Specialists Directing FM to Write Scripts?

[mgriffiths]

Curious how often others run into this?  I work in FM and regularly get bombarded by patients saying Dr. Specialist told them to have me write their prescription.  Cardiology asking me to write BP meds? SURE, no problem at all - makes sense!!!  But, it's becoming more and more frequent that rheumatologists or other very narrow specialties are asking  for me to take over prescribing medications I NEVER prescribe.

Example: 87yo male presents with jaundice, new onset bilateral LE edema, and fatigue. History of RA and is treated with methotrexate and hydroxychloroquine (plaquenil) by rheum.  Directed patient to call his rheum doctor as both of these meds can irritate liver, rheum told patient to stop methotrexate until problem resolved.  Workup reveals patient is severely anemic due to acute GI bleed - gets admitted, 4 units of blood, bleed resolves, discharged and sees me today for hospital followup doing really well.  Direct patient to call rheum about restarting methotrexate and rheum tells them to have me restart med.

I have never written a prescription for methotrexate and don't really plan on that changing.  I don't treat RA, I do initial workup and if rheum problem supported the patient is referred and treated by rheum.  This isn't even about extra work, it's about asking me to prescribe "specialist" meds that I am not very familiar with because I NEVER prescribe the med.  I mean what is the point for the patient to continue following with the specialist every 6 months if I'm the one prescribing their meds?

[CAdamsPAC]

What does your SP have to say about these requests?

 

[Joelseff]

Curious how often others run into this?  I work in FM and regularly get bombarded by patients saying Dr. Specialist told them to have me write their prescription.  Cardiology asking me to write BP meds? SURE, no problem at all - makes sense!!!  But, it's becoming more and more frequent that rheumatologists or other very narrow specialties are asking  for me to take over prescribing medications I NEVER prescribe.

Example: 87yo male presents with jaundice, new onset bilateral LE edema, and fatigue. History of RA and is treated with methotrexate and hydroxychloroquine (plaquenil) by rheum.  Directed patient to call his rheum doctor as both of these meds can irritate liver, rheum told patient to stop methotrexate until problem resolved.  Workup reveals patient is severely anemic due to acute GI bleed - gets admitted, 4 units of blood, bleed resolves, discharged and sees me today for hospital followup doing really well.  Direct patient to call rheum about restarting methotrexate and rheum tells them to have me restart med.

I have never written a prescription for methotrexate and don't really plan on that changing.  I don't treat RA, I do initial workup and if rheum problem supported the patient is referred and treated by rheum.  This isn't even about extra work, it's about asking me to prescribe "specialist" meds that I am not very familiar with because I NEVER prescribe the med.  I mean what is the point for the patient to continue following with the specialist every 6 months if I'm the one prescribing their meds?

It happens to my patients too but if u don't agree or feel comfortable managing the med I would refuse and send them back to the specialist. Had an argument once with a Psychiatrist and I kept telling him that the med he wanted me to write for the pt was out of the scope for FM and I did not have much experience with it (neither did my CP). They can't force you to write it. Neither can your SP/CP. Good thing my CP usually sides with me.

 

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[ventana]

I have had specialists try to do this, as well as transportation forms to their office, and papwerwork specific to their meds. 

 

I simply explain to the patient and then call their office directly that they need to complete the scripts, forms, meds.... period

just refuse politely and professionally 

[UGoLong]

I work in cardio and we write our own scripts. Referrals are for assessment and treatment. We also do our own refills and send reports from each visit back to the PCP.

We will only do disability forms for cardio problems and occasionally give short refills for non-cardio meds until the pt can get in to see their PCP.

I’m surprised everyone doesn’t do this.


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[Joelseff]

I work in cardio and we write our own scripts. Referrals are for assessment and treatment. We also do our own refills and send reports from each visit back to the PCP. We will only do disability forms for cardio problems and occasionally give short refills for non-cardio meds until the pt can get in to see their PCP.

 

I’m surprised everyone doesn’t do this.

 

 

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There has been a lot of this "reverse punting" the past few years in my system. It's a head scratcher. Seems PC becomes a catch all for scut from some specialists. If we Primary Care providers allow it though it will continue. A couple of the docs in my office scream about this but only recently have been pushing back and moving it up the chain to mgmt.

 

One doc friend of mine refused to do a certification of dementia which was punted back to her by a neuro. She called and got chastised (!) by the doc then he put his practice manager on. She got our practice manager and our medical director on it and it became a big fight. The neuro backed down and finally did his damn job after back and forth fighting lol.

