How to refuse to Rx narcotics to chronic pain patients?

[EMEDPA]

2 hours ago, ral said:

Respectfully, everything that EMEDPA listed can be ordered on an outpatient basis by primary care.

Again, it's not a question of whether or not a patient needs a workup.  You are certainly right on that front.  It would stand to reason that if a patient has a syncopal episode right there in front of me in a primary care setting, that I would send the patient to the ER for a workup.  If they made an appointment, and came in telling me that they have been passing out lately, I would begin an appropriate outpatient workup.  I'm simply saying that the ED is not the blanket answer, when the same level of non emergent care and testing can be obtained elsewhere.

Much peace.

no offense taken. every case is unique obviously, but it looks bad if you send the recurrent syncope patient home without labs or CT and they are found to have a GI bleed or brain tumor(for example) weeks later. I agree that if primary care can get this stuff as fast as I can in a stable patient then that makes the most sense as ER care is the most expensive care.

[GetMeOuttaThisMess]

Same goes for our former “TIA” folks. OP work up versus parking them in house and testing showed no significant variance in bad outcomes. The 2% “missed MI” rate with a bad outcome in the ED that had everything but the kitchen sink thrown at them yet “if we’d only kept them”. What the heck else could one have done? Cath everyone with CP? Suspicion for bacterial meningitis in a college student that you tap and is initially negative but gets treated anyway and sent home and yet shows up in arrest the next day? What then? Parking them in house doesn’t make the outcome any different sometimes. Time is the great equalizer, not the location of the wait.

 

As I get closer to the end I’m starting to sound more like an a actuary than a PA.

 

 

Sent from my iPad using Tapatalk

 

[camoman1234]

On 12/8/2017 at 11:57 AM, ral said:

Sorry the conversation has taken this turn but, since it has, I feel compelled to answer the question as to why the ED cannot do referrals.  

EMERGENCY.  Perhaps some of you haven't worked in emergency medicine, others may be ignorant to the definition, the remainder I can only guess have become as brainwashed as the general public, that the ED is the catch all for shit.

Your chronic headaches which you have been discussing with your PCP, that have encouraged three to four CT scans, at two different hospitals, over the past five years, does not need me to wake up Dr. Meningioma at 0100hrs. My job in the ED is to make sure that there is very little likelihood that something is acutely occurring or brewing right here, right now, or in the very foreseeable future (like hours away) that would be a threat to life, limb, or eyesight.  To saddle me with making sure your patient gets a referral to the appropriate specialty service, on a non-emergent basis is ridiculous.  Your inability to get the patient to the appropriate service as an outpatient does not warrant an ED visit.

I don't bitch when primary care sends over a 57 year old with numerous risk factors, complaining of chest pain, for me work up to rule out an ACS.  That makes perfect sense. Don't bitch when I send him back, having ruled it out, for you to finish off the work up with appropriate care and referral, because that also makes perfect sense.

It makes perfect sense to do it what is best by the patient and placing a cardiology referral because you have seen the guy has had  multiple ED returns with appropriate extended workup at the PCP, but refuses to return to his PCP for "just a referral" / ED f/u, so that he has to pay is $20 copay and $135 office visit cause he has not met his deductible. Most patients are fine to go to a specialist if warranted, but do not want to pay the extra money for "another office visit with my PCP" just for him/her to place a referral when you in the ED are more than capable of placing it.  

[Guest ral]

On 12/7/2017 at 10:46 PM, rev ronin said:

 I have a patient I sent to the ED for a recurrent syncope workup, primarily because no neurology practice in town would see her.  

 

On 12/8/2017 at 2:50 PM, rev ronin said:

she had been having periodic syncope....over six weeks while I tried to get an urgent neurologist referral.  They got her in fast, but completely failed to actually use any of the tools at their disposal that I didn't already have. 

18 hours ago, rev ronin said:

 I didn't see any of that ER-specific workup happen.

 

4 hours ago, EMEDPA said:

no offense taken. every case is unique obviously, but it looks bad if you send the recurrent syncope patient home without labs or CT and they are found to have a GI bleed or brain tumor(for example) weeks later. I agree that if primary care can get this stuff as fast as I can in a stable patient then that makes the most sense as ER care is the most expensive care.

Quoting rev, as to show what I am seeing about the hx of his patient.  He saw her, started a work up, referred to neurology, wasn't happy with what they didn't do, so sent her to the ER, and is unhappy because they didn't do what he thought should have been done either.

If I had seen the patient in the ER, I would have done the workup, similar to what EMEDPA posted.  Why?  Because it is now my job to make sure that I am confident that I have covered the bases, just as I explained in an earlier post: make sure there is nothing showing up as a cause for concern of immediate threat to life.  BUT, I am once again left with asking myself if the patient NEEDED to come to the ER in the first place.  A problem going on for six weeks, that had a neuro consult, that was not acutely symptomatic (or at least rev didn't infer such on the day he sent her to ER).  Let me get this out there right now: I applaud rev for being such a strong patient advocate.  I am only questioning the "send it to the ER" fallback that too many folks use, when frustrated with a system that makes us all want to poke our eyes out at times.

So, that brings us back around to the "referral" thing.  I guess I will direct the question to EMEDPA.  When you are working at your rural ER gig, with possibly limited services and specialties (I did a lot of work at a CAH that had one family practice doc in the town, and a general surgeon that visited once a week to do consults) did you actually arrange the referral prior to discharge of non-emergent patients with negative workups?  I'm not talking about calling up ortho in the town 30 miles away, discussing a pediatric supracondylar fracture, and having the guy on call say, "Yeah, have them call the office tomorrow morning and set up an appointment."  I mean an actual referral: paperwork, insurance information, confirmation of appointment time, forwarding all pertinent chart info and visit history, everybody on board.  It doesn't happen where I have hung my hat, big or small hospital.  If it's that urgent, the specialty, if available, is consulted to see the patient in the ER, or I am transferring the patient to a hospital that has those capabilities.  

Maybe I am not understanding what we are talking about.  Wouldn't be the first time that I am reading things wrong.

[EDGuy]

On 12/7/2017 at 9:58 PM, EMEDPA said:

I work with a doc who uses haldol in his migraine cocktail. I think it is an excellent idea and have used it for folks as a last resort before narcs. not too many folks can complain about a bad headache after haldol/ativan/benadryl....

LIVE AND DIE by Reglan, Compazine or Phenergan with Benadryl.  No narcs unless I see it in the neuro's recommendation.  Haldol study completed a couple of years ago in my shop and looking for publication.  Otherwise, Haldol seems good unless there is an underlying request.  Then, NO!

 

[dmdpac]

1 hour ago, ral said:

 

I mean an actual referral: paperwork, insurance information, confirmation of appointment time, forwarding all pertinent chart info and visit history, everybody on board.  It doesn't happen where I have hung my hat, big or small hospital.  If it's that urgent, the specialty, if available, is consulted to see the patient in the ER, or I am transferring the patient to a hospital that has those capabilities.  

Maybe I am not understanding what we are talking about.  Wouldn't be the first time that I am reading things wrong.

I may be misunderstanding, too.  However, I read it as Ral reads it.  I can provide contact information for any number of specialists at the time of discharge from my ED.  If they need the actual referral from an insurance standpoint, though, they need to get that from their PCP.  It's not something we do in our shop.

[EMEDPA]

2 hours ago, ral said:

 

 

  I mean an actual referral: paperwork, insurance information, confirmation of appointment time, forwarding all pertinent chart info and visit history, everybody on board.  It doesn't happen where I have hung my hat, big or small hospital.  If it's that urgent, the specialty, if available, is consulted to see the patient in the ER, or I am transferring the patient to a hospital that has those capabilities.  

Maybe I am not understanding what we are talking about.  Wouldn't be the first time that I am reading things wrong.

not once in 21 years working in the ER. paperwork like that is one of many reasons I am NOT a pcp.

