Interesting interaction with outpatient doc

[Antares]

hes older. 60s I am guessing

haha, everyone’s older than someone

[Otolith]

If specialists insists on specific test then they should order it period. If a specialist sees concerning features that warrant screening for certain conditions not managed by that specialty I absolutely agree with being sent back to PCP.

[Eye3md]

As a retinal specialist, I do have the pt go back to their PCP, or cardiologist, for heart or carotid workups. As DUSN stated, it’s amazing how many systemic medical problems you can find on ophthalmic exam. If I find something that can lead to further systemic issues, on the eye exam, I want the PCP involved (or made aware) as soon as possible. It’s not that I don’t want to order the testing for the workup, I just don’t know what to do with the info once I get it back. Ophthalmology is very isolated, and we truly do not recall all the same medical minutiae as the rest of the medical world (at least I don’t). As with other specialties/PC docs, the amount of journal reading, in my sub-specialty, is never ending and I rarely have time to read about up to date medical information outside of ophthalmology. Love it, or hate it, but no one in my group works in the local hospital and we have almost zero interaction with anyone else in the medical community (except other ophthalmologists and the anesthesiologists at our surgery center).

If I get the test results back, I don’t know how to interpret some of them, and if positive, I have no clue who to refer to for further evaluation or surgery. I don’t ask the PCP to proceed with the workup as a “dump”. I have huge respect for my PCP colleagues and would never look upon you as the person to “do my dirty work”. The thought has never ever crossed my mind to say “I don’t want to do this. I’ll just let the PCP do it”. I do it because I assume the PCP is way more knowledgeable than me about the heart/carotids, and the PCP has a much better relationship with docs in the community who take care of these problems. I am sorry if it is ever interpreted any other way.

With regards to uveitis, I will order all of these labs because I believe this is an area where I have more knowledge than my non eye MD/DO colleagues. And most of the time, I don’t have to get the PCP involved because the workup discloses info I can usually manage myself (ie, treat the eye problem with intraocular steroids or oral meds).

[NumberWhizMD]

I would have and have stopped referring patients to someone who does this.

Typically not the groups I refer to. Coming more from patients who don't need a referral and come to me after the findings with the reason "my doctor told me I need to follow-up with you to get more testing done". Half the time, I'm lucky if they even have the concerning results from the exam. At least give me a call if you really think they need to urgently follow-up with me for more testing.

I think the biggest issue is just the vague follow-ups I get sent back to me. I would have no problem having a discussion with a specialist about their concerns and the next steps in work-up. At least if I know what I should be looking for, I can help get things moving in the right direction. Unfortunately, the groups that do this are also the ones that don't send notes or bother to call.

[Fugue]

Typically not the groups I refer to. Coming more from patients who don't need a referral and come to me after the findings with the reason "my doctor told me I need to follow-up with you to get more testing done". Half the time, I'm lucky if they even have the concerning results from the exam. At least give me a call if you really think they need to urgently follow-up with me for more testing.

I think the biggest issue is just the vague follow-ups I get sent back to me. I would have no problem having a discussion with a specialist about their concerns and the next steps in work-up. At least if I know what I should be looking for, I can help get things moving in the right direction. Unfortunately, the groups that do this are also the ones that don't send notes or bother to call.

That's usually the way I approach it. Almost all the PCPs that refer to me have my cell. I usually will text/call to discuss and explain my thought process. As a dermatologist I've never really trained on how to order or interpret a TTE. I never thought PCPs would be offended if I asked them to help me with a test out of my comfort range. This thread is a good one, helps me to understand the other POV. I think I'm generally good at collaborating with PCPs and I don't think any have ever stopped referring to me but I'll be more sensitive to these situations.

Tangential question - do PCPs hate if a specialist makes a referral? Do they prefer I notify them to make the referral or am I just adding to their workload? Eg sending a patient with psoriasis and joint pain to a rheum, sending a pt suspicious for pseudotumor cerebri to ophtho.

[Fugue]

As a retinal specialist, I do have the pt go back to their PCP, or cardiologist, for heart or carotid workups. As DUSN stated, it’s amazing how many systemic medical problems you can find on ophthalmic exam. If I find something that can lead to further systemic issues, on the eye exam, I want the PCP involved (or made aware) as soon as possible. It’s not that I don’t want to order the testing for the workup, I just don’t know what to do with the info once I get it back. Ophthalmology is very isolated, and we truly do not recall all the same medical minutiae as the rest of the medical world (at least I don’t). As with other specialties/PC docs, the amount of journal reading, in my sub-specialty, is never ending and I rarely have time to read about up to date medical information outside of ophthalmology. Love it, or hate it, but no one in my group works in the local hospital and we have almost zero interaction with anyone else in the medical community (except other ophthalmologists and the anesthesiologists at our surgery center).

If I get the test results back, I don’t know how to interpret some of them, and if positive, I have no clue who to refer to for further evaluation or surgery. I don’t ask the PCP to proceed with the workup as a “dump”. I have huge respect for my PCP colleagues and would never look upon you as the person to “do my dirty work”. The thought has never ever crossed my mind to say “I don’t want to do this. I’ll just let the PCP do it”. I do it because I assume the PCP is way more knowledgeable than me about the heart/carotids, and the PCP has a much better relationship with docs in the community who take care of these problems. I am sorry if it is ever interpreted any other way.

