Friday, July 13, 2007

An Open Letter To My Referring Docs

Dr. Rob recently posted a very good letter to consultants. Here's my response, in the form of a letter I'd (never, even in my most erotic dreams) write to referring docs. And may I state that I love reading Dr. Rob: his humor and brilliance and insight are like a cool breeze (it's been really hot around here). If I actually worked with him, I'm certain he'd not be the recipient of such a letter (nor I of his!):

Dear Doc:

Hi, howya doin'? By the way, thanks for the note. It's one of my favorite wines. Glad you liked it.

I'm intruding on your valuable time with a couple of comments on our relationship, hoping they can improve care for our mutual patients. If you don't have time to read this now, maybe when you get home. And then if you want to talk to me about it, give me a page: I'll be at the hospital.

  • Surgeons aren't all assholes. I'm not an asshole. OK, I am, but NEVER to your patients. Ever had any complaints about how they were treated? Right. And you never will. By the way, sorry I yelled at you the other day.
  • I actually know stuff. In training, we used to say "a general surgeon is an internist who can operate." Whereas it might have been more true back then, when we considered it a personal failure (to put it more correctly: attendings considered it my personal failure) if we needed medical help, I still take it as a point of pride that I'm aware of and can manage most of my patients' peri-operative needs. It's more efficient that way, and cheaper for the patient. Plus, I'm there. You're not.
  • Rumors to the contrary, not every surgeon simply wants to cut no matter what. (How's Mr Jones, by the way? The one you sent for a chole who I discovered had gastritis?) Much as I like it when I don't have to think, I'm more than willing to do so. In fact, I'd be quite happy to be involved even before you send me a patient: working together, I bet we can get where we need to go and save a lot of the tests you'd otherwise have ordered. Give me a call. You may have noticed my nurse will get me right away when a doctor calls. (You may also have noticed that when I call you, I call you; I don't make you wait by having my nurse place the call.)
  • There's nothing wrong with early referrals; or failing that, early phone consults. Much as you hate it if I make a reference to the care you rendered before I see your patients (I bite my tongue; I really, really do), it's beyond frustrating to see a patient days, weeks, or months after a problem that you knew to be potentially surgical was handled, uh, suboptimally, alone. HMOs and gate-keepers notwithstanding, it doesn't save money in the long run.
  • In a related matter, how 'bout a call before ordering the interventional procedures recommended by radiologists on mammogram reports? If you think I'm trigger-happy... Seriously, lots of the things they see can safely either be followed, or are palpable and can be much more cheaply sampled by a fine-needle aspiration. I don't charge for phone consults, as you've noticed. I'll even have a look at the film if you'd like. Gratis.
  • Placing all sorts of restrictions on me up front is, y'know, sort of insulting. "Consult only. No tests authorized. You must discuss any intervention with me." We've worked together a long time, buddy o' mine. If you can't trust me, I guess you need to find another surgeon. Have I ever done unnecessary testing or operating on your patients? Ever failed to keep you in the loop? Right. And I never will. I really hate those referral forms. Maybe you do, too. I know we can't get rid of them, but hey, let's make it as infra-onerous as possible. You want my reports short and to the point? You're singing my song, baby.
  • I actually do think you're important. What you do isn't easy. If I liked sitting in an office all day, I'd have chosen to. Oh, and I have no idea what's fair compensation. I know you resent that I make more than you, but here's the thing: I get up every morning at 5 am to make rounds; on a good day I get home at 7:30 or 8 pm, assuming I'm not on call, which I am every third night and every third weekend. I take calls all night, whether I'm on call or not. I go back in, in the middle of the night, a few times a week. You? When I'm in deep doodoo in the OR, I can't take a break, or sleep on it, or have someone bail me out. I'm the bailer-outer. We both work hard; but doggone it, I work harder. And we both know our patients would be worse off if the garbage stopped being collected or the toilets backed up than if you or I shut down.
  • One last thing: please don't tell your patients what operation I'll be doing and how and when I'll be doing it before I've had a chance to see them. It's embarrassing to all three of us when I have to unexplain and disabuse. Sort of related: there are differences among acute cholecystitis, biliary colic, and common duct stone. Surgical approach, urgency, and timing: not the same.

Hey, man, it's been great. I tried calling but your nurse said it was your day off.



Anonymous said...

Hey. I've always told my junior partners and surgeons that as frustrating as surgeons can be, that my worst surgeon is probably easier to deal with than my surgeon's best internist/fp. (well, maybe not quite, but almost..) the only problem with surgeons and anesthesiologists is that we spend too much time together; when it's good, it's great, but it's easy to get tired of seeing a face for 10 hours a day, twice a week, eh?



Anonymous said...

LOL!! But seriously, referrals exist with "No tests authorized" BS?!? Please tell me that's an HMO/managed care thing (not to repeat an exam knowing it will come out of pt's pocket) and not the imperiousness of the referring physician...jeez!

