Home Forums Discussions General Discussion Not gonna happen

I finally got hold of an adult GI to see if I could refer my 22 yo extremely sick patient with Crohn's. I was pretty excited, because our office had gone through the go around trying to even get this office to call us and accept the patient. But, I figured colleague to colleague would get me somewhere. So, after I told him who I was, I asked him if he would accept my patient, and he says, "Not gonna happen, not gonna happen." Well, I thought that was a little unprofessional. Well, maybe a lot unprofessional. I don't think I have heard another doctor every say a phrase like, "Not gonna happen." He had two reasons, may one or both were valid, I don't know.

He said he had read the record, and he sounded too sick to manage. I don't know, I know that some G.I. doctors specialize in IBD so maybe he only does hepatology and constipation. But, he still knows a little bit more than I do. The other practice in town stated they could see him on March 11. Hopefully, I can talk to them and get him in. So, the doctor suggests he go to Portland, which fortunately is ONLY 2 1/2 hours away. When I pointed that out, he said "Other people do it."

I will say in all fairness that he used to go there and transferred out and some offices have a policy about taking patients back. But, his surgeon wants to operate fairly quickly and she wants G.I. to get his flareup down a bit. Normally, he is on Remicade, but I guess he will have to go to Portland to get it.

My guess? your patient had already had a colonoscopy. Why take on a problem for $12.73?

Having said that, let me give you my take. I do a fair amount of GI stuff. If I want to get someone to actually use intelligence in addressing an IBD problem, I go straight to the University of Washington. I have yet to find a private GI specialist in state who looks beyond procedures. Yes, I know I will offend several friends on this group, but it is true. Reimbursement is reality. If I need real thinking, I go to a teaching facility.

......... waiting for GI Jon to chime in before I get in trouble.

Hepatosplenic T-cell lymphoma has occurred mostly in teenage or young adult males with Crohn?s disease or ulcerative colitis who were taking TNF blockers with azathioprine or mercaptopurine.

22 and surgery?, sounds bad. If he needs surgery, then can he really wait for March to see GI, April to get the auth and infusion arranged, and June before the Remicade captures his Crohns?

You have a diagnosis, a treatment, and a surgeon. You need labs to verify no infection, and the surgeon can poke on the belly to make sure there isn't a fistula ready to pop. Your hospital could infuse 5 mg/kg next week if you can get an emergency auth for continuity of care on Remicade with worsening illness. Probably a call from you would do it. A PPD would be nice if more than a year. Do you have histo there? HepB testing should also have been done if he's been on Remicade.

In a pinch, rheumatologists have samples of injectable TNFs in their office. We don't want to play GI, but I infuse 2-4 GI patients a week. Amazing what they can do for Crohns n UC. A local heme-onc might be willing to get involved

...that is if Jon doesn't get riled

I am one that is not eager to take a patient back, so if he knew which patient it was (and perhaps had issues with that patient), I could understand his reluctance.

Perhaps the "not gonna happen" was specifically designed in his mind to stop further lobbying. He may not have liked that patient.

On the other hand, if he didn't know which patient it was, he was rude and doesn't "deserve" the patient. The patient would be better served by someone who cares.

GI docs are interested in procedures not management. Follow the dollars.

Any time a fellow doctor calls you personally asking for help, one should try to help. On the other had, I can think of a few "dismissed" patients I would not take take back no matter how personal the call.

Remember med school and residency when we realized that we are fellow members of an elite club and need to look out for each other, not just making $$$.


Larry
Solo IM
Cincinnati

Larry, I agree 100% with you that we should always try to help our colleagues and vice versa, as we are members of a brotherhood like no other. That is what sets doctors apart. I will never forget when my pharmacology professor, Dr. Vincenzi came out dressed in his graduation gown and hood, during my second year of medical school and emphatically pounded this point into our heads. Of course, this was back in the 1980s, when things were different (?). I also remember, one time, early in my practice, when I had a severely depressed female patient, who was being abused by her husband, brought into the office by her children, and who I was able to convince to go into the hospital for some help. I called a local psychiatrist for help and endured a 10 minute diatribe on the telephone as to why he and his partner were no longer coming to the hospital after 5:00 at night. The patient ended up leaving the hospital AMA the next day and I never saw her again. That still haunts me because I was not able to help her. I think that each of us should remember, always, why we got into medicine, the Hippocratic oath, and what it would be like if the tables were turned, if we refuse to help each other.

