Over at KevinMd a post suggested that outpatient primary medical doctors should have their fees raised by reducing the fees of subspecialist. Under current RVU/RUC rules the physician payment system is a WIN/LOSE system. For every winner there is a loser.
A responder to Dr Kevin's post, a specialist, left this comment:
There also seems to be a feeling that all of these procedures we do are unnecessary and unindicated. As a specialist, the vast majority of patients I see are referred to me by primary care physicians because they feel their patients need additional care. Why would they send me patients if they felt that further treatment was not indicated?
Years ago, I had a patient I was consulted on for a deep venous thrombosis from a subspecialist. For whatever reason, the hematology service was consulted as well. I ran into the hematologist reviewing the chart. I explained that patient probably got their VTE from a surgery they had several weeks prior. I asked them if they were going to order the horridly expensive profile of coagulopathy tests. And you know what they said to me?
"I usually would not, but since I was consulted I probably would".
After discussing the case we decided not to order all the tests that cost thousands of dollars to run. I bring this up in relation to the above comment because of the above specialist's comment.
Just because you consult as a specialist, doesn't mean you HAVE to do something. As a hospitalist, a lot of what I do is watchful waiting. I don't do anything and the patient gets better. Just because a primary MD sends a patient to you as an orthopaedist doesn't mean you have to do anything. If the question is what to do, doing nothing is certainly an option.
I think this is an important difference between primary trained MDs and subspecialty trained MDs. Being a subspecialist does not relinquish your right for watchful waiting. But I find many times that concept is alien. Perhaps it's the thought that not doing anything will not please the primary. Perhaps not doing anything means a loss of procedural revenue. Perhaps not doing anything leaves open an irrational fear of legal liability.
Whatever the reason, I take offense to the subspecialist who suggests that primary MDs refer patients because something has to be done. Sometimes, it just doesn't. Really. Doing nothing is still an option
2 Outbursts:
I would think that primary care docs often refer to specialists to find out whether further treatment is needed, and often the answer is "no." The notion that a specialist "has to" do something because the primary care doc made a referral is just rubbish, and suggests that specialists don't have any training or clinical expertise of their own to rely on--yet I'm certain they'd one and all take umbrage if a primary care provider ever ordered them to do something.
I am an oncologist. Recently, I had a patient sent to me for a mild lab abnormality. Two years ago, she had been seen by another oncologist, and told that it was a benign process. Now, with two additional years worth of labs showing absolutely no change, I concurred with the initial evaluation and told her no additional testing was needed. The patient told me "my PCP told me that he will feel better, I will feel better, and you will feel better if you do a bone marrow biopsy to make certain." I don't feel better doing better marrow biopsies....especially when they are for very weak indications. It is that unveiled threat of failure to diagnosis that drives so much inappropriate testing. I discussed the case with the PCP. We agreed that a bone marrow biopsy was not indicated (and he had never made the above statement to the patient). Unfortunately, in our now-is-when-I-want-it-done society, watchful waiting doesn't go over well (plus or minus that "irrational fear" of legal liability).
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