[gbrothers98]

Re: original post

2 things. State put in new opiate prescribing rule that provides pathway for patient with acute or chronic pain. Chronic pathway definitely requires an established relationship rather than the temporary the ED provides. So I provide the statute to the patient and arrange for prompt PCP follow up. Included in the statute is that attempts should be made to treat the chronic pain initially with non-pharmaceutical modalities and non opiate medications if the patient is new. Since they all are new to me, that is the start I provide. Next, is the safety issue of prescribing to the chronic pain patient particularly when they are on other meds you may or may not know about, particularly benzos. As for the angry, abusive and potentially violent patient, that is what security is about, anticipate and have them ready to intercede.

Referrals. I have the experience of go as smooth as silk from the ED. Also have them kicked back by insurance, practice rules and consultants particular practice. I refer from the ED for the obvious, eg nondisplaced closed distal fibula fracture to Ortho. There are also the urgent and emergent transfers that do not need PCP involvement. The remainder, the low risk syncope, the suspected CAD, the migraineur, the nonspecific abd pain, all go back to the PCP. Whenever they question me on that process, I relay I consider the patient their primary responsibility and they are the gatekeeper, particularly for problems that are not urgent since that is what I take care of for them. I cannot track individual PCP preferences for various conditions. Alternatively, I never say no to them even when I get the clear 5:01 pm dump. Smile and tell them I will take care of it. I also take a little extra time to communicate to them what I did, what I thought and what I may have planted the seeds for. But I never tell a patient what their pcp should do for them, unlike the patients that literally come to the ED with a list in hand of what their PCP requires for the evaluation. That is downright micromanaging at it's worst.

G

[Boatswain2PA]

18 hours ago, camoman1234 said:

It makes perfect sense to do it what is best by the patient and placing a cardiology referral because you have seen the guy has had  multiple ED returns with appropriate extended workup at the PCP, but refuses to return to his PCP for "just a referral" / ED f/u, so that he has to pay is $20 copay and $135 office visit cause he has not met his deductible. Most patients are fine to go to a specialist if warranted, but do not want to pay the extra money for "another office visit with my PCP" just for him/her to place a referral when you in the ED are more than capable of placing it.  

So I should refer all of your diabetic patients to endocrine?  All your HTN patients to cards?  All your rash patients to derm?  All your asthma/COPD patients to pulm?

You just want to do well-child checks??

Remember, I typically don't know WHAT you do in your office, and I rarely have access to your records to see what you HAVE done for your patients who I see in the ED.  HA in the ED = r/o bad things, treat the pain, and have them follow up with their PCM.  CP in the ED = r/o bad things, treat the pain, and have them follow up with their PCM.  

If I can't r/o bad things, then I need an EMERGENT CONSULT (which is NOT a 'referral').  I need that consultant to understand that I'm not calling them at 0230 for a chronic migrainer who may (or may not) have received extensive treatment from PCM....if I'm calling from the ED it's because I have suspicion of badness.

Additionally, I don't know what ELSE you may be comfortable doing.  PCM's have incredible variety in how they treat and the procedures they do.  If you were a FP who does culposcopies, joint injections, colonoscopies (etc ad nauseum) and I referred those procedures out for specialists then you would lose a LOT of money.  

You have a great point about not telling patients what PCM (or anyone else) WILL do, however there is a fine line between education and prognostication...and patients often don't catch that line.  I may tell the HA patient that they need to follow up with you and discuss a neuro consult, they may hear "the ED told me I needed a neuro consult)".

[sas5814]

"the ED told me I needed a neuro consult)".

 

This... I can never tell if patients hear it differently or shape the story to their desires though I suspect the latter. I used to bust on them when they came into the clinic and said "they refused to see me in the ER" which I know is total BS...especially when it was my ER. What that means is "I went to the ER with a routine problem and they told me I'd have to pay $200 to be seen so I left."

I have also had many patients say "I called my doctor and he said I should come here and get >test name<" to which I would reply "they have a license and can order whatever tests  they think appropriate."

This job would be a lot more fun if it didn't involve people.... :-)

 

[rev ronin]

Sure, I can get an outpatient U/S or MRI... in a matter of weeks.  A week if I'm pushing and pleading with both the radiology center and the patient's insurance.  I don't have the patient's permission to discuss her case in detail, but suffice it to say that there were other things going on that made me more suspicious that something actionable and image-worthy was going on. Oh, and my local hospital situation is... challenging.

