I work at two very different hospitals. One is generally a younger population.
Trauma
Mental Illness
Drug/ETOH abuse
Cancer
Neuro/neurosurg
The other hospital is for generally the older population
The hearts
The weakness
The multiorgan failure
The chronically functionally debilitated nursing home patients.
This is a broad category.
The ambulances know to take hearts to one campus, homeless drunks to the other.
It is the nature of the services provided. The nursing experience. The culture of the hospitals.
Across every spectrum of medical specialists I have talked with, the coming of the hospitalist movement has been like a release of the ball and chain.
What used to be a system of
1)Ambulance comes to the ER at 2 am
2)Patient looks sick
3)ER doc calls primary doc
4)Doc tells ER to call pulmonary, call renal, call cardiology, ID.
5)Primary doc comes in the next day to read the chart and "follow along."
I have been told on more than one occasion, that this scenario was not out of the question. In fact for many nights on call by a specialist, it was their normal night. A very normal, painful night. And frequently, these consults would not result in a procedure.
On 3 liters of oxygen? call the lung doc
Afib running a bit fast? call cards
Abdominal pain? GI needs a call
Creatinine 1.8? call the bean boys and girls
I have heard how it "used to be"
Our group has been present for a bit tad over 5 years. And I have heard the praises of the specialists. We are a 24 hour in house 7 day a week shift model of care.
We have brought a sense of life back to the docs that we depend on for their specialist input. And they are grateful.
As I have said many times before, being a great doc is knowing what you know, but more often and importantly knowing what you don't know. I will be up front and center and call a specialist with no shame when I have no idea what is going on in my patient. But I do not reflex a consult for the sake of consulting (the vast majority of the time)
Some of my greatest nights on call have involved deathly ill patients in septic shock and multiorgan failure. The last thing on my mind is calling in a specialist at 3 am unless they can do a procedure that I am not qualified to do.
A bronchoscopy
Dialysis
A heart cath
Emergent surgery.
Medically, my comfort level for treating the sickest of sickest is in the end zone. I do not have any doubt about my abilities in these situations.
The other week I admitted a very elderly patient with a BUN of 140, creatinine of 5 and a potassium of 8.7.
That's 8.7, verified.
A little calcium, some D50, insulin and a ton of fluid was all she needed.
It never occurred to me to call a nephrologist. With my training, appropriate stabilization measure, a central line and fluid management, I was able to correct her out of ICU range within 24 hours.
Now, would I do this with every patient? No. My experience told me I could help her. Me. Alone.
Clinical judgement of an internist is a major determinant of when a consult should be obtained. I trained to manage acute and chronic organ failure. But I do not feel the need to consult a specialist for every case of
COPD
CHF
CAD
ARF
N/V/Diarrhea
Diverticulitis.
HA
In fact I find frequently that consults I do obtain, when in doubt, are of no extra benefit than my own medical management and clinical judgement.
These "when in doubt" consults, while they make me feel better, often times add no additional benefit to the patient, and come with excess costs/procedures.
Unfortunately, there are patients/families who don't believe that an internist is capable of managing 90 year old granny's pneumonia or CKD, or CHF and ask, and sometimes demand that a specialist be consulted.
In these situations, depending on the dynamics of the situation, I either stand my ground or consult away, full of knowledge that additional input in these slam dunk situations is unlikely.
For that, dear specialists, I apologize from the bottom of my heart. The words "spread the misery" often ring so true in these situations.
The vast majority of chronic illness can be managed by an internist. Whether they chose to or not is an entirely different story.
Having a consultant see a patient occurs for many different reasons.
1) They have always managed that patients problem
2) The PCP is too busy to manage it themselves
3) The PCP lacks the knowledge base to manage it themselves
4) The PCP is lazy or desires not to manage it.
5) The PCP needs a procedure done
6) The PCP wants "to be sure"
7) The PCP is going out of town
8) That's just the way things are done in this town
9) Urgent therapies and options need to be discussed
10) The PCP doesn't want to deal with the family or that specific problem
11) The patient/family requests it
12) Rare illness with limited experience.
13) Advanced stages of common medical problems.