Bert, I suppose you knew that I would weigh in here. Where to begin? Certainly not by trying to defend our "colleague" whose behavior is terrible on multiple counts. We (meaning all gastroenterologists) are trained to manage inflammatory bowel disease, and while there are certainly cases that are too sick to handle, it sounds like this guy is looking for excuses. The patient is ill enough to require care, but not emergency admission or even an emergency visit... in fact, it sounds like you already know he needs Remicade or some other biologic agent. So this GI should be able to help you and the patient and handle that. If not, he should offer you more than "send him to Portland".

Larry, while it is true that some "GI docs are interested in procedures not management", that really is not true for all of us...I can see why someone like this would encourage that stereotype though.

The only other reason I could see for him to refuse the patient is that he had already left the practice. Many people have a policy against taking someone back. But again, even if he is unwilling to help the patient, he should at least be helpful and polite to you, his colleague.

This type of story never ceases to amaze me. Partly because I feel like Mel and Larry that we are "in this together" and should support each other. In addition, I am in an area where many specialists are tripping over each other. Our livelihood depends on providing good care and good service; we rely on referring physicians. Whenever I hear a story of a rude or unhelpful specialist, I always tell the primary care provider, "just don't ever send them another patient; in fact, spread the word to your friends about how you were treated". I am sure things are different when you don't have many choices... Maybe it is time for me to move.

Bert, contact me if you want to discuss management of this patient.

Come WEST young man!!!!!

I second that.

Hear there are some specialists in high demand along the Rockies. Also, more non-Broncos fans are in serious need.

testing, testing 123

I guess I'm back to first class status with the Amazing Charts gods.

I hope this isn't too much of a tangent. I might lose my regained ability to post. Anyway, what is the back story? Did the pediatric GI say no mas? Did the patient just move to Maine or your area? Was his disease dormant and now flaring? Why is a pediatrician and surgeon involved for a 22 year old, and not a GI? Just being nosy.

I think we get so insulated in the security of a stable high income, and start to feel like we really work hard everyday when we sit and talk, and start to feel superior to mere mortals, and start living larger with debts that lock you into having to make more and more money, such that we forget all the most important lessons we learned in kindergarten.

Jon, apologies, I should not have generalized so broadly about GI docs. Here the market is pretty competitive and there are a minority that will take the time and interest to do thorough management. I try support this minority by sending them routine colonscopies.

First, I have no age limit on my practice. I don't take a new patient over 18, but many have been with me since birth. A lot (mostly males) have a very strong rapport with me and do not feel the need to move on to an "adult" doc.

This kid is a GREAT kid. He never complains. He goes to college. He was at this practice, and he left because they refused to use propofol. He went to the other group. Everything was fine but he moved to Portland to go to college there. When he got too sick to stay there by himself, he came back to Bangor. His abscesses and infections required surgical care. She wanted him to get a CT, and she asked me to get him a GI. I tried to get him in to the "bad" office because I didn't know he had been there. When I called today to the new office the on-call doctor was so nice I didn't even know what to say. Listen to the difference in this statement than the previous one. "This patient sounds like he needs help and since you are asking for a consult I will see him whether I have to come in at 6:30 am or stay until 6:30 pm"

Jon, I certainly will.

I quit I used no strange punctuation and another great and thoughtful post was sucked in to the black hole It is making me feel positively unwelcome

Don't just go West, go PNW! I live in an area that has 70,000 people and is one of the fastest growing boroughs in the nation. We have very good reimbursement rates with a low PPO/HMO penetration. We have an excellent hospital with nice scoping suites. And guess what, there are NO GI specialists within 40 miles. The closest GI clinic is in Anchorage. The surgeons are doing all of the scopes. I send GI specific problems 'into town'.