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I suggested lightheartedly that hospitalists would be required to consult for pain management on surgical patients who's doctors have never learned to prescribe anything but Percocet and Vicoden, two drugs which may have seen their last days. The conversation got off track with this anonymous subspecialist comment, but I thought it raised some important issues to discuss.
Anonymous said...
anon. There is a big difference between being asked to consult on a patient with an acute problem. We both get that. For me it is to see patients for elevated blood pressure or blood surgar or elevated white count. These are easy consults, but it's easy because it's my field of expertise. The requesting physician is asking me a question.
This is not the same as "follow post op for med management". I am not needed to reorder home meds and write discharge orders and field calls about post op nausea. That's what a PA or NP should be hired to do if the subspecialist doesn't want to be bothered with such hospital annoyances.
Let's imagine you are a GI doc. Let's imagine a patient, who has intermittent abdominal pain but not currently (chronically on Soma), comes in with pneumonia. Me asking you to see this patient because they may get abdominal pain (which I wouldn't anyway) would be like you admitting a patient of mine with a GI bleed and a history of stable HTN, CAD and then asking me to see the patient because they may get high blood pressure or chest pain. You are saying you would consult me. Would you want me to have you "follow along" just in case the patient gets abdominal pain? I wouldn't think so. But perhaps you'd like to. That is not my experience.
How about a cardiologist. Should I consult the cardiologist for medical management of their asymptomatic CAD ( on beta blocker, statin, ASA and Acei) when I get a patient admitted with cellulitis because they may get a heart attack? I wouldn't think so.
Should I consult the general surgeon who did my patient's lap chole three years ago because they may get a bowel obstruction while in for meningitis? I wouldn't think so.
I am more than happy to see a patient for which you are asking me to address an acute problem. If that blood pressure goes up, I'm happy to see. If that blood sugar is out of control or give me a call.
My skills are not necessary to manage stable conditions, just like they aren't needed for the patient to live with their stable medical problems outside the hospital. I don't follow them around when they're shopping at Walmart because they might get an elevated blood sugar.
I do frequently get asked to "evaluate", young health (even old healthy) surgical patients with no significant medical problems. What they really want is someone to do their busy work. I gladly screen the patient, bill their insurance company (which I consider bordering on fraud but I'm not working for free), and sign off with the written statement in the chart to "call back any time with any acute medical questions."
Bill a lower code? Billing a lower code is as much fraud as is billing a higher code. I bill for the work I do and submit that bill based on the requirements set forth by E&M. Now, you may be asking me to do less of a consult or you may consider the work I do in the consult as medically unnecessary. And that's a whole other bridge to turn over.
Very eye opening. I will definitely check with my hospitalists to see which of the groups feels that following post op patients with medical issues is too mundane for their vaunted skills....and then send patients to the other group.
I have always believed that physicians should be cooperative. I see dozens of consults for common (to me) issues that easily could be cared for by PMD, but I also realize that I see 3 a week, while the PMD sees 3 in a lifetime. My care for those patients saves everyone money. The patient gets the best care, with the least number of tests in the shortest possible time. This versus the PMD care who will treat with a shotgun approach, ordering unecessary tests and follow ups hoping the problem will go away.
Perhaps you truly see completely routine patients who have no medical problems and are treated as a post op care specialist, in that case, I have to agree that it is inappropriate. However if you have a patient with hypertension, diabetes on multiple meds, they may no longer be "stable" after surgery.
My personal favorite is you complaining about the cost of the consult, while you rattle off billable items such as "discussing care plan with nurse". Perhaps, if it is really that easy, you could just bill a lower code? But I am learning a lot here, I never thought that speaking with the nurse about patient care could be considered billable....maybe I need one of your billing courses....
That chip on your shoulder regarding internists seems a bit larger than usual today.
I'm curious Happy.
Don't you make a living by seeing the "Specialist's" patients?
I don't mock the internists when they send me common things that they could treat....I figure they are happy to see my general medicine patients post op.
Am I wrong?