I have on occasion asked consultants to see patients when I didn't think it was necessary, because I could sense the distress in families. That their granny's "fluid" is usually only managed by the kidney doc, or the heart doc. The polyconsult mentality family who only "deserves the best".
Or on that day where I am so busy, I don't feel like I can adequately sit down and think through a medical problem that deserves my time. That my failure to get a consultant would not be in the patients best interest, I apologize, to you specialist, for that as well.
At my facility nurse practitioners have taken over the role of consulting on all cardiac and GI consults. They are the first responders. The data gathers. And they do a fantastic job. Their H&P are some of the best I have ever seen. And they have been trained to the tee to maximize revenue generation in every single consult and follow up visit they see according to the E&M rules and regulations of the Medicare National Bank. HPI? 4 elements. PMFSH? everything there. ROS? 12 points every time. Physical, the whole shebang, every time.
3-4 page dictated consult notes
Every time.
Every day.
Every visit.
What does the doc write? Frequently, a sentence or two. Usually the culmination of a 3-4 minute patient encounter. From GI, it's usually, CT today, scope tomorrow. That's what they do. They scope.
From cardiology? Echo for, well, just about any reason. Stress test. Amiodarone for afib (universally an accepted practice).
Neuro? MRI, EEG
The point here being that part of being a doctor and evaluating a patient is getting their story. Understanding what happened first hand that landed them in the hospital. That job has been relegated to an extender, which does a great job of data gathering, but I have no doubt in my mind that unless you do the job yourself, critical information of the encounter is lost in translation. From patient to extender. From extender to doctor.
My experience has been, and the RVU system of reimbursement backs me up, is that extenders have taken over inpatient medical (and some surgical) specialists for the evaluation and management of cognitive cares.
Unfortunately, the money is much better in procedures, and the more time they spend with their toys and pictures, the more money they make. Minimizing the "interference" of patient contact, which inevitable always takes lots of time, allows for more time in "the lab"
This frees up an enormous amount of time to do procedures. When you have an extender doing the doctor work for you, you can simultaneously perform procedures for much higher reimbursement, while your extender is doing the grunt work of data gathering. 2 scopes this hour? 2 consults out of the way.
Simultaneously.
When you see a patient for 3 minutes and the reflex order, over and over again, year after year, order CT today, scope tomorrow. Or Echo, stress test, amiodarone, (I, me personally) lose faith in the quality of the consult.
I don't blame procedural heavy specialists for going down this route. It is in their best interest. Financially it is of course, the correct decision. It is also cheaper to higher a slew of extenders than a slew of doctors to do the data gathering for you.
Imagine, as I do, spending upwards of 1 hour on every admission I do. Imagine if you, doctor, had to spend one hour, doing your own work, listening to the patient, their families, their hard of hearing, their rambling, their tangents. Imagine if you had to do this 6-7 times a day.
You would never have time to do your money making procedures, with hospital subsidized overhead. So I understand the games that are played.
And that's why my consulting relationship, while cordial, has moved to a point where I more confidently practice my medicine and call only when I know I can't handle the issues at hand.
Or when I know I need a procedure or are requesting a procedure.
The "dumping consults", the ones where no procedure is indicated, are fewer and farther between, thanks in part to your confirmation of my skills over the past 5 years. Agreeing with my plan, day after day, year after year.
From this stand point, please understand that when I call you, it's because I really really need your opinion, not just because I think I need your opinion.
Happy.
photo credit
13 Outbursts:
i hope your specialists are not billing consults for those visits where the extender does all the work
i'm not sure what the point is of training the physician extenders to maximize notes for the purpose of billing. they can't bill a physician consult. i suspect you are giving them too much credit in their billing prowess, and that their thorough notes result from their own meticulousness.
