Inappropriate referrals from Mid-level PCPs

My attendings keep 1hr slots open for new patients. Just this week I had a patient say that I'd given them more information that their prior doctor ever did.

I hadn't even spoken as yet. I just sat there and gathered history. A lot of patients really just want to feel heard.

Also physicians are almost always asked to see far more patients than midlevels. That leaves a lot less time to be sociable.

V true. Goes for all of life

This here is exactly what happens. Live in a HCOL area with really demanding patients who do their “own research” who think they need to see a specialist for absolutely everyhing.

At this point I know who I can reassure and the ones that I know will spend the remainder of their appointment trying to convince me otherwise, sometimes it’s just not worth it

Having been in training recently changes things - I see straightforward referrals all the time as a specialist and I get it - a PCP seeing 25 to 30 patients per day cannot get into nuance with every patient - I am happy to see a patient with new paroxysmal a fib or HTN or a murmur - easy visit for me patient is happy and I send the PCP a note with my recs and thanks

As a subspecialist on the receiving end of referrals like this the problem is we don’t have infinite new patient appts and when these patients take up a slot, someone w a legit problem has to wait. So I triage all referrals to our group and decline the ones that don’t require a specialist. Just as antibiotics need stewardship so do specialist appts.

This is it. When I have one of these type referrals I usually put in my note something like this- “Advised patient that Hypertension can be managed in this office, however he insists on cardiology referral for their opinion. “ I make sure a copy of the note is sent to the specialist so they don’t think I am a complete idiot. It seems everyone wants a specialist. I feel like an air traffic controller in Family Medicine sometimes. Just sending people here and there. It’s crazy. And what’s sad is sometimes I never get a note back from the specialist and the patient gets medication changes that I never hear about. People don’t even know what medicine they take and they go to multiple pharmacies so it’s hard to track everything down. It’s frustrating. However, if I have a legit referral I try my best to do as much of the work up as possible before I send. Also I use e-consults a lot just to ask questions to see if there are other recommendations before I send people out.

Actually I want to hear about this bridge game drama! (joking)

As a specialist (pediatric subspecialty), I also say something similar! However, instead of saying “maybe if you see a primary care physician they would be able to manage that,” I say (in a very nice tone of voice) “I highly recommend switching to a physician for primary care, because your child deserves to always get expert-level care. NPs are only required to have 500 hours of training before they are allowed to diagnose and prescribe. A physician, including a primary care pediatrician, is required to have minimum 15,000 hours of training.” The whole things takes me less than 60 seconds to say. Almost always, the parent is not only shocked but thankful for the information, and they frequently end up switching to and MD or DO.

Kind of a no brainer though. Patients don't have medical knowledge, how can they really assess skills or brilliance other than who makes them feeled cared for. Bedside manner is a critical skill for a reason.

I’m not blaming them, just pointing out the irony and the pitfall. The absolute best doctors I’ve ever met have been very under appreciated by patients bc they aren’t the most charismatic or consoling people. They also don’t have time to sit and listen to patients talk for a long time because they have a lot of patients to see. The reality is that you can get most of the info you really need from patients in a few minutes. 90 plus percent of patients who want to talk for a long time talk your head off about completely irrelevant things. Your mid level isn’t taking that time bc it’s needed for your care, they’re doing it because they have more time and likely because they have a harder time figuring out what is relevant vs what’s not. It’s just unfortunate that health care providers are judged by their willingness to be therapists.

Medicine is like one of the few profession, especially a high end one, where the customers care a lot about the personality and the hospitality end of things, so much so that it even affects customers’ own judgement and what kind of service they will choose from whom.

Like when you think about it, you wouldn’t pick a lawyer, a pilot, an engineer, or even a car mechanics or an electrician based on their personality and how nice they are. Not at all, you would much prefer the ones who have very good experience, training, and knowledge, and basically the ones that have the highest chance to solve your problems.

But medicine is not like that. Part of it is. But the other part of it, that personality side of the doctor can change so much how the patient will perceive and judge if that doctor or provider is good or not, and they could have no idea whatsoever how experienced and knowledgeable that doctor or provider is. We are almost like a restaurant, where people don’t always go just because the food is good, that sometimes customers are willing to go even if the food is very mediocre at best but the vibe and the staff of the restaurant is very nice and customers are willing to pay for the experience.

Paying for a provider that doesn’t know much but seems more friendly is almost like that, you are paying for the experience of the encounter, and not necessarily for the expert opinions.

As you said, a lot of it is because patients are vulnerable when they go see a doctor. The hospitality contributes to the sense of “I am being well taken care of”, and that feeling is crucial when you feel vulnerable. I guess this is why the “art “ side of medicine never truly goes away no matter how evidence based we have become, and we are constantly being reminded that during our training.

I can tell you back when I was in training and began practicing, docs did have the time. Hospitals were physician-run and that time is valued. As much as people today want to believe docs are too busy or don't want to spend the time, it is not true. Most docs learned in training how to be expeditious while still providing quality care and talking to patients. But the medical culture changed in many ways:

1. Private equity/Corporate practice of medicine(CPOM) entered the picture and began controlling not only the hospitals, but the contract medical groups for whom many docs work.
2. Corporations are only interested in profits. Volume versus value. Thus began the "metric system". That is, stats being kept on docs as to how many patients they are seeing, admitting, doing surgery on, etc. and then a major focus on billing for every little thing so the the employer and facility get paid. That volume metric literally ensured patients would me moved like meat through a processor. There is a reason that hospitals like Kaiser limit appointments to 15 minutes per patient, regardless of complaint. And docs never stay on time because it is impossible. Every patient is different.
3. The corporations also began hiring more NPPs to replace physicians because they are cheaper. But they are not as efficient or thorough in their history taking or medical management. Ordering a bunch of labs and x-rays does not constitute "thorough". In addition, someone has to do the work behind the scenes to manage the patients, come up with treatment plans, follow up lab/radiologic results, talk to consultants, etc. There is a reason the term "bedside nurse" came into existence. Nurses always spent more time with patients because their role was different from physicians-it was supposed to be. In clinics, EDs, ICUs, etc., docs are still expected to see a high volume of patients while NPPs are not. In the ER I was expected to see 25-45 patients in a moderately high volume hospital. A NP might see 8-10. They slowed me down and made me less efficient. PAs were more efficient and generally saw "fast track" patients. They are trained in a medical model so it was easier working with them.

Many docs, sick of the CPOM, left to start their own Direct Primary Care practices. They don't take insurance and are their own bosses. That is where you will find the docs who take the time to talk to patients. It is an entire movement that is growing rapidly. Docs and patients love it. There are no corporations involved. Docs took a pay cut but they are happier, as are the patients. Other docs left medicine or like myself, left the country. I can now practice the way I was trained. It is appreciated. One problem is Americans are impatient. They hate to wait unless they are the one's docs are spending time with. They have no understanding that a doc is behind because they are doing the same for every patient, not just them. So they complain which feeds into the CPOM fast food medicine mentality and can lead to a doc's termination. They contribute to the problem.

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I’m sure there are. Just echoing my experience. All of the MD referrals I’ve seen so far have been appropriately worked up.

My wife, FM attending, is guilty of minimal work up and just referring. She has no other choice from lack of staff, time, and burnout. She has had to room her own patients from no MAs able to work and no other coverage available. When an ENT rudely pointed lack of work up, she removed him as a referral source. They are a dime a dozen here. Just to offer another angle.