[Guest ral]

5 hours ago, rev ronin said:

Sure, I can get an outpatient U/S or MRI... in a matter of weeks.  A week if I'm pushing and pleading with both the radiology center and the patient's insurance.  I don't have the patient's permission to discuss her case in detail, but suffice it to say that there were other things going on that made me more suspicious that something actionable and image-worthy was going on. Oh, and my local hospital situation is... challenging.

^^This makes your case.  You made a judgement call at the time, that you felt was warranted.

My apologies to rev ronin, if I offended.  

 

[sas5814]

^^Don't get me wrong. I send things to the ER almost every day I am in the UC mostly because people don't understand the difference between a UC and ER. I get chest pain patients, amputations, LOC etc. I had a lady 2 days ago who was 5 days SP heart valve replacement with SOB and unexplained weight gain. I have sent folks to the ER from clinic for the same kind of things.

Like most things it is about balance and reason.

[camoman1234]

22 hours ago, Boatswain2PA said:

So I should refer all of your diabetic patients to endocrine?  All your HTN patients to cards?  All your rash patients to derm?  All your asthma/COPD patients to pulm?

You just want to do well-child checks??

Remember, I typically don't know WHAT you do in your office, and I rarely have access to your records to see what you HAVE done for your patients who I see in the ED.  HA in the ED = r/o bad things, treat the pain, and have them follow up with their PCM.  CP in the ED = r/o bad things, treat the pain, and have them follow up with their PCM.  

If I can't r/o bad things, then I need an EMERGENT CONSULT (which is NOT a 'referral').  I need that consultant to understand that I'm not calling them at 0230 for a chronic migrainer who may (or may not) have received extensive treatment from PCM....if I'm calling from the ED it's because I have suspicion of badness.

Additionally, I don't know what ELSE you may be comfortable doing.  PCM's have incredible variety in how they treat and the procedures they do.  If you were a FP who does culposcopies, joint injections, colonoscopies (etc ad nauseum) and I referred those procedures out for specialists then you would lose a LOT of money.  

You have a great point about not telling patients what PCM (or anyone else) WILL do, however there is a fine line between education and prognostication...and patients often don't catch that line.  I may tell the HA patient that they need to follow up with you and discuss a neuro consult, they may hear "the ED told me I needed a neuro consult)".

Please re-read my comment, MULTIPLE ED returns for chest pain, H/A, etc. I do not want you to do my job as I know as a PCP I would be better at it cause I know the patient better, the only time I would want the ED to refer out is when said patient comes in 4 times in 4 months for chest pains and that patient needs more work up and refuses to go to PCP for "just a referral." My patients will see the ED more times for the craziest things rather than come to me because we are booked or it is after hours. It is not hard for you to place a referral in certain situations when you know that patient as been in your ED multiple times for the same issue. Lastly, you gives a crap less is the PCP "loses money" cause your scared to piss someone off cause they might do "extra" things. That is NOT the point of medicine, the point of medicine is to take care of patients and not worry what others things about you...  "I referred those procedures out for specialists then you would lose a LOT of money." This comment REALLY rubs me the wrong way and this should never be the reason you don't refer out. If it is then you need to grow a pair and treat the patient. 

You can have your staff fax a referral or just send it via EHR. I rarely every contact the specialist for a basic referral. You ED guys/girls do not have to "talk" to everyone. 

I see all my DMI/DMII/COPD/CHF/HTN/Hyperlipidemia/Asthma/Bipolar/Depression/etc without referring to any specialist. I have sent 1 diabetic to ENDO in the last 3 years, I have sent 2 patients to pulm. and then I took back over their care after they got stable. 

We in primary care (at least I do) keep most my patients here in my office without a referral, but it just pisses me off when they come in for a ED f/u for a referral only and it takes 1-2 weeks to get records and then I can set them up for neurology, etc with an appointment in 2 months.  

[Guest ral]

So, the fact that it has been explained by many ER providers in this thread, that we do not do referrals from the ER, obviously means absolutely nothing to you.  This will be my last post to this particular thread.  I'm starting to feel like Bill Murray in Groundhog Day.