With regards to uveitis, I will order all of these labs because I believe this is an area where I have more knowledge than my non eye MD/DO colleagues. And most of the time, I don’t have to get the PCP involved because the workup discloses info I can usually manage myself (ie, treat the eye problem with intraocular steroids or oral meds).

Same. I never viewed any of this as a dump. I just legitimately don't know how to interpret or order certain tests. I always viewed it as collaboration. ED docs and PCPs will often text me photos and I'll help them over the phone, or get their patients in the same day. Maybe it's the way you go about it.

[HikingDO]

Tangential question - do PCPs hate if a specialist makes a referral? Do they prefer I notify them to make the referral or am I just adding to their workload? Eg sending a patient with psoriasis and joint pain to a rheum, sending a pt suspicious for pseudotumor cerebri to ophtho.

Speaking for myself, I greatly prefer that if you as a specialist wants the patient to see another specialist for you to refer them yourself. Notifying me to make the referral just adds to my and my staff’s workload without adding anything beneficial to the patient’s care.

[Savedfpdoc]

If you make the patient come in to see you then yes it's win-win for you and the specialist but it is an extra burden to the patient. I'm not judging you and I would probably do the same thing if I was in that situation but somebody has to pay. I think the situation being described as the specialist wants the PCP to order the test and deal with the headache of getting it approved or through a prior authorization and then interpret it and deal with the results for free.

Yes, I make them come in. Extra burden for the pt yes, however most testing specialist request requires prior auth and it helps to have a visit to document need and submit to insurance etc so if the patient complains I’ll tell them that.

[ACN]

Ortho here.

Had a CT ordered for my patient for their knee replacement. Radiologist picked up a pelvic mass, recommended additional CT. I ordered it, ovarian cancer, made referral to ob/gyn.

Dr called me and said he was shocked and confused on why ortho was referring him a patient when he saw the referral on the schedule.

I usually will order follow up imaging exams, such as CT chest for nodule workup after preop cxr. However, I typically refer back to pcp after I order the fu exams. Typically findings are a nodule that needs 6 month fu. Seems appropriate for pcp to manage that.

[AR]

OK, so lets say I order tests (normally for me it is imaging) and there are unrelated incidental findings, is it OK for me to ask the PCP to follow up on those. I do that on occasion. I also tell the PCP that if the answer is that the patient should be referred to another specialist, I am happy to make that referral.

[CM]

Ortho here.

Had a CT ordered for my patient for their knee replacement. Radiologist picked up a pelvic mass, recommended additional CT. I ordered it, ovarian cancer, made referral to ob/gyn.

Dr called me and said he was shocked and confused on why ortho was referring him a patient when he saw the referral on the schedule.

I usually will order follow up imaging exams, such as CT chest for nodule workup after preop cxr. However, I typically refer back to pcp after I order the fu exams. Typically findings are a nodule that needs 6 month fu. Seems appropriate for pcp to manage that.

I agree.

[Hank]

I am a specialist and I see this all the time when my pts go see a MD turned Holistic/Herbalist. They come back with a laundry list of bizarre, rarely ordered, difficult to interpret tests that the Herbalist requests I order I always tell then the person is an MD and if they want these tests ordered they can order them and interpret them

Good to see that evidence based medicine is alive and well.

[TheDangerZone]

I am a specialist and I see this all the time when my pts go see a MD turned Holistic/Herbalist. They come back with a laundry list of bizarre, rarely ordered, difficult to interpret tests that the Herbalist requests I order I always tell then the person is an MD and if they want these tests ordered they can order them and interpret them

Must have missed this the first time, so just to clarify: by stating you “see this all the time”, are you equating an ophthalmologist recommending an embolic workup based on (presumably) retinal vascular findings with “holistic/herbalistic” medicine and consider carotids, echo and head imaging to be “bizarre, rarely ordered and difficult to interpret” ?

[EH]

Good point! But if I ordered an ekg I don't even know where the pt would get it. I guess it's more of a logistical issue than anything else.

This sounds like an easy logistical problem to overcome especially given where you work. I am typically annoyed when I am asked to order tests that the specialist needs the results to manage the patient, as I am not going to reduce the antipsychotic. And trust me I have to look up normal qt length every time too.

for the above optho case I push back on specialist to order the appropriate tests as they are the ones who have determined that. I am happy to have results forwarded to me with context to review and follow up on if they are uncertain with what to do with them. Otherwise it just creates tons of extra work for me - I get message from doc, patient calls, sometimes patient books totally unnecessary appointment (of no monetary benefit to me in my job!).

[gap55u]

- i no longer refer to the cardiologist who asks that I monitor for amiodarone toxicity as a stock part of his notes.
- ditto a select few other specialists (one had this ludicrous excuse of “I don’t know when they are next getting bloodwork, I want to save them a stick”- right)
- the communication matters. Someone I have a good working relationship with and is clear on differential, it’s no biggie compared to no note no call “my specialist told me to have you order…”

- specialist referring to specialist- I generally don’t mind but use your judgement. Minimally abnormal EKG- let me see the patient don’t refer to cardiology. Abnormal thyroid labs- don’t refer to endo, etc.