also, the reason we have physician extenders is to extend the abilities of physicians. the physician extenders cannot perform procedures independently. however, they can certainly see patients and gather information independently. that is one purpose for their existence. if no one comes to see the patient for hours, is that better for the patient? if no one came, the hospitalists would be screaming about lack of support and inability to reduce hospitalization times. just because the specialist physician didn't spend a lot of time in face to face contact, doesn't mean they didn't spend a lot of time thinking about the patient. they certainly discussed the pertinent issues with their extender. by your own admission, many of these patients have multiple severe illnesses, and you spend an hour admitting them? perhaps the specialists spend less time since you are there doing the grunt work. for that, i am sure the specialists are thanking you while you stab them in the back for doing their jobs.
hospital subsidized overhead, hah. i guess that's why there is such a rush to build specialty surgical centers. i guess the money to support the hospitalist programs has to come from somewhere.
anon 852. My understanding of the rules say as long as a physician "sign's off" on an extender note, they can bill 100% of their fee. Correct me if I'm wrong.
anon0923. I don't have any problem with extenders. I have a problem with physicians who use them to replace their duty to be a doctor.
When all you have a specialist has offer the vast majority of my patients year after year is CT, scope. CT, scope, I have a hard time believing any significant thought process went into the request for the consult. Its hard to offer alot when you are spending 5 minutes with the patient.
Hell, I can order a CT. I don't need three years of extra training to do that.
Can you understand the difference?
I am not stabbing anyone in the back.
I am asking for a thoughtful consult. Not
CT today, scope tomorrow.
And any scope done in the hospital is subsidized overhead. It used hospital equipment, hospital nurses and hospital rent, so I'm not sure why you are opposed to me calling it subsidized overhead.
The facility fees' on the other hand that a scope can generate are often times more than the procedure itself pays, so yes, it does pay to open your own building so you can bank it at an exponentially larger rate.
I'm not saying using extenders are bad. I'm just saying it dumbs down my opinion of their opinion, because the opinion is frequently the same through a vastly different patient poppulation.
The money for subsidizing the hospitalist programs comes out of a necessity to get low paying pneumonia patients out quicker so the money making CABG's and total knee arthroplasties have a place to go.
You are correct, if all illness were created equal, I would likely be out of a job.
the physician cannot bill for inpatient consult if the npp provides and documents the service. inpatient consults, procedures, critical care cannot be shared between physician and np/pa either. depending on how you interpret the rulings, if a npp is involved at all, including gathering old records, reconciling the medlist, sh, fh, you may not be able to bill consult at all.
less stringent interpretations have been that npp's can gather data for you as long as you personally review it all and include it in your note.
anon, what is going on is the PA/NP does all the data gathering, AND dictates the note in the doctors name with their signature indicating they did the dictation for the doctor.
I don't know who the rules work in this situation. And I don't know how they bill, but I'm fairly certain that it gets billed out at either 85% of doctor fee or 100% of doctor fee.
anon, what is going on is the PA/NP does all the data gathering, AND dictates the note in the doctors name with their signature indicating they did the dictation for the doctor.
I don't know who the rules work in this situation. And I don't know how they bill, but I'm fairly certain that it gets billed out at either 85% of doctor fee or 100% of doctor fee.
i am getting confused by your timeline. on the one hand, you say you only consult if you need a procedure you can't do. then you say you are upset when the consults come back recommending ct and scope. iow, they agree that your medical diagnostic and treatment plans are good. so why get upset? unless you mean you don't consult anymore because you were only getting the same answers you came up with yourself.
secondly there are two general strategies for doccumentation. one is to document all your thoughts, including extensive differential so as to demonstrate you did think of it in case someone checks on you later. the other is to minimally document so that someone can't say you didn't think of it since you didn't write an extensive note that might have omission in writing suggest that ommission of thought also occurred.
i can see how you think that the few recommendations imply that they haven't thought a lot about the problem, and maybe in your hospital that is true, but arriving at the same recommendations doesn't always imply the same thought process has occurred. like i say, you're at the peak of your skills right now. in 20 years we will see if you exhibit the same confidence in your skill set. god forbid you may someday get sued and want 'certified coverage' for your decisions. lastly, i see hospital medicine as exciting and growing now. we will see what happens. the different practices we contact with seem to be going in very different directions. some incorporate preadmission vists and postadmission visits. some stop working with primary care docs and only support surgeons. some are not doing any icu work. as we see the hospitalists subspecialize, we may see some similar pains as you are experiencing now with specialists.
