Dr. Andy

Reflections on medicine and biology among other things

Saturday, May 06, 2006

Doctors communicating

Flea has a great post about specialists not giving credit to primary care docs for staring the work-up and, often, making the diagnosis before the specialist even sees the patient:
In his letter, however, the gastroenterologist failed to mention any of the work-up that I had performed, and stated matter-of-factly that he had made the diagnosis.

In a collegial manner, I offered that at best the diagnosis was a joint effort.

My colleague's reply was "My goodness, I didn't think you guys (i.e., you fleas) actually read these letters!"
I respond in his comments, but I'd like to lodge a complaint from the other side of this interaction. Specifically, any workup you do is of no use to me if I can't get hold of it.

Again and again I see a patient referred for "immunodeficiency." Like many kids, the patient has been on antibiotics a lot. The primary (PMD) has sent some lab tests and apparently they were abnormal. I say "apparently" because I don't have them. The parents assumed the PMD's office would send or fax them but they didn't. Our nurses are happy to call, but don't appreciate being on hold for 15 minutes, then being told the office is too busy to fax it over right away. At times I have to personally call the doctor to plead with him to have someone fax them right away. Meanwhile, the family sits for an hour while we wait for the results of these tests. Usually, the tests are fine (one lab locally doesn't correct the "normal" immunoglobulin range for age, so all kids come back artefactually low), and I can reassure the patients, but it would sure be helpful if I had those tests right away.

So, primaries, think about using your consultants wisely. Everyone benefits when the workup you've done is available to the consultant: it makes my life easier, I can communicate what I think to the patient and parents in person not in a phone call later, and unnecesary and duplicate testing is avoided.

UPDATE: added link to Fleas and his original post which I swore I'd already put in.


At 7:17 AM, Blogger Flea said...


There was a time in the recent past when pedie and consultant used to actually talk to one another prior to the consult! I know that sounds icky, but that was before the days of fax or email.

These days, you don't actually have to face the prospect of engaging in verbal intercourse with your consultant if you're too not liberated enough, or you've got hang-ups about intercourse, or whatever.

Fax or email is the way to go for those guys!



At 1:01 PM, Blogger Aggravated DocSurg said...

Amen, to both of you. As a consultant, I am delighted to see patients in referral, but it does not make sense for the patient to sit in my office for hours while we wait for the results of one test or another --- to determine even if they need to see me! I have occasionally had to send folks home to return a week later just to make sure we have all of the relevant information available to make a good clinical decision.

What is more concerning to me, however, is the lack of communication in the hospital. Orders left on a chart stating "Consult Surgery" leave one wondering whether the one doing the "ordering" is really in the same profession, and whether he/she understands the importance of communicaiton in patient care.

Sorry for the rant -- had to vent!

At 12:17 AM, Blogger Dream Mom said...

Just an observation-I can't seem to understand what the fuss is all about; from a patient standpoint, I think the primary care doc's job is to refer you to the specialist and the specialist runs the tests and makes the diagnosis and sends a letter back to the primary care with the diagnosis. If the primary care doc contributed to the diagnosis via the work ups, does it really matter? I mean, yes, there is some revenue to be generated by the primary care doc (by running the tests) but it's been my experience that most docs want to run their own tests at their own facilities. To argue over who gets credit or who didn't gets credit seems a little childish to me. I would expect that as physicians, there would be more pressing matters to attend to than this.

Seems like you docs should be able to communicate a little better than this.

At 12:47 PM, Anonymous Anonymous said...

communication=time. Time=money. There is a strange phenomenon I encounter when talking with other physicians. Regardless of whether I call them or they call me, I am inevitably put on hold. If I'm called by the ER, I'm put on hold. If a specialist calls me out of the exam room, it is really his nurse and I am put on hold. If I call the specialist, I'm on hold.

"Seems like you docs should be able to communicate a little better than this." That's like saying, "I wish you would spend more time with me, or on my case." I totally agree with you. I also wish that grass tasted like chocolate, or that running shoes cost $5.

In my limited experience (5 years), when there is a serious problem, most prudent doctors make the time necessary to talk to the person they need to. If I'm referring someone to a specialist for a problem and I've already forwarded the records, it makes no sense to talk to them, as they are obligated (I hope) to take a history from the patient. That takes time, and it may be quicker (i.e. more lucrative) for them to crib off of my history. If that is what upsets the specialists, I don't have much sympathy. If they are upset they can't get labs and previous tests. I completely sympathize.

At 1:50 PM, Blogger frostedlexicharm said...

Communication between my son's docs is something that has frustrated me for 3 1/2 years now. (Don't know if it's cool to mention which hospitals he gets treatment at, so I'll be coy and say YouSeeNorCal and YouSeeSoCal.) He was born at "YSNC" but needed a double-transplant of a type that "YSNC" didn't perform, but as "YSSC" does that type, we started being seen at "YSSC" as well. For transplant-related illnesses, we head down to "YSSC". For line sepsis or GI issues, we go to "YSNC". For regular run-of-the-mill pediatric issues, we go to the Pediatrician. Now, part of getting our system to work properly and run in an organized fashion is getting all the docs on the same page. There's nothing like showing up at the Pediatrician and expecting them to have the "latest" info from whichever hospital we just got released from, only to be told "No, got nothin' here from "SC" since the last time you came through when he had that bilateral ear infection." I will state that "NC" is a lot better about this than "SC"...any lab results or discharge summaries generated through "NC" automatically get faxed to "SC" as well as the pediatrician...it's just "SC" that appears to be the information black-hole (it goes in but doesn't come out).

Heck, the two hospitals don't even "talk". I can't tell you how many times I've had to have "SC" docs call me in the patient room at "NC" just to get the docs talking and agreeing on a treatment plan, or how many times I've been sitting in the doc's office at "NC" waiting for lab results to arrive from "SC" (if son's had labs drawn on a Monday at "SC" and we're at our regular clinic visit at "NC" on a Wednesday, why poke him again if the values from Monday are WNL?).

At 4:50 PM, Blogger Dr. Andy said...

Good comments all.

Flea, I don't mind talking to primaries, but I see 20-25 new patients a week, so at if I talked with the referring doc before and after each one times 10minutes per call (including time on hold, etc) that would be like 7 hours I'd spend talking, which emphasizes FLCs comments.

Dream mom, I agree; my point was only that if the PMDs start the work-up it is helpful as a specialist to have the data when I see the patient.


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