris

[tygerli11y]

The past 2 years I've learned to live with the OB's sending every littlenon-pregnancy related matter my way (we all work under the same rural clinic sothey simply add these patients to my schedule) but in turn I have been sendingsome gyn stuff their way. A week ago I sent a lady in her 50's with a fairlylarge cervical polyp for removal. I was told it was unnecessary for me to placeher in their schedule and I should have just removed it myself. This sounds alittle unfair no?

[unewillow]

Working close to the OB floor I see a lot of the other side of this. The ED sending up medical patents to be evaluated just because they are pregnant.