i know you are trying to trumpet the problems of primary care, and i applaud you for it (disclosure-my wife is primary care and brings home a good chunk of our bacon). i think an observer such as myself sometimes feel rather than identifying problems with the primary care your posts come off as insinuating specialists don't deserve what they are getting (don't see patient, don't think about patient, charge high $$$). i'm not sure that is the message you intend to send. i really think we need to unify rather than split amongst ourselves. anyways, if you truly aren't getting good service from your specialists, maybe they deserve to be called out. i wouldn't be so sure from reading the notes that was the case, although you may have other information supporting that opinion. however, calling them out here is not a fix for that problem. :)
in our community we have investigated a number of options for supporting primary care, some of which may not be legal-we are investigating. we are wondering if the specialists can pay signing bonus for the primary care docs. we are looking at forming a non profit community organization that might do that or repay loans or things like that. we have formed committees to see whether we could incorporate primary care docs into our own specialty practices. there are lots of ideas being investigated, i am sure, in many communities throughout the country.
anon 1239:
I have learned, based on my specialist referring patterns what happens when I consult certain groups and even certain people in certain groups.
there is an automatic reflex to order specific tests
GI-scope
Cards-echo
Neuro-MRI/EEG
It's not limited to only specialists. I also agree, this practice style can also infest primary care as well, and other hospitalists. But I don't have the luxury of consulting primary care, since I'm a hospitalist. My experience is with specialists.
It is a reflex, it seems. Independent of the clincal case of the patient, the recommendations are always the same.
Do I think every patient I consult to GI/Cards/Neuro/Pulm needs a procedure or an image.
No. And a frequent result, in my clinical experience, is that they do, AND I get a non actionable data point for a very expensive price.
We proceduralize the patient to death because of that tiny what if thought in the back of the mind of all docs. What if I'm missing that rare case of ....
I really believe that a significant portion of testing could be avoided with a little thoughtful evaluation and watchful waiting.
But the money flows towards procedures and it confirms the negative diagnose over and over again.
I am willing to document my thought process and work through many medical problems without proceduralizing a patient to death.
There are those patients I have that require extensive radiographically and procedural evaluations.
The ones where I am stumped clincally and medically. That require me to have multiple specialists. Multiple procedures.
I understand that is part of being really sick.
But we do it more than we need to and at a significant cost to our Medicare/Insurance system.
So now, when I consult a specialist, it is usually because I either know I need a procedure or I don't know how to manage a problem myself. SO it may or may not need a procedure/image/test.
I don't consult for every case of N/V/Abdominal pain. Every case of Afib. Every case of abnormal cardiac enzymes. every case of infection. Every stroke. Every case of COPD or pneumonia. And on and on.
I am quite comfortable managing a vast array internal medicine problems without the need for confirmation by a specialist. That is my point. So like I said at the bottom of the post, when I consult a specialist, most of the time its because I need you, not because I think I need you.
In my experience, the use of extenders has become THE consult from my specialists who use them and I have now limited my exposure by managing many issues myself. Issues that I feel don't need to be proceduralized, but would, if they got involved.
My specialists do a great job. But I think I can do just as great a job, and at a cheaper price, on a regular basis. So I'm not really calling them out, or complaining that they do a bad job. They just do what I would do, but cost more.
Do you understand what I'm saying?
It's a very real difference.
Let me repeat. I love my specialist. I just think my knowledge base for a vast array of common medical problems is equal. And I am fully qualified to manage them.
As far as the last section of your comments, no I have no problem with specialists making alot of money. I think any doctor should be able to charge what the market will allow. The problem with the current system, which is not the fault of any specific specialist doc, is that procedures are reimbursed at the expense of primary care reimbursement because of the flawed RVU/SGR system. To increase reimbursement for one group you have to decrease it for another group.
It is absolutely a ridiculous system that needs to be abandoned and separated. This is the system that pits doctor against doctor. Not me. I'm just calling a cat a cat. Each trying to get their own fair share of the fixed pot.
The reason I love my job is because hospitalist medicine has exited that fixed pot with its own side pot of money.
