Monday, July 9, 2007

SPECIALISTS: THE DELICATE GENIUS

A recent thread of posts about the relationship between PCP’s and specialists, spawned by Dr. Rob’s sardonic “open letter” has inspired me to comment on one particular beef I have with consults.

Specifically, in-hospital consults.

I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.

No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!

Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.

And then at the end it says “Assesment/Plan: Colonscopy Monday.”

Ummmm, excuse me? That’s an assessment?

No, that’s a test.

So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”

Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.

(Oops, there I go, talking about fellows. Must … re…sist)

But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!

95 comments:

Happyman said...

not just hospital - if i ask for an outpatient GI eval, I usually get the question "you want an EGD or a colonoscopy?"

btw see my most recent post on my blog.

OB Doctor said...

I think your complaint is right on. What does this behavior say about the state of medical care? Professionalism amongst physicians? Medical education?

I'm afraid the current lack of communication reflects very poorly on the medical profession.

jerry said...

As an ER doc I have to call and talk with the PCP or specialist directly regarding a concern. Often I am asked to be the "go-between" comminicator between the PCP and specialist. On the floor I notice that a consult is just "ordered" and then a secretary or nurse calls the consult to the specialist and the two never actually talk to each other. I have talked with specialists who hate this and PCP's who feel like they get no feedback. C'MON PEOPLE, talk to each other

Mike said...

I would love it if secretaries could call consults for me. Are you kidding? I have to call a consult to get a consult. I can't imagine there's a hospital where secretaries would even AGEE to do that.

Anonymous said...

happens all day every day in my hospital. Sometimes you don't even get a call it just shows up on your list and you have to figure out what the consult is for.

Anonymous said...

Hmmm . . . consult.

As in, "please have a look at my unfortunate patient, dear colleague, and tell me whether I have considered all the possibilities, and perhaps recommend a course I might follow?" Or perhaps you meant, [speaking to ward nurse] "please have the attending [you fill in the specialty]-ist see my patient about her [again, fill in the blank], who you expect to take care of the problem, that day. You might consider them both to be "consults", but in reality, as concerns the Medicare and payer definition of consults, only the former qualifies. So in all likelihood, you have made a referral, but you want the same written "feedback" as if you had made a consult, even if you aren't the one to manage the problem. That is understandable, because once upon a time, a participating specialist got paid by the third parties enough to have long detailed letters typed by his secretary without impacting the bottom line. No more, I'm afraid.
In our brave new world of annual Medicare reductions, that letter, now costing $.10 a line plus stationery and postage to produce becomes a significant line item expense. Hence the short scribble. And if you the referrer aren't professional enough to pick up the phone and call the specialist you want to give some details about why you feel the patient needs to be seen right away, then don't whine when the specialist leaves a note that seems to suit your own apparent level of interest and collegiality. Just a hint: a one-minute phone call, personally made to your "consultant" will probably produce the results you want.

Anonymous said...

Anon 7/10 4:40 -
That "1 minute" phone call is in an ideal world where there are no phone tags, and you have all the time in the world to dedicate in waiting for a return call...

Believe it or not, many times, I have written reasons and specific questions in the consultation - YET I get back a response [if at all] that is nowhere near the questions that need to be answered. The truly good consultants are rare and far between, imho.

Nurse K, Generic ER Nurse said...

I was a unit secretary back in the day and a significant portion of my job was to organize consults.

"GI Consult" would be the written order and I'd have to go through the chart and attempt to figure out why a GI consult was requested on a neuro patient (usually it wasn't that hard if you read the attending's note...IF you could read the attending's note) and then summarize with a brief reason and enter all that into the computer and/or call the consultant and let them know they were tagged and who tagged them if it was normal business hours so they could see the patient before they went home if possible. Sometimes the consultant had been informed by the attending, sometimes not.

I'd also do the ubiquitous call back to the doctor who wrote the order asking if they wanted an "ASAP" or "am consult". IF you just write "GI Consult" with no qualifiers, that means "right now."

Anonymous said...

I'm a Palliative Medicine/Hospice consultant at the VA. I like to think we write very nice H&Ps and extensive A/Ps.

My pet peeve is the consult with no question. (manage pain? manage all symptoms? hospice care? address advance directives?) Don't get me started on the consults that come in with "Patient does not know diagnosis. Patient does not know prognosis." In small print it should say "Patient has no frickin idea you are coming."