[rev ronin]

3 hours ago, ral said:

^^This makes your case.  You made a judgement call at the time, that you felt was warranted.

My apologies to rev ronin, if I offended.  

 

No apology needed, and don't you dare think you can't disagree with me just because I have an admin job around here.  If I'm that petty that I can't learn from a colleague in another specialty, I don't deserve to have it.

[camoman1234]

1 hour ago, ral said:

So, the fact that it has been explained by many ER providers in this thread, that we do not do referrals from the ER, obviously means absolutely nothing to you.  This will be my last post to this particular thread.  I'm starting to feel like Bill Murray in Groundhog Day.

That is YOUR choice which does inhibit patient care. I did referrals all the time in a busy UC. I see no difference and not reason for a patient to make a "ER f/u" for a referral, but you keep on doing whatever you think is correct. 

[EMEDPA]

I think we are quibbling over definitions here.

what we do in the ER is recommend a f/u and sometimes give the # of the specialist(say ortho) for nonemergent issues, like getting a wrist fx casted and followed.

a true "referral" at least to me means assuring date/time of appt and making sure pts insurance accepted there, filling out preauth paperwork, etc.

For urgent issues I will sometimes talk to a specialist and they say "have them see me tomorrow at 2 pm" and I give the pt the address and phone # of the specialist, but don't have anything to do with their insurance, etc

In the case of h/a x months without worrisome ED findings I either send them back to their pcp if they have not addressed the problem yet or I might give them the phone # of a headache/neurology clinic, which will not get them in any faster than if the pcp did it. I don't call specialists to arrange f/u of routine issues. that is not my job. I call them if I need them to do something for a patient in the next 24 hours.

[camoman1234]

1 hour ago, EMEDPA said:

I think we are quibbling over definitions here.

what we do in the ER is recommend a f/u and sometimes give the # of the specialist(say ortho) for nonemergent issues, like getting a wrist fx casted and followed.

a true "referral" at least to me means assuring date/time of appt and making sure pts insurance accepted there, filling out preauth paperwork, etc.

For urgent issues I will sometimes talk to a specialist and they say "have them see me tomorrow at 2 pm" and I give the pt the address and phone # of the specialist, but don't have anything to do with their insurance, etc

In the case of h/a x months without worrisome ED findings I either send them back to their pcp if they have not addressed the problem yet or I might give them the phone # of a headache/neurology clinic, which will not get them in any faster than if the pcp did it. I don't call specialists to arrange f/u of routine issues. that is not my job. I call them if I need them to do something for a patient in the next 24 hours.

I do not call specialists either, you just put in the system the specialists (neurology in this example), dx: chronic worsening migraines and your done. Everything else is set up, called, done by someone else in the scheduling department. At least for my area and EPIC EHR (when I worked in UC) a referral is extremely simple and doesn't evolve all the things you are thinking it involves. It is as simple as giving them a phone #, but I understand ER is different than FM, but if your system allows easy referrals then just do it as it is not more work. I have said my peace and you ER peeps will do whatever you think is right and we PCP peeps will shove the crap up that everyone else leaves for us as it is always the PCPs responsibility.  

[EMEDPA]

ERs don't have scheduling depts....

[Boatswain2PA]

20 hours ago, camoman1234 said:

the only time I would want the ED to refer out is when said patient comes in 4 times in 4 months for chest pains and that patient needs more work up and refuses to go to PCP for "just a referral." My patients will see the ED more times for the craziest things rather than come to me because we are booked or it is after hours. It is not hard for you to place a referral in certain situations when you know that patient as been in your ED multiple times for the same issue. Lastly, you gives a crap less is the PCP "loses money" cause your scared to piss someone off cause they might do "extra" things. That is NOT the point of medicine, the point of medicine is to take care of patients and not worry what others things about you...  "I referred those procedures out for specialists then you would lose a LOT of money." This comment REALLY rubs me the wrong way and this should never be the reason you don't refer out. If it is then you need to grow a pair and treat the patient. 

You can have your staff fax a referral or just send it via EHR. I rarely every contact the specialist for a basic referral. You ED guys/girls do not have to "talk" to everyone. 