 

Personally/professionally I would have just taken the neuro's notes or spoke with him as I filled out the ppwk so the pt can get what she needed (in this case a US citizenship test exemption) but I see my colleagues point to.

 

Future of Medicine? Everybody wants to be hands-off?

 

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[GetMeOuttaThisMess]

One of the reasons I told the VA to take a hike.  Post-op patient discharged that day, floor service failed to write for pain med for pt.  They sent family to ACC to get prescription.  Uh, NO.

[UGoLong]

There has been a lot of this "reverse punting" the past few years in my system. It's a head scratcher. Seems PC becomes a catch all for scut from some specialists. If we Primary Care providers allow it though it will continue. A couple of the docs in my office scream about this but only recently have been pushing back and moving it up the chain to mgmt.  
One doc friend of mine refused to do a certification of dementia which was punted back to her by a neuro. She called and got chastised (!) by the doc then he put his practice manager on. She got our practice manager and our medical director on it and it became a big fight. The neuro backed down and finally did his damn job after back and forth fighting lol.
 
Personally/professionally I would have just taken the neuro's notes or spoke with him as I filled out the ppwk so the pt can get what she needed (in this case a US citizenship test exemption) but I see my colleagues point to.
 
Future of Medicine? Everybody wants to be hands-off?
 
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Maybe part of this is that we’re an independent practice that still depends on word-of-mouth and PCPs to refer to us.


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[Joelseff]

Maybe part of this is that we’re an independent practice that still depends on word-of-mouth and PCPs to refer to us.


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That may be. 5 years ago I worked in "Pill Hill" in Oakland California, an area made up of independent practices that was pretty close knit and never had this issue.

My current site is a "system" so we have to first refer to the providers in our system. They don't care if they burn us because we are all just cogs in the wheel.

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[delco714]

I make a lot of patients prn if symptoms have been controlled.

 

I would expect you can continue to refill finasteride, Flomax, and basic anticholinergics

 

If the symptoms get worse or refractory, then send them back

 

That's how my note is written

 

As a specialist, I hate seeing controlled symptom patients coming in for refills with no changes otherwise. Or they tried to have pcp refill and they refused, so they ran out of pills waiting to get in to be seen.

 

I know urology meds typically aren't that scary

 

Also, stop using doxazosin to treat bp and Flomax.. That's soOoOoOo 1995

 

We don't have a billion open spots to see follow ups.. So when you have a yearly or similar routine follow up.. Maybe I'm jaded to but.. It's easier for you to see them. We need more room for new patients, and I'll admit a lot of the new referal patients are BS.

 

 

[ventana]

11 hours ago, delco714 said:

 

We don't have a billion open spots to see follow ups.. So when you have a yearly or similar routine follow up.. Maybe I'm jaded to but.. It's easier for you to see them. We need more room for new patients, and I'll admit a lot of the new referal patients are BS.

 

 

 

 

point heard

 

but none of us have a lot of room

 

I tire of the specialists not wanting to do anything but do new patients and make recommendations

 

This puts ALL paperwork on the PCP - when the PCP has already been screwed by the specialists (DRG/RVU  and reimbursements for years and years have been set by a panel of doc's heavily weighted to the specialists)  So specialists get more money, less paperwork, and in general can crap on the pcp.....  

No thanks - they are your patient and you should be managing them in your specialty....

 

also last time I saw almost ALL specialists are dual boarded with Medicine being one of their credentials (meaning they finished a IM residency..)    So, anything that is beyond this "simple refill" should be handled by the specialist office - if they are too busy maybe they should hire more PA and NP

 

 

I sort of agree on the simple refills - is flomax - BUT if they are that simple when not just give them a one year script and see them yearly?  Would that not be better then pushing everything off to the PCP - - ie that simple flomax - the Uro can do the yearly rectal and decide when to Bx....  

 

Another way of saying it - specialist still put their pants on one leg at a time and are  DOCTORS (PA/NP) first and are certainly able to follow the care and patient just like every PCP out there......

[UGoLong]

This cuts a few different ways. If we’re seeing an in-patient for a long QTc, we’ll flag all the affecting drugs, switch PPIs for H2 blockers, cut back on amiodarone, etc, but we leave dinking with Zofran and psychoactive drugs to the primary because he or she best appreciates the big picture.