Anonymous said...

Anon Pall Consultant from VA:

An advanced dementia vegetative veteran has to have "frickin idea you are coming"???

What happened to records review you would do anyway, from distrust you have of your colleagues trying to "dump" a patient to you?

Mike said...

At my hospital, the only way to get a consult is to call the physician themself. No secretary or nurse would do it. So I have no experience with this consult problem the specialists are talking about. If you didn't even get a phone call from the primary, then that does indeed suck.

As for the palliative consult, I think those speak for themselves. I mean, we certainly aren't consulting you to diagnose anything.

Happyman said...

ditto on the palliative care consult - you think we're asking for MAGIC? or did you forget last year when you were on the other side, then decided to become a "specialist" by doing a one-yr "fellowship" in dishing out opiates & sitting in ethics meetings (not that I don't think those are useful)?

Most internists I've come across do a MUCH BETTER JOB of managing end-of-life issues that the "palliativists". The rare occasions I have had patients enrolled in hospice have been thoroughly disappointing: long-winded notes but management is still left up to me.

I've learned that hospice exists strictly for the lump-sum Medicare payment to be had by having a referring PCP designate someone as terminal. What a scam.

Anonymous said...

Wow, you are a bitter group of people. I like your assumption that PCM is only called for vegetables or for people dying within days. Please realize we are consulted by primary care and by oncology and by the HIV team and by geriatricians etc etc for people who have life expectancies from months to years. PCM is not all hospice end-of-life care.

It is interesting that the medical community here jumps to the same conclusions we see patients making. Try to imagine what a 30yom with newly diagnosesd testicular CA thinks when I introduce myself with no forewarning from his "dedicated, loving, absolutely awesome, rock star" PCP. All I am asking is for PCPs to let them know we are coming. Tell them they have HIV and need to start HIV meds and you are asking us to assess them.

I am not asking for a lot. And, as I said, I work at the Veteran's Hospital. I am 100% salaried and I never see lump sums of anything.

Anonymous said...

You know angry I have seen it both ways. I was a hospitalist/internist before going back to fellowship. I was frustrated with consultants who didn't try to ask the question I was asking. I am now equally frustrated with primary docs/hospitalist's who don't have the decency of calling me and explaining the situation as to the c/s. A phone call does wonder's (I get phone calls from clerks just saying Dr X wan't a c/s on Mr ABC). It is about communication. I call back with my recs. It is a two way street. Constultant speaks to primary and visa versa. Additionally, I often get c/s that frankly should be better evaluated by primary docs. My classic is pt's "has a mass". Well, I was an internist long before I became a H/O doc. IMO, evaluation of a mass fall's into the realm of internal medicine. You should be able to order a biopsy and have it completed before sending over to H/O. Hell it may not even be cancer which I have seen. Think about it, you send a pt with a "mass" (not worked up) to H/O and it is not even cancer. What do you think is going through the poor pt's mind. Another classic (using your anemia analogy) is a pt referred for "anemia" when it is clearly an iron def anemia to a GI bleed. No rectal, no guiac by the PCP, just a h/o c/s. Personally as a board certified EXPERIENCED internist, I find that kind of doctoring embarrassing. I am happy to help. However, I have long experience in both H/O and internal medicine. The lack of communication among doctor's today, especially the c/s without a phone call and the corresponding return phone call from the consultant is sad. Don't even get me started on ER docs.

PS: For what it is worth I find one palliative care doc in my town excellent. Yes, I am an oncologist and I clearly do alot of my own "palliative care" but sometimes it is better to have a view from a doc who is not actually giving the chemo. It gives a fresh viewpoint to the pt and doc. Additionally, I do not agree with the statement about internist's doing a better job than PCM docs. It really depends on the internist. Some are great at this issue. Some frankly are not. In fact there is a significant minority of patient's in whom I have become the primary care doc because there own PCP's have written them off because they "have cancer".

Anonymous said...

From the patients point of view, I have been the patient waiting for a GI consult made by the receptionist at my PCPs office. I received an appointment by mail from the GI for 7 months out. When I returned to my PCP for a recheck 2 weeks later, he asked me what the GI doc had found. I informed him I didn't even have a first appointment until 6.5 months yet. He then left and called the GI himself and I was having a colonoscopy and EGD within a week. Obviously thats what should have happened to begin with.

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