If pt comes in 4x in 4 months (for whatever reason)...my job is STILL to find and treat emergent causes (if there are any), and then refer back to YOU.

If they don't come to you because it's after hours, then they won't go to a specialist after hours either.

Maybe we work in vastly different environments, but I DON'T do the insurance-based referrals.  I have NEVER filled out insurance paperwork for a referral in the ED, and won't do it.  I don't do occupational medicine paperwork in the ED either (which has really pissed off a state DOT manager).  I certainly can't just have my staff fax a referral or send it via EHR, that's NOT how it works in the ED.   If I need do a referral it's an EMERGENT referral....I have stabilized the patient (intubated, administered TNkase, TPA, cardioverted, reduced/relocated and stabilized, achieved hemostasis, sedated, etc), started initial treatment (heparin or antiarrhythmic drips, antibiotics, sedation, analgesia) and now need to make sure they get TIMELY follow up for their EMERGENT condition.  This could be NOW, or it could be to ensure they have are scheduled for orthopedic surgery tomorrow, or for urgent reevaluation next week.  It is NOT to begin specialty care for a chronic problem...that's not what the emergency department is for.

And actually...I DO care about PCM's making money.  You guys are vastly underpaid for what you do, and I know that a lot of the money you make comes from procedures, etc.  The wealthiest PCMs are the ones who have the CT/MRI/Dexa machines in office, and they do tons of minor procedures in office.  Maybe you're a purist who would work for free, I think money is important.

 

 

18 hours ago, camoman1234 said:

I did referrals all the time in a busy UC. I see no difference and not reason for a patient to make a "ER f/u" for a referral,

UC is different than ED.  Many UCs are WICs of FP clinics and for their specific patient population, and are tied in with the EMR and have the same scheduling staff.  I've been picking up a few shifts at a place like this recently and I have my nurse put in referrals (I still don't know how to do it, she just does her nursing magic and tells me where to sign).  

 

 

17 hours ago, camoman1234 said:

I do not call specialists either, you just put in the system the specialists (neurology in this example), dx: chronic worsening migraines and your done. Everything else is set up, called, done by someone else in the scheduling department. At least for my area and EPIC EHR (when I worked in UC) a referral is extremely simple and doesn't evolve all the things you are thinking it involves. It is as simple as giving them a phone #, but I understand ER is different than FM, but if your system allows easy referrals then just do it as it is not more work. I have said my peace and you ER peeps will do whatever you think is right and we PCP peeps will shove the crap up that everyone else leaves for us as it is always the PCPs responsibility.  

You don't call the specialists because you send your emergencies to the ED.  I call the specialists because I have FOUND a TRUE emergency that they need to help me with NOW.  

I have not worked in a single ED where I can just "put a referral in the system"...and I've worked at about 15 different hospitals from micro-EDs to a triple-coverage major hospital (haven't worked academic center yet).  

I certainly don't have a "scheduling department."

I agree PCP handles a lot of "crap", which is why  A) I couldn't do it, I would leave medicine in about 3 days, and B) you guys are vastly underpaid.

You seem to be really upset about this whole thing and that's unfortunate.  I hope that you are able to re-read many of these comments and better understand the difference between an emergent consult/referral that we DO from the ED and what you are expecting us to do from the ED.  It may help you relax a little bit and realize that we are NOT intentionally dumping the "crap" on you.

[camoman1234]

52 minutes ago, Boatswain2PA said:

If pt comes in 4x in 4 months (for whatever reason)...my job is STILL to find and treat emergent causes (if there are any), and then refer back to YOU.

If they don't come to you because it's after hours, then they won't go to a specialist after hours either.

Maybe we work in vastly different environments, but I DON'T do the insurance-based referrals.  I have NEVER filled out insurance paperwork for a referral in the ED, and won't do it.  I don't do occupational medicine paperwork in the ED either (which has really pissed off a state DOT manager).  I certainly can't just have my staff fax a referral or send it via EHR, that's NOT how it works in the ED.   If I need do a referral it's an EMERGENT referral....I have stabilized the patient (intubated, administered TNkase, TPA, cardioverted, reduced/relocated and stabilized, achieved hemostasis, sedated, etc), started initial treatment (heparin or antiarrhythmic drips, antibiotics, sedation, analgesia) and now need to make sure they get TIMELY follow up for their EMERGENT condition.  This could be NOW, or it could be to ensure they have are scheduled for orthopedic surgery tomorrow, or for urgent reevaluation next week.  It is NOT to begin specialty care for a chronic problem...that's not what the emergency department is for.

And actually...I DO care about PCM's making money.  You guys are vastly underpaid for what you do, and I know that a lot of the money you make comes from procedures, etc.  The wealthiest PCMs are the ones who have the CT/MRI/Dexa machines in office, and they do tons of minor procedures in office.  Maybe you're a purist who would work for free, I think money is important.

 

 

UC is different than ED.  Many UCs are WICs of FP clinics and for their specific patient population, and are tied in with the EMR and have the same scheduling staff.  I've been picking up a few shifts at a place like this recently and I have my nurse put in referrals (I still don't know how to do it, she just does her nursing magic and tells me where to sign).  

 

 

You don't call the specialists because you send your emergencies to the ED.  I call the specialists because I have FOUND a TRUE emergency that they need to help me with NOW.  

I have not worked in a single ED where I can just "put a referral in the system"...and I've worked at about 15 different hospitals from micro-EDs to a triple-coverage major hospital (haven't worked academic center yet).  

I certainly don't have a "scheduling department."

I agree PCP handles a lot of "crap", which is why  A) I couldn't do it, I would leave medicine in about 3 days, and B) you guys are vastly underpaid.

You seem to be really upset about this whole thing and that's unfortunate.  I hope that you are able to re-read many of these comments and better understand the difference between an emergent consult/referral that we DO from the ED and what you are expecting us to do from the ED.  It may help you relax a little bit and realize that we are NOT intentionally dumping the "crap" on you.

You do not have to fill out insurance paperwork, even I do not do that, but sounds like I will never get you to understand referrals are very easy. 

If they don't come to you because it's after hours, then they won't go to a specialist after hours either. This comment makes no sense... If patient X has a H/A, chest pains etc as 3 AM or on a Sunday they can't come to me NOR a specialist....Most all my patients will go to a specialist as they are open the same times I am open as well as they want help and tired of going to the ED. 

I know PCP are underpaid, but again that is NOT your problem to deal with and to make a medical decision that could affect a patients outcome cause you are worried about my wallet being filled with money. I know you guys are NOT dumping crap on us, I just don't get how putting a quick referral in to get the process started for a patient is so hard. The UC care I worked at had the same EHR as well as when I work at the corp FM clinic, same system, same referral process, very easy and takes about 10 secs of your time. No paperwork, just type in name of doctor/specialty and problem. 

I do not work for free and would never get underpaid for what I do and have worked hard to get, but helping out the patient is number one. Good luck to you. 

[EMEDPA]

to complicate matters further, many of the specialists in my area will only take non-emergent referrals from pcps because they want a specific individual to interface with, send reports to, etc.

[camoman1234]

47 minutes ago, EMEDPA said:

to complicate matters further, many of the specialists in my area will only take non-emergent referrals from pcps because they want a specific individual to interface with, send reports to, etc.

I completely agree and this seems to be based upon each individuals area, etc. I am trying not to say that all ED providers need to do referrals for all patients, but I feel like there are some circumstances that warrant a referral from the ED. 

[medic25]

Agree with the EM folks above; I'll refer people for emergent follow-up (e.g. splinted fracture that'll need surgery in a few days), but beyond there you get a name and a phone number to call for the most part.  I wouldn't know the first thing about filling out paperwork, managing insurance rules, etc. 

One nice thing that we've started doing at my hospital is having our patient follow-up nurses help to facilitate referrals to specialists.  We can click a button in EPIC doing our discharge papers and send a message to these nurses to either help the patient get a PCP, or help them get scheduled with a specialist.  It's not uncommon to hear from patients "I called XYZ specialist and I can't be seen for 2 months"; our nurses can help to pull some strings and help to get them in to see someone sooner.