I once had an attending get mad at me for adjusting lytes because it was his job. Too bad dude; I wasn’t going to sit around waiting for a patient with an Mg++ of 1.2 to go into NSVT or worse.

Medicine should be a team sport no matter where you sit.


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[delco714]

 
 
point heard
 
but none of us have a lot of room
 
I tire of the specialists not wanting to do anything but do new patients and make recommendations
 
This puts ALL paperwork on the PCP - when the PCP has already been screwed by the specialists (DRG/RVU  and reimbursements for years and years have been set by a panel of doc's heavily weighted to the specialists)  So specialists get more money, less paperwork, and in general can crap on the pcp.....  
No thanks - they are your patient and you should be managing them in your specialty....
 
also last time I saw almost ALL specialists are dual boarded with Medicine being one of their credentials (meaning they finished a IM residency..)    So, anything that is beyond this "simple refill" should be handled by the specialist office - if they are too busy maybe they should hire more PA and NP
 
 
I sort of agree on the simple refills - is flomax - BUT if they are that simple when not just give them a one year script and see them yearly?  Would that not be better then pushing everything off to the PCP - - ie that simple flomax - the Uro can do the yearly rectal and decide when to Bx....  
 
Another way of saying it - specialist still put their pants on one leg at a time and are  DOCTORS (PA/NP) first and are certainly able to follow the care and patient just like every PCP out there......

Urology is a surgical based specialty that has internal medicine thinking... But that goes right back to the point of if there's no changes and just need a refill. It's an easy enough appointment.. But a lot of patients would prefer to not have to go to multiple doctor's and it would be more cost effective, and open my schedule for a complicated re referral...

We're both not Wrong. Who's the intermediary? Tele medicine!?? Ah! I may be on to something

[ventana]

16 hours ago, delco714 said:

Urology is a surgical based specialty that has internal medicine thinking... But that goes right back to the point of if there's no changes and just need a refill. It's an easy enough appointment.. But a lot of patients would prefer to not have to go to multiple doctor's and it would be more cost effective, and open my schedule for a complicated re referral...

We're both not Wrong. Who's the intermediary? Tele medicine!?? Ah! I may be on to something

Honestly

Hiring more PA and NP

 

putting more boots on the ground, allowing PCP to function as such, limiting the referrals out to specialists - really why does BPH need uro?

 

Then the specialists managing the stuff in their specialty...

[sas5814]

Interesting thread. I worked in FP for a long time and we were , compared to what I see today, tight with referrals. We treated everything until we couldn't and then referred. Referrals were usually for consults and once the patient was tuned up we managed them until something changed. Then we sent them back.

Today I see way too many referrals and I'm not sure if it is laziness, fear of a law suit, or spreading the money around. I had a new grad ask me what to do with a very simple uncomplicated distal nasal bone fracture and I said "nothing". It is a self limiting problem that doesn't require intervention. My SP intervened and directed a referral to ENT "because we don't know what they do with these problems."

*sigh*

[delco714]

Interesting thread. I worked in FP for a long time and we were , compared to what I see today, tight with referrals. We treated everything until we couldn't and then referred. Referrals were usually for consults and once the patient was tuned up we managed them until something changed. Then we sent them back.
Today I see way too many referrals and I'm not sure if it is laziness, fear of a law suit, or spreading the money around. I had a new grad ask me what to do with a very simple uncomplicated distal nasal bone fracture and I said "nothing". It is a self limiting problem that doesn't require intervention. My SP intervened and directed a referral to ENT "because we don't know what they do with these problems."
*sigh*

I'll add..I see the worst of that!!! Oh we don't know what to do with this... But don't even start the work up or do basic testing!! Ordering testosterone but not FSH LH.. no scrotal sono for ball pain.. the wrong imaging for renal masses and hematuria.
My favorite.. dipping positive for blood and not testing microscopy..

We need to find a better way through and through

[weezianna]

Those of us working at a VA clinic see the ultimate in prescription requests from specialists (and primary care providers) from patients who have what we call "dual care" - they see a community primary care provider and/or specialists, and come to the VA once a year to get all their meds filled.  The VA generally fills prescriptions requested by outside providers as long as there is supporting documentation from that provider, narcotics included.  So, in many instances the VA and its providers are a glorified pharmacy service, and don't actually treat the patients, who prefer to see their real docs on the outside and show up only for lower cost, or no cost med benefits.    $8.00/month copay for 30-day supply, unless the vet is 50% of more service-connected or meets income levels that exempt him/her from copays.