Sid Schwab said...

enrico: the specific reference was to an HMO form, a very real one. But I believe in one of my much earlier posts I described how I resigned from the board of my clinic, when a fellow board-member and family doc brought in for approval his own form, which was even more restrictive. And insulting. As I said over my shoulder, on the way out.

Anonymous said...

Please, this stuff gets so old. You'd think with all the threats to doctors from malpractice lawyers and declining compensation that we could all band together, but no, we have to spend our time insulting each other and explaining why we're the smartest, hardest working, whatever. Surgeons aren't all jerks, consultants aren't all infallible, and internists and emergency docs aren't all stupid. They all went to med school and passed the same licensing exams. Some have more training than others, some have worse hours, some get paid more, but everyone makes an important contribution to the care of their patients. NOBODY IS PERFECT. For every story a surgeon has of some stupid internist who misdiagnosed an ulcer as cholecystitis, there's an internist who has a story of a stupid surgeon who consulted him for a blood glucose of 180. Likely both stories are taken out of context anyway and aren't as ridiculous as they sound. Stop bitching and start helping each other is what I say.

Judy said...

When I was diagnosed with colon cancer, the GI doc called the surgeon he recommended BEFORE I was fully awake. Talked to him. I thought I wanted a different surgeon until I called the office and said, "Dr. GI wants to talk to the surgeon before I see him."

"We don't do it that way here," was the response.

"Wrong answer," I said - and made an appointment with the surgeon recommended by my GI doc. He also had no problem chatting with my internist and keeping her informed.

From my perspective it's really nice when you folks keep in contact with each other.

Jeffrey Parks MD FACS said...

How about the "referral" at 4:30 pm on a friday for someone with "abdominal pain, rule out appendicitis." "Needs to be seen today." You scramble around to make time, have your office worker stay a little late, patient shows up at 5:30 looking marvelously healthy. A few pointed questions reveal the pain to have been present "for a few years", but today it's "really bad", especially during her yoga session at noon. No peritoneal signs on exam, but she winces a little when you press everywhere. "Dr. PCP said you would get me a CT scan," you are informed. "I'm meeting my husband for dinner at 7pm, do you think I'll be able to get it done by then?" And when you try to contact Dr. PCP to give recommendations, his answering service says he's left for the day, is not on call, and giving out his cell phone number is strictly prohibited. So now your office worker is shooting arrows at you with her eyes, it's 6pm, no one is answering the phone in radiology, and the patient is waiting for you to do something.

And Monday you have to dictate a letter to Dr PCP..... "Dear Frank, Thank you so much for allowing me the pleasure of seeing Mrs. G...

Dr. Rob said...

You nailed it, my friend.

I do have a better position in that I can choose (mostly) who I refer to, so I tend to have a very good relationship with most of my consultants (especially the general surgeon who did my Chole in February - who, by the way, sees me as his internist). You, however, have to accept referrals from docs you would not go to yourself.

It is very nice to have a pcp and specialist who are in sync with each other. I generally know what my specialist friends will order and can sometimes do work for them. They, conversely, can count on patients from me having had enough of a workup that they don't have to waste as much time.

Thanks for the kind word, by the way.


Anonymous said...

Surgeons save lives. Internists save articles.

Sid Schwab said...

Mat: I have no argument with you; what you said is well-said, indeed. I posted this mostly in response to the post I referenced. And both, I'd say, were not without a certain amount of tongue.... in cheek. On the other hand, whereas such a "letter" (which I said I'd never send) may not be the ideal way to do it, communication between primary docs and specialists will always be imperfect and will always need attention; likewise, the differences between, say, primary docs and surgeons will always exist. I think I've said it previously: one of the best things about working in a multispecialty clinic, as I did, is the ability to develop collegeal relationships, based on trust.

buck: been there, many times.

rob: I wish I'd had a chance to work with you.

Anonymous said...

"Truthfully, it galls me a bit that you get triple my income while I play the lead role and you support me in my job."

Is this serious? The "lead role"? By that logic I suppose primary care nurse practitioners should make more than cardiothoracic surgeons for the vital nature of their 35 hour work week. *boggles*

Bongi said...

i enjoyed this post. i enjoyed the tongue in cheek bits too.

being in the lowveld, my referrals come from a very large drainage area. one gp practise in a town about 2 hours drive away apparently has a problem referring to the physicians (internists) at our hospital. knowing surgeons can't really refuse patients, especially when they are bleeding, what he does is buffs the story to add bleeding and referrs to me. the rectal bleeding is then absent, the hematicrit is an astounding 46% and the patient is on the brink of a diabetic ketoasidotic coma. when i go into the history, trying to understand the referral, it becomes painfully obvious that the patient never bled and that the gp had picked up on his diabetic crisis. he just knew that the specific physician on call would have fobbed him off. so be it. i handle the case and refer to my very good friend, the other physician. anyway, i've treated many a dka. (often part of a diabetic foot).

anecdotal i know, but sometimes we have to adjust ourselves to strange politics of our areas.

SeaSpray said...

Interesting post Dr Schwab.

Lynn Price said...

Great post, Sid (and Dr.Rob). I just finished writing a huge scene that's based on this very scenario. What a relief to see that I got it right. You rock.

Anonymous said...

This whole PCP/surgeon reminds me of the first appointment I ever had with a neurosurgeon. After he walked into the exam room, the following took place -

Neurosurgeon(bellowing): Who sent you to see me???

Me(scared): My family doctor, Dr. S. She says I need to have epidural steroid injections, because I have a herniated disc.

Neurosurgeon (bellowing): You don't come here for that! You go to an anesthesiologist.

The exam devolved downward from there. Naturally, the two-page single-spaced dissertation/report that the neurosurgeon sent to my PCP failed to mention the above exchange. There was, however, the requisite 'thank you for sending me this patient blah blah blah.... Please refer her back to me if her symptoms should worsen blah blah blah....'

What the neurosurgeon did not know was that I had a serious disagreement with my PCP about her decision to send me to him. I did not want back surgery, and had told my PCP this. She insisted that I needed these injections and possibly surgery, so to avoid antagonizing her, I went along with her assessment.

I ended up caught in the middle between two doctors, neither of whom were on the same wavelength. As it turned out, I had a peripheral nerve condition, not a spine problem. It was an astute neurologist who figured this out. Neither the PCP nor the neurosurgeon considered this other scenario, for reasons that I cannot discern.

So, to surgeons I say this: Sometimes a patient is sent to you in error. The PCP is either not certain what is wrong, or thinks that only one thing could be wrong and is not considering other alternatives or other types of specialists to consult. This is not the patient's fault. Do not yell about the PCP's decision-making abilities in front of the patient. If you have that kind of concern, here's two things you could do: 1) Call the PCP or 2) suggest to the patient that they be evaluated by a non-surgical specialist.

Yelling at a patient about their PCP, then trying to cover it up with a unctious report does no one any good, least of all the patient.

Sid Schwab said...

LIR: I don't deny surgeons can be assholes. Whatever the basis, it's inexcusable to treat a patient that way. Stories like that embarrass me.

Anonymous said...

Similar story here. Was sent to an oral/maxillofacial surgeon by my dentist after she'd discovered a large white mass at the base of my tongue. He did a biopsy (benign), removed the lesion, and that was that. Until it recurred...five times in two years, and each time, the surgeon did the exact same thing -- cut it out, biopsy, see you in six months.
My dentist got involved after the fifth surgery (she was already upset at not receiving any reports from the surgeon after the biopsies, and told me very directly that she "couldn't get any straight answers" out of him).
Situation deteriorated rapidly after that. I was "terminated" by the surgeon ("due to past interactions", according to his letter) which left me without access to insurance-covered care in that specialty without a 100-mile drive. The lesion problem stopped after the dentist simply smoothed off some teeth in the area. Apparently it was being caused by abrasion.
I suppose I should have done the "empowered patient" thing and insisted that the surgeon explain his plans beyond the repeated cut-and-biopsy, but hell, I don't know anything about medicine. You sort of have to trust them to know what's best, don't you?

Greg P said...

I guess what I don't like about either the Dr. Rob original or the Dr. Sid response is that each paints with a broad brush.

When we begin to react with statements like, "All you consultants..." or "All you referring docs..." we might as well jump in with those who rant about "All you doctors...", "All you Americans..." and so on.

It isn't highly painful, to be sure, but it's hurtful to be unjustifiably be castigated as part of a broad category, even when you're not doing any or hardly any of the alleged offenses.

So I try to be selective. I will go out of my way to help those who have been good and kind and appreciative in the past, but not for those who constantly have some ax to grind. When someone shows up 45 minutes late for an appointment, I will make them reschedule even when with a little effort I might squeeze them in; I don't have any other way of teaching them to be considerate.

Enrico said...

Greg: Both authors of this great exchange said their side was tongue-in-cheek, or the equivalent. The fact is generalizations are always true to SOME degree; that is, they have their basis in actual fact. The fallacy is when you try to apply a generalization to a specific case.

Painting with a "broad brush" is illustrative in itself. You lose detail, but you can easily see the larger picture. I think what's been said shows, in their own overly-exaggerated, sardonic ways, what shouldn't happen and what should be avoided. Hyperbole can be just as or more useful than "correctness" to illustrate a point.

Pursey Tuttweiler said...

Well, if I ever need surgery I sure hope my insurance plan will cover me leaving the state so you can do the operation! I have had very good luck with doctors and so far surgeons (my husband's) but it was the hospital that was the problem. Of course they tried to blame the surgeon, but I am not buying it, not one bit. At first I did, but I spent too much time pre and post-op with him and even if he made a mistake I think he would come clean. