“I can do that?”
During a recent morning practice session, a resident was presenting a patient who had had several episodes of syncope which culminated in a trip to the emergency room. She had a brief stay there, and on the discharge plan was written “follow-up with PCP and with cardiology.”
We went through her history and physical examination, we talked about how to further evaluate this problem, and started coming up with a plan. Since she had no telemetry monitoring in the emergency room, we figured we’d start with a new EKG and a Holter monitor to see if she might have any significant arrhythmias contributing to her symptoms.
Interestingly, that is when the intern said, “So I’ll refer her to cardiology for that.”
I asked him why he thought we needed to send the patient to cardiology for an arrhythmia monitor, and he replied that since this was a cardiology problem we were evaluating she should see a cardiologist. He thought that only they had “the power” to order this specialized continuous monitoring device. I told him that this was well within the range of something we can handle, both in the evaluation and possibly even the management of this patient.
We should be ordering these all the time, if needed. We can and do.
I needed to figure out how to get out of his head that there were these restrictions on what we could do as primary care doctors.
Interestingly, at our institution, we find that there are patients with a specialist or subspecialist for every health condition they have. A cardiologist follows them for their high blood pressure. A gastroenterologist follows them for their gastroesophageal reflux. A pulmonologist follows them for their asthma. An ENT for their allergies.
And often when we look at the care these patients are receiving for these fairly simple problems, it doesn’t seem so special (or sub-special).
True, when a patient has refractory hypertension and we need some help, sending them on to the specialist for some help or an opinion makes sense. Sometimes they are able to tease out an answer or look at the problem in a different light, and overcome barriers we failed to recognize.
One patient we took care of years ago had blood pressure out of control on five medicines, and nothing anyone tried seemed to do the trick. Finally she saw a hypertension specialist, who removed all the medicines we had her on and put her on one she had tried and failed in the past.
Something about the TLC and attention she got made the difference.
And to us it just seemed like, “No fair!”
We also turn for help when patients have some medical condition the treatment of which is beyond our comfort zone. Surely then calling for help is the right thing to do for your patients.
Each provider has such a threshold, the level at which we decide we’re comfortable taking care of the condition, and we’ve decided to go no further. I will treat condition X with medication Y, but if they need medications and treatments PQRS and T in addition to Y, then maybe I need some help, some consultation, some reassurance that this is still an appropriate standard of care.
But for the most part, they should ultimately just come back to us, freeing up our specialist and subspecialist colleagues to continue to see fresh problems, new patients with new issues but that we and our patients need help with.
Most consultations should be one, or two, and off.
But it seems that we’re not doing enough when it comes to returning care to the primary care doctor. Our specialists and subspecialists seem overwhelmed with ongoing management of patients they have been asked to see for a consultation. In most cases those patients can and should return to the day-to-day care of their primary care team.
This will also have the added benefit of freeing up their schedules, so that when we need to find a gastroenterologist to see someone acutely we are not told that there is no one who has availability for three months.
If they’re returning the bread-and-butter, and even the croissants and baguettes, back to us for ongoing care, then we can save their finely tuned consultative skills for the mysteries that lie hidden in the future.
I told this resident that he could take the patient’s blood pressure and pulse, listen to their heart, and do an EKG, all no big surprise. Sure, that was all stuff we do every day here in our practice. If he wants to take it to the next step, he can get a Holter monitor, a long-term event monitor, an echocardiogram, a stress test, a CT angiogram. Whatever he thinks he needs. He was amazed to learn that he could send his patients directly to cardiac catheterization without the need for a separate consultation in a cardiologist’s office beforehand. I told him that if he and his supervising attending decide that a patient warrants the aggressive intervention of a cardiac catheterization, then he as a PCP can call up one of the interventional cardiologists and request the procedure directly, right to cardiac catheterization to get the answer they need.
I don’t want him to start ordering cardiac caths on everybody, and we probably won’t end up putting implantable loops recorders into patients in our practice or doing tilt tables or electrophysiology studies in the back office, but it helps to be able to expand the repertoire of things you’re comfortable ordering and doing, and not just feel you have to send everything off to somebody else.
Many primary care practitioners are limited in what they can end up doing in their office because of time, space, and the pressure to see more patients. In the old days we used to do lumbar punctures in our practice, incision and drainage and suturing, injection of joints, paracenteses and thoracenteses. I even remember the days when all the residents got certified doing flexible sigmoidoscopies right here in our office.
Now, for the most part, those things go off to somebody else to handle.
As we change the health care system, we want to change things back so that it returns to us, we practice up to our license (and no further). I am licensed to practice medicine and surgery in the State of New York, and all that entails (although no one really wants me operating in the office despite what my license entitles me to).
Give us the resources, the infrastructure, the equipment, and the time, and we will do skin biopsies, we will drain joints and do bedside ultrasounds, we will extend our skills into areas that are currently being sent out for consultation.
While nobody, including me, wants me doing appendectomies or cholecystectomies in the office, many of our subspecialty colleagues think we are sending too much stuff their way, and many of our patients are frustrated with being referred away about things that used to be handled by the internist.
As we move our practice back to a more patient-centered model, and continue to evolve health care in the 21st-century, we need to think what we can capture back, provide services for patients without making them wait such a long time to get the answer to the things that are challenging their health.
Then we can say, “We can do that.”
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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