I pose this hypothesis. What if procedures were reimbursed at similar rates to cognitive care? My hypothesis would suggest that the proceduralization of America would disappear.
Let me give you an example. None of our GI docs do paracentesis. None of the ID guys and very few of the neuro guys do LPs. And only a handfull of the onc guys do their own bone marrow biopsies.
Who does them?
Our interventional radiologists.
Why?
Because these procedures pay very little.
A paracentesis/LP/BMbx/ has the equivalent payment of a mid level hospital followup or less.
Do I believe that if a paracentesis paid on the order of a colonoscopy on that the GI docs would be doing them?
Yes, I do.
The same goes for bone marrow biopsies and LP.
They don't do these procedures because the payment is not worth their time. In other words, the payment is equivalent to a hospital cognitive note, which isn't worth their time. They could better spend their time in the endoscopy lab.
These are the step child procedures of the world. Banned to the poor interventional radiology guys who may use fluroscopy and end up charging 10x the rate had it been done bedside.
It's not the specialist fault. In fact, If I was a procedural specialist, it would be hard to ignore the financial incentive of doing something often that very few in this country are trained to do or question the necessity of, especially since it generally pays well.
Needed or unneeded, I would be trained to do a procedure that very few others can do or even question the necessity. I few well placed words for indications, and they will always get approved. And paid. Thats the reason why heart hospitals, orthopaedic hospitals and overnight surgical centers have exploded, because the reimbursment rates are so good.
I don't think my reimbursment for a cognitive physician should be tied to a system dependent on a group controlled by specialist physicians who continue to give themselves a rate of reimbursment that far exceeds cognitive care, on a time or risk axis. My reimbursment should be independent of the number of or cost of colonoscopies done in a year. Right now it is throught the SGR/RVU fiasco. Because its easier to do 50 colonscopies a week instead of 25 when you have PA's doing all your notes/dictations and less well paying thinking work load for you.
That is a fact of reality. I don't blame them. It's a great business decision for those specialist who employ their extenders in this way.
I hope I have clarified myself. I would be glad to answer any unaswered questions.
Cognitive care reimbursment should be separated from that fixed pot of money. I believe it should be allowed to function independent on a market basis with balance billing and let the free market forces determine the right price based on rings of service being offered.
we'll just agree to disagree. i certainly think a generalist can manage many problems ably. certainly some specialists don't keep up, and some primary care docs may know more about specific areas of interest than the relevant specialist. i still don't think they think about things the same as a specialist, even if the ultimate treatment winds up being the same. i think they don't have the opportunity to focus on history and physical exam and discuss things with the patients in the same way due to time constraints.
wow, the hospitalists are like the er of internal medicine. i hope you are as smart as you think you are. lol. peace.
Thanks for the photo cred!
I work as a hospitalist in a small, rural critical access hospital. I wish I had more specialists to consult! Like you, I enjoy from a cognitive standpoint the really sick ICU patients in septic shock, multi-organ failure, etc. What a rush to get them out of the unit without lasting sequelae! But, I suspect that I've been in practice a bit longer than you.... Watch out for those families of the 90 year olds who want their loved one's fluids managed by the nephrologist or cardiologist. Ninety year olds have a bad habit of actually dying once in a while, and the son or daughter who for whatever reason is not expecting that will be pretty bitter with you for not going along with their concerns. I try never to get into a disagreement about when to refer with family members. If they suggest it, it is time to refer. I don't want to have to deal with some bogus lawsuit later.
A doc can bill a shared service code with a MLP as long as it is an E/M code and the physician documents a "face to face" interaction with the patient. Procedures may not be billed as a shared service.
Just out of curiosity, what made you think that fluids alone would stabilize the renal failure lady? Most cases I see with numbers like that go straight to HD and I've never heard the renal folks suggest another option....
shadowfox. Because that's what I see day in and day out. Year after year.
I knew very well I could fix her. I knew her base line history. I knew her CVP. I knew she didn't need dialysis because medicines could stabilize the K+ and fluids would fix the renal failure.
I probably saved her from dialysis and another week, at least, in the hospital.
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