[delco714]

Those of us working at a VA clinic see the ultimate in prescription requests from specialists (and primary care providers) from patients who have what we call "dual care" - they see a community primary care provider and/or specialists, and come to the VA once a year to get all their meds filled.  The VA generally fills prescriptions requested by outside providers as long as there is supporting documentation from that provider, narcotics included.  So, in many instances the VA and its providers are a glorified pharmacy service, and don't actually treat the patients, who prefer to see their real docs on the outside and show up only for lower cost, or no cost med benefits.    $8.00/month copay for 30-day supply, unless the vet is 50% of more service-connected or meets income levels that exempt him/her from copays.

Beats me getting crap press ganey scores last week for telling a patient I can't fill their regular non Urology meds and them getting pissed off at me.

[thinkertdm]

9 hours ago, weezianna said:

Those of us working at a VA clinic see the ultimate in prescription requests from specialists (and primary care providers) from patients who have what we call "dual care" - they see a community primary care provider and/or specialists, and come to the VA once a year to get all their meds filled.  The VA generally fills prescriptions requested by outside providers as long as there is supporting documentation from that provider, narcotics included.  So, in many instances the VA and its providers are a glorified pharmacy service, and don't actually treat the patients, who prefer to see their real docs on the outside and show up only for lower cost, or no cost med benefits.    $8.00/month copay for 30-day supply, unless the vet is 50% of more service-connected or meets income levels that exempt him/her from copays.

As long as the medication and disease makes sense, I'm all for it.  The documentation is usually pretty piss poor, either fast noted from epic or without any rationale as to their thought process as to why they chose a second line med vs first.  If it's for a med the VA doesn't carry for whatever reason, I'll fax over the pharmacy criteria to the doc and give a copy to the patient, who is a member of the team too.  This usually happens with dabigatran and  apixaban, which has a number of restrictions.  The patients usually whine about the va at this point, but civilians have this issue too, just not as transparent.  The grass is always greener.

[NeoTrion]

I did Rheum for multiple years.  I have never asked primary care to write my scripts or restart my biologic medication.  MTX is definitely something that labs need to be monitored on restart, or at least that is how we did it.  Make them attend to their own mess.  Pretty soon you will be stuck chasing labs, and they will conveniently forget they said restart MTX.  Hydroxy is so much of a problem, but I have no issues restarting my own meds.  Plus they might want to lay eyes on him/her before restarting a medication that may have contributed to the hospitalization.   

[mgriffiths]

15 hours ago, delco714 said:

I'll add..I see the worst of that!!! Oh we don't know what to do with this... But don't even start the work up or do basic testing!! Ordering testosterone but not FSH LH.. no scrotal sono for ball pain.. the wrong imaging for renal masses and hematuria.
My favorite.. dipping positive for blood and not testing microscopy..

We need to find a better way through and through

I try to never do this, but I'm sure I'm guilty.  In my area, most specialists won't accept a referral without at least some workup.  It get's frustrating sometimes though when ortho ALWAYS wants an MRI before they will accept the patient and it's not warranted (i.e. chronic knee pain and patient wants to try viscosupplementation).  But, in general I can understand the frustration.

One excuse is that it seems insurance companies push back more on FM in approving imaging/labs etc., whereas things can more easily be green lit by a specialist.  I recently had an angina patient that I could not get approved for a stress test.  Finally called cardio PA friend,  apologized for the referral with no workup.  Helaughed and said no problem.  He (the PA, not an MD/DO) ordered the stress test sight unseen and it went straight through for approval...grrrr

[weezianna]

As far as non-formulary drugs at the VA, you just submit a NF request to the pharmacy and they decide whether the request meets criteria.  If not, then we pass the information on to the patient and the non-VA prescriber and recommend an alternative, or the patient can get the med through their private insurance.  Requests for anticoagulants all require a pharmacy anticoagulation request.  We generally get the office notes; what is annoying to me is to see how non-VA specialists talk about "leaning on the VA" to get expensive meds, like the VA is somehow holding out on them.  It's a matter of formulary.   A lot of vets are very well insured, besides having VA benefits.  They get the cheap stuff from the outside and the expensive ones at the VA.  We get little or no say in what we have to fill - if they ask for a special shower head, the consult goes in.