Roulette

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\”I want you to get me a new doctor,\” she told me, a bit of disgust coming out in the sharp tone in her voice.

\”What happened?\” I asked.

\”He asked me if I was nauseated, and I told him no, I was just vomiting.  Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting.  He then told his nurse to write down nausea and abdominal pain.  When I objected, he just gave me a bad expression and walked out of the room.\”

I tried to come up with a plausible explanation for his action, but there was none.  \”I\’m sorry,\” I said.  \”There are a lot of people who come back from him feeling really happy and listened-to.  It\’s obvious that you saw none of that from him.\”

\”I asked his nurses if he aways acted this way,\” she continued, \”and they just shrugged and told me that he sometimes did.\”

\”I\’m happy to send you to a different doctor,\” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

  • I am not qualified to offer the treatment or procedures the specialist can give.
  • The specialist has far more experience with the problem, and so can offer better care.

But there is one thing I am not doing: giving over care of the patient.  Patients are more than just diseases or problems to be solved.  Patients are more than a single organ system.  It is my job as a PCP to orchestrate and oversee the care my patients get as a whole, including those areas also managed by other physicians.  I am, in essence, borrowing the specialist for their experience and skill to help me take care of my patient.

So when I have a patient come back from an encounter like this one, it not only bothers me for the sake of the patient, I feel a personal sense of being let down by the other doctor.  I need help, and the person I chose to help my patient didn\’t do the job I need them to do.  Were they just too lazy to listen?  Were they just having a bad day?  Do they understand the question I was asking them to answer?  Did the patient somehow come across in the wrong way?

I am never quite sure for the reasons for these bad experiences, but I hate playing specialist roulette every time I send people to another doctor.  It\’s not only a waste of time and money, it also undermines the person\’s trust in me for choosing the specialist, and often hurts their overall view of my profession.  Why bother going to the doctor and pay lots of money only to be patronized, trivialized, or simply ignored, while not seeing their problems get better?

I get the same sinking feeling when I send a patient to the ER.  When I have a person come to the office with problems that need immediate attention, it is often quickest to send them to the emergency room, where they can get labs, x-rays, and specialty consults in a very short period of time.  There are times when I call the ER physician to explain my rationale for sending the patient – especially when I think the reason my not be apparent to someone seeing them for the first time – but there are other times when it is glaringly obvious to me what\’s going on and what needs to be done.  Yet, again it feels like a game of roulette, never knowing if the doctor will see what I see and do the proper workup, or if the patient will call the next day saying nothing was done in the ER.

From my perspective, the big problem is one of information.  I am working with much more information than the other doctors.  I\’ve often seen the person for many years and in many circumstances, knowing how significant it is when this particular person comes to my office complaining of pain.  I actually had a physician come to me with an acute appendicitis, and even my staff knew how serious a problem it must be for a physician to want to be seen immediately.  I also have all of the previous workup on a problem, a history of previous problems, and I know the family, home, and psychological landscape in which the person lives.  When the person goes to the specialist, the other doctor has only what I send them and what the patient tells them.  What seems obvious to me may not be the same for someone seeing them without my information.  But I do expect them to consider not only the patient\’s motivation for wanting to be seen, but my motivation for sending them.

It comes down to a single thing: respect.  Patients deserve to be treated with respect, and I am angry when my patients get otherwise.  Beyond that, I deserve to be respected by my colleague for having put thought into my decision to ask for help.  The visit my patient described was not just insulting to her, it was insulting to me. I try to give other doctors the benefit of the doubt, as sometimes personalities don\’t work together, and everyone has moments where they drop the ball.  Encounters like this one before go into my database when I decide who I will ask when my patients need more than I can offer.  My lack of consults to certain providers, especially after I had been using them in the past, should send a message to them about my opinion of their care.  I\’ve had several physicians ask me why I wasn\’t sending them as many consults as I was doing previously.  My universal answer is this: my patients had bad experiences at your office.

They are my patients, and I expect them to be treated well.

12 thoughts on “Roulette”

  1. I’ve had encounters like that a few times and it’s infuriating.  I would sometime like to hear the situation explained from the doctor’s or nurse’s point of view. I walk away from those situations wondering what it was that I missed.

  2. I had a similar experience with one doctor within the past decade or so, and I’ve since learned that my experience was not unique… good on you for keeping records of your patients’ interactions with specialists.

  3. Dr. Rob, 
    On a related note, can you explain why it is apparently acceptable to some physicians (present company excluded) to send their patient to a specialist, but then take no further steps to follow up with that specialist, even when the specialist doesn’t call or send a letter back to the referring physician?  I was recently diagnosed with an autoimmune disease but went undiagnosed for several years while I was passed around from doctor to doctor, and I can only think of one or two instances when there was open dialogue between the referring doctor and the specialist.   In all other cases, my follow up appointments with the referring physicians would typically go something like this:Doctor:  Well, did you end up seeing Specialist Doctor?Me:  Yes, didn’t you hear back from him?Doctor:  (rifles through my file). Nope.  So what did he say?Me: ???? Am I really in the best position to tell you what he thinks???Doctor:  Just tell me anyway.Me:  Well, he said A, B, and C.Doctor (somewhat crankily):  But he didn’t say D?  And he didn’t test you for X, Y, Z?  I don’t agree with what he told you and I think he should be doing more testing.  That’s why I sent you to him in the first place.At that would literally be it.  Even after hearing my best attempt to describe what was in Specialist Doctor’s head, Referring Doctor never followed up with Specialist Doctor.  I would walk out of these appointments completely dejected and confused.  Did I walk out of there with an action item?  Was I supposed to go back to Specialist Doctor and tell him that Referring Doctor thought he was full of it?I strongly feel that I would have had a diagnosis much, much sooner if only my doctors were capable of communicating with each other.  I have a few other friends who have described similar experiences, and their theory is that the Referring Doctor can’t bill for follow-up calls with the Specialist Doctor, so therefore he doesn’t do it.  Is that it, or is there something more going on here?

  4. I’ve actually written on this before.  The handoff between me and the specialists is a total mess.  The problem is that communication is very time consuming and is not paid for.  The system works against me communicating well, as it pays less for me to do so.  It’s not all about money, but it shouldn’t surprise anyone that if you pay more to not do something than to do it, it doesn’t get done very much.  Here’s the link: Our Broken System – #3: Dropping the Baton

  5. JenniferDavisEwing

    “…I do expect them to consider not only the patient’s motivation for wanting to be seen, but my motivation for sending them.It comes down to a single thing: respect.  Patients deserve to be
    treated with respect, and I am angry when my patients get otherwise.”

    I was recently “fired” by the neurologist I’d been seeing for the past six years.  I couldn’t even get in to see him until my GP intervened–even after I told his staff I’m hydrocephalic, they didn’t take my concerns seriously until my GP’s office called to make the appt for me.  Over the next six years, my interaction with the neurologist went fine, as long as I nodded, smiled and agreed with everything he said.  On the rare occasions I dared to suggest I might know more about my specific circumstances than he did (I’ve lived inside this body for 40 years, he’d only been seeing me for six), he became very rude and abrupt.  His decision to “fire” me as a patient came about because “I was a very difficult patient, never listening to him (pot, meet kettle), and always accusing him of things that weren’t true”. 

    I understand that a patient who’s convinced every minor headache must be a brain tumor can be a waste of time for a neurologist.  But I wish my former neurologist had understood that I actually do know the difference.  If I’m complaining of symptoms, and I can clearly see he’s not even pretending to write them down, that doesn’t make me a bad patient.  That makes him a bad doctor.  The most infuriating part of that experience is that I’d been complaining of numbness in my extremities off and on for at least two years prior to the date he “fired” me.  Yet he threw me out of his office because he claimed that I’d “never” told him about those symptoms.  When I said, in a perfectly calm tone of voice, “Maybe you forgot to write them down?”, that’s when he told me to get out of his office and not come back.

  6. Of course, I had the experience of hearing the doctor tell me why my daughter was seeing a specialist, and the specialist addressed those concerns exactly and appropriately, and then my daughter’s doctor said the specialist didn’t look at something else (maybe because she didn’t have ANY signs of it? and because he didn’t ask the specialist about it?), so he instead wanted us to see yet another specialist an hour away for expensive genetic testing.  For a disorder she has no signs of and that the specialist did not see. (in a nutshell, she is in puberty and in some areas she tans more than others, the doctor thought she had tuberous sclerosis and gave me her ADHD as more ‘proof’ that she had this…lol).  And, FYI, I fired that doctor. 
    My doctor, on the other hand, knows me well and has seen me for years.  She knows I don’t get sick often and I don’t panic. So when I came in last week and she found me in the examining room in the fetal position crying with a fever of 103.8 and a sore throat and total body aches and wanting to die, she took it seriously.  Rapid strep was negative but strep c wouldn’t show on it…so I got a shot of rocephin, naproxen, and followed up with clarithromycin for 10 days.  By the next day fever was lower and body aches gone but still sick and really week, by the next day less week, fever gone and almost normal, by the next day I was good to go. Just have to finish this really disgusting antibiotic (it seems like it makes saliva coming out of the salivary glands really bitter, 24/7).  I am GRATEFUL that she remembers me, knows me, and takes me seriously, but doesn’t overdiagnose like my daughter’s doctor, who has a track record of sending patients to specialists constantly (not just my kids). 

    Great blog as usual, love them!

  7. I’ve actually asked Dr. Internist to give me a note explaining his concerns to present to Dr. Specialist so there was no misunderstanding about why I’m there. Dr. Specialists reads the note and tells me why he thinks Dr. Internist is off his rocker. There is nothing I hate worse than being the go between for two people who refuse to communicate with each other. Visit reports are written, just send it to the other doctor…can we all be on the same page?

  8. Hello Robert,
    Can I ask you how you currently track those referrals you send to a specialist, I am assuming you write it down or use excel? 

    I am building a new application called referralMD, that we plan to launch later this year and would love your feedback on it

    Can we set up some time to chat?
    my email is jonathan@getreferralmd.com
     

    What is it?
    ReferralMD streamlines the patient-referral and insurance authorization
    process so you can exchange, manage, and track information including lab
    & imaging results online, both pre- and post- appointment.  http://getreferralmd.com

  9. We use an EHR system for the referrals and use searches and order completion to keep track of which consults have been fulfilled. We are in the midst of several changes and upgrades and so I don’t think it would be fruitful at this time to cloud things with another option. I have a saying: A good idea at the wrong time is a bad idea. Right now is not the right time for anything new in our practice. Thank you for the offer, though.

  10. […] happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist. “He came in and started spouting that he was busy saving someone’s life in the ER, and then […]

  11. Sending a patient to the ER doesn’t work. They will triage you and if the nurse doesn’t think it’s as important as the patients PCP they make you wait hours. I’ve even had nurses roll their eyes or get snotty when I said my PCP told me to go to the ER.
    As for specialists I had one that was a real a-hole. He was a PA who thought he was a doctor. He diagnosed me with something that was wrong and if I had kept going to him for “treatment” I probably would have died. Luckily I am a smart person who knew his diagnosis was wrong because of my symptoms and the first visit was the only visit. All the other specialists diagnosed me with a completely different thing and they were looking at the same MRI as the A-hole. I plan on filing a complaint against him with the State medical board.

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