For those of you that work with PAs/NPs

[W19]

A good PCP doesn't need to send everyone to specialists. Hell, a good PCP can take care of the vast majority of a patient's needs if they're so inclined.

This is not what happens in the world of medicine, and you know that...

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[VA Hopeful Dr]

This is not what happens in the world of medicine, and you know that...

You'd be surprised

 

[deleted87716]

This is not what happens in the world of internal medicine, and you know that...

FTFY.

 

[Mad Jack]

This is not what happens in the world of medicine, and you know that...

It's easy to be a bad primary care doc. It's hard to be good one. I've had the pleasure of working with a good one.

 

[smq123]

A good PCP doesn't need to send everyone to specialists. Hell, a good PCP can take care of the vast majority of a patient's needs if they're so inclined.

This is not what happens in the world of medicine, and you know that...

"If they're so inclined" is definitely important.

I once had a patient who complained of popping/crackling in her ears. She vehemently disagreed that it could conceivably be Eustachian Tube dysfunction - she was convinced that the WiFi signals in the air was causing a reaction in her brain. I was more than happy to send her off to ENT for "a specialist's opinion."

 

[deleted87716]

"If they're so inclined" is definitely important.

I once had a patient who complained of popping/crackling in her ears. She vehemently disagreed that it could conceivably be Eustachian Tube dysfunction - she was convinced that the WiFi signals in the air was causing a reaction in her brain. I was more than happy to send her off to ENT for "a specialist's opinion."

The four major reasons I refer to specialists are (in descending order by frequency):
1) For a specific procedure that I don't do (e.g., colonoscopy, EGD, nasopharyngoscopy, cardiac cath., etc.)
2) To cover my ass (happens more often than it should).
3) To manage a condition that I don't treat (e.g., fracture, schizophrenia, hyperthyroidism, RA, sleep apnea, cancer, etc.)
4) For a second opinion on something straightforward because the patient doesn't take my word for it (see @smq123's previous post).

 

[Bacchus]

Regarding the above and referral by mid-levels. When I came to my practice a CRNP had just left. I inherited a lot of her patients. Besides them all being on B12 which I had the hardest ****ing time to get to stop she always over tested and referred. Patients routinely wanted extraneous lab testing. 'I need my vitamin D, B12, CBC and TSH checked.' "They were normal and you're not having symptoms." 'So and so checked them.' "If you have the couple hundred dollars to pay for the tests, I'll order them." 'No, that's ok.'

My biggest referral complaint from said provider was the excessive amount of people sent to cardiology (usually for rare ectopy a holter and/or echo would show were benign) or GI for mild transaminitis (which usually corrects itself with patient unit modification).

 

[FrustratedFamDoc]

Regarding the above and referral by mid-levels. When I came to my practice a CRNP had just left. I inherited a lot of her patients. Besides them all being on B12 which I had the hardest ****ing time to get to stop she always over tested and referred. Patients routinely wanted extraneous lab testing. 'I need my vitamin D, B12, CBC and TSH checked.' "They were normal and you're not having symptoms." 'So and so checked them.' "If you have the couple hundred dollars to pay for the tests, I'll order them." 'No, that's ok.'

My biggest referral complaint from said provider was the excessive amount of people sent to cardiology (usually for rare ectopy a holter and/or echo would show were benign) or GI for mild transaminitis (which usually corrects itself with patient unit modification).

Have had patients (stable, non-diabetic) come from other practices in town that the doc retired and they demand full labs Q4 months just like doc so and so did. Frustrating for sure.

#4 that BD mentioned takes the cake. Dr Google has everyone convinced that their normal TSH means jack ****, adrenal fatigue (not the extra 150 pounds they're carrying) is the reason for their "chronic daily fatigue," and palpitations are a warning sign of HOCM that REQUIRES a trip to Cardiology. It's gotten to the point where I can tell in the first 5 minutes of an encounter if I have any chance of getting out of the room without a specialist referral.

 

[VA Hopeful Dr]

Have had patients (stable, non-diabetic) come from other practices in town that the doc retired and they demand full labs Q4 months just like doc so and so did. Frustrating for sure.

#4 that BD mentioned takes the cake. Dr Google has everyone convinced that their normal TSH means jack ****, adrenal fatigue (not the extra 150 pounds they're carrying) is the reason for their "chronic daily fatigue," and palpitations are a warning sign of HOCM that REQUIRES a trip to Cardiology. It's gotten to the point where I can tell in the first 5 minutes of an encounter if I have any chance of getting out of the room without a specialist referral.

Yeah, in these folks I'll do a full thyroid panel and AM cortisol because why not. Its cheap and fairly harmless.

There is some decent evidence behind an echo for persistent tachycardia and those are fairly cheap as well, assuming that will work for the patient and not the full referral to cards.

Sometimes you just can't win.

 

[VA Hopeful Dr]

Regarding the above and referral by mid-levels. When I came to my practice a CRNP had just left. I inherited a lot of her patients. Besides them all being on B12 which I had the hardest ****ing time to get to stop she always over tested and referred. Patients routinely wanted extraneous lab testing. 'I need my vitamin D, B12, CBC and TSH checked.' "They were normal and you're not having symptoms." 'So and so checked them.' "If you have the couple hundred dollars to pay for the tests, I'll order them." 'No, that's ok.'

My biggest referral complaint from said provider was the excessive amount of people sent to cardiology (usually for rare ectopy a holter and/or echo would show were benign) or GI for mild transaminitis (which usually corrects itself with patient unit modification).

I see this a lot in my new patients as well. I'd love to do a study of cost savings between me and any NP anywhere.

 

[scharnhorst]

The four major reasons I refer to specialists are (in descending order by frequency):
1) For a specific procedure that I don't do (e.g., colonoscopy, EGD, nasopharyngoscopy, cardiac cath., etc.)
2) To cover my ass (happens more often than it should).
3) To manage a condition that I don't treat (e.g., fracture, schizophrenia, hyperthyroidism, RA, sleep apnea, cancer, etc.)
4) For a second opinion on something straightforward because the patient doesn't take my word for it (see @smq123's previous post).

sometimes the better PCP WILL REFER
I have seen several patients who were misdiagnosed and mistreated just because the PCP was too cocky or confident and did not order the appropriate diagnostic tests or referred when 1st 2nd and 3rd line meds failed.
Have a healthy suspicion and a broad differential diagnosis.A big reason we never find zebras as we are not looking for them

 

[scharnhorst]

Definitely. Referrals for things that are routinely managed in primary care are viewed with contempt by most specialists. Sometimes, they're even blocked (none of the rheumatologists in my area will see fibromyalgia, for example). You don't want to be that guy.

I recently had a newly-diagnosed diabetic self-refer to endocrinology after I started her on metformin (HgbA1c still <7.0%). I was pissed when I found out, and made sure the endocrinologist know that it wasn't my idea.

Agreed many PCP are too lazy see tons of referrals for migraines, DM, HTN etc

On the flip side , I have seen tons of patients labelled with " back pain" "headaches" "palpitations"or " IBS" by PCP for yrs w/o a proper diagnosis or workup

I think the goal should be to TRY to narrow the differential, and offer the best possible treatment.If the PCP can do this by himself that is great if he cannot he should not be shy about referring them.

last week I sent 5 people to the ER in 1 day, most of the midlevels and other docs were making fun of me.3 of them got admitted, one had a fracture and last one was d/c after STAT labs and CT.In other words I did not regret my decision,and will do the same if needed.

 

[scharnhorst]

My experience with NP is totally the opposite , most of them tend to act too cowboy

Just last week

one ruled out Angina by a single normal EKG in the clinic w/o trop

one treated "hyperthyroidism" by starting methimazole w/o any other labs , turns out was slightly low TSH

was filling RA meds for a yr w/o eye exam or labs done

was prescribing high dose Klonopin with SSRI for 1.5 yrs to a bipolar pt he has not seen psych in 5 yrs ( not on any mood stabilizers)

I had to be the "bad guy" ordering tests and referrals , F%$# my life

 

[scharnhorst]

, in our population its the same problem either patients who have no indication are getting labs with every holiday ( inc MLK day and columbis day) or people who are on a ton of meds are getting meds filled w/o labs for yrs

 

[Bacchus]

My experience with NP is totally the opposite , most of them tend to act too cowboy

Just last week

one ruled out Angina by a single normal EKG in the clinic w/o trop

one treated "hyperthyroidism" by starting methimazole w/o any other labs , turns out was slightly low TSH

was filling RA meds for a yr w/o eye exam or labs done

was prescribing high dose Klonopin with SSRI for 1.5 yrs to a bipolar pt he has not seen psych in 5 yrs ( not on any mood stabilizers)

I had to be the "bad guy" ordering tests and referrals , F%$# my life

One of the few things I learned from my rheum rotation haha.

 

[scharnhorst]

One of the few things I learned from my rheum rotation haha.

exactly
I'm not saying they are dumb or anything like that God forbid I'm sure most of them are smarter than me , but its all about exposure and training.If I was to run a dialysis center or a occupational medicine clinic I would be just as clueless or worse.It has little to do with intelligence.
But the attitude I have seen from some of the NP that they think they are just as good as FP and cost much less so are more beneficial to the healthcare system as a whole.This kind of arrogance is dangerous.

 

[857770]

I'm not sure what to tell you. Midlevels are a fact of life in almost every specialty. If you're concerned about midlevels taking over family medicine, then don't go into the specialty. I'm not worried, and I don't think that you should be either, but I also don't particularly care if you go into primary care or not.

As more health plans switch to a capitated model, I think that NPs and PAs will be increasingly squeezed out unless they drastically change their curriculums. There are a few private practices that refuse to hire PAs/NPs because they accept a lot of capitated plans.

My new FP had just hired a physician assistant, and I made sure to tell the staff that I wanted to continue seeing the doctor. I see that the FP hired the PA for monetary reasons. But, as long as docs continue to hire midlevels, we will always have to be concerned about them taking over.

 

[JustPlainBill]

Agreed many PCP are too lazy see tons of referrals for migraines, DM, HTN etc

On the flip side , I have seen tons of patients labelled with " back pain" "headaches" "palpitations"or " IBS" by PCP for yrs w/o a proper diagnosis or workup

I think the goal should be to TRY to narrow the differential, and offer the best possible treatment.If the PCP can do this by himself that is great if he cannot he should not be shy about referring them.

last week I sent 5 people to the ER in 1 day, most of the midlevels and other docs were making fun of me.3 of them got admitted, one had a fracture and last one was d/c after STAT labs and CT.In other words I did not regret my decision,and will do the same if needed.

Caught one that had to be cath'd stat, one NSTEMI and one pericardial effusion in similar situations -- No one questions me regarding sending people to the ER anymore....