Home Forums Discussions General Discussion Primary care rant

I practice in a community with relatively few subspecialists, and as such I am used to caring for most of my patient's needs. When consultation is required, I initiate it, and the consultant reports back to me, and generally makes recommendations to me about care which I then integrate into the overall management plan.

I have a couple of patients, however, who have arranged to see one or more subspecialists on their own, and who now are the poster children for fragmented care. When the patient comes to see me, they are on unidentified medications from various doctors who not only do not communicate with me, but do not communicate with each other. Literally, I do not know how to provide care for these folks. Any records I can eventually pry out of the other offices are out of date, and bereft of any overall plan for care. I feel like some forensic anthropologist trying to reconstruct a skull from bone fragments, and every time I turn my back an army of ants comes in and rearranges the fragments.

My reading of posts and magazines leads me to believe this is common rather than rare in other parts of the country. How do primary care physicians function in that environment?

This is probably one of my biggest problems. We have a certain HMO that comes in to our office stating they want us to:

1) refer patients when necessary
2) notify the patient when the authorization comes in (mind you it's mailed to their home address)
3) Follow up with patient to make sure they made their appointment
4) Make sure they went to their appointment
5) Document all of the above

Yet, there is NO REQUIREMENT for the specialist to send us notes on a timely basis.

I rarely know they went to the specialist. I hardly ever get records. When the patient comes back to my office, they don't know what meds they were given or what tests were ordered/done. We request medical records but usually get them later in the week after the patients appointment.

You aren't alone.

You have precisely described the world of taking care of seniors in Florida.

I cannot claim any success with prying records loose from consultants, but we won't see anyone without their medicine bottles -- no bottles, go home and get them. A few trusted patients who are computer-literate, we accept a list, as long as it is complete. Since using AC, we give them our list to take home and bring to every other doctor. It has made a big difference.

Most recent consultant horror story: An elderly patient of mine failed to keep an appointment, and my staff called his contact numbers for days with no return call. The gentleman also sees a nephrologist, cardiologist and pulmonologist frequently. We called all 3, the cardiology & nephrology offices had no idea what had become of him. On the other hand, the pulmonary office told us (after much time on hold) that the patient had died (in October, 2 months ago). Later that day, we received a encounter note from the cardiologist, regarding an October hospital visit, dictated the afternoon we had called(and after they had told us they didn't know what happened to him). Better late than never, I guess.

I tell patients to sign a note with me if they dont know medicines that they are taking - therefore absolving me if they have an untimely demise. I rarely get a patient in without bottles anymore.

Can I get a copy of the note for this?

It should come as no surprise but, my friends, it works both ways. I am a specialist and
see new patients by direct referral only. When new patients have had lab work, pulmonary
function tests, sinus Xrays etc perhaps only 10-15% of the primary docs have forwarded this
information prior to the initial visit. Almost never does the referral doc send along
a list of previous meds and I too end up asking the patient "was it a white bottle with
a blue top? Did you inhale it or stick it up your nose, or something else? " etc.

Been in this specialty for 30 years and the only thing that's improved is
now when I call the referring docs (it's a pain and need luck to get through) their
office can belatedly fax the information to me. Before fax machines it was write it down
or wait for snail mail.

From my end the primary doc gets a custom dictated referral letter (non AC generated) faxed within
24 hrs of the patients visit. I must admit follow up information is sent only if I feel there has
been a major change. Many, many thanks to Amazing Charts for facilitating these follow up faxes
as using the letter writer and including the patient's "Plan" has eased my burden.

While we are into pet peeves, another one is the other specialists I refer to who then send
me a 5 page computer generated consult letter. For example, a local ENT doc checking skin
turgor, clubbing, mentation, babinski?? Really? Gimme a break. After wading through boilerplate
computer verbage I might find where it's mentioned what's actually wrong with the patient.

thanks for your comments Bob. It's nice to know you try hard to get back to the PCP, and good feedback for those of us in primary care.

We have an office policy whereby the patient must have been seen by me for a particular problem in order to get a referral. For example the patient needs a referral for breast reduction surgery, we could easily just call the plastic surgeon's office and make this referral. However we make them come in. The patient may balk saying "I was just in for an annual physical, why do I have to come back?" My staff tells them that the specialist will not see them without a letter of referral and we require that you see our doctor in order to get a referral letter. I talk to the patient, document the reason for referral in an office note, and generate a letter with AC. The specialist has the med list, problem list, and some documentation as to the reason for consultation. The patient while initially balking at the need to come in, is relieved to know their referral is happening. The specialist has the information they need, the patient has what they need, and I got to bill an office visit and thus don't feel like we are being abused by our patients so I'm happy. Win, win, win.

I also take patients selectively in consultation for Osteopathic Manipulation Treatments. I find it equally annoying, like you, when there is little to no information sent by the referring office. The classic terrible referral is when I get only a computerized phone message from their office stating "patient called for referral to Dr. Lauer for back pain, referral processed." I don't take that referral. But I have my own family medicine practice which keeps me very busy, so I don't have to take all referrals requested of me.

You are correct Ches....I am probably the only doc in my area that sends a detailed list of meds and problems to specialists when the referral is made...it takes time....but I get the same response from them when I get the patient back from the specialist...it took 7 years with the help of AC to get to this point..I remember as a resident that I was yelled at by a rheumatologist when I sent a patient to him without information....his scathing review of proper procedure still is true today.....

I send a letter and the AC note with every referral. (This is why we need a better letter writer. I tried to tell AC that this is the PRIMARY advertisement for their program - the thousands of generated letters the program spits out, and they should really want to look professional here. eCW and others have them beat there!) My note has all the information from PSH to med list to allergies. It goes out, every time!

I agree that a better letter writer would be superior advertising for AC. I hope the AC programmers are reading this...

Hi BoonDoc and Dr. Lauer,

I don?t know if you guys are aware, but an improved third-party Letter Writer will be released this spring. Click on the link below ?Letter Writer Project for Amazing Charts ? link in my signature to check out the details.

This is a 3rd party app that will run as an add-on? Lawrence do you have a release date projected?

It will be a standalone word processor that will interface with Amazing Charts. If it?s the Lord?s willing I will have it completed on March 30, 2012. It will be available to download the first week in April. I will let the AC community know when that time comes. Thank you for your questions, Dr. Lauer. I hope to earn your support.

thanks lawrence

You're welcome.

It looks good: I just downloaded and checked it out. Right now it looks very similar to the letter writer built in, but I see I can change fonts, colors, and so on. I am hoping there will be good functionality to have letter head, logos, and such automatically imported. A key issue will be how easily it integrates and how many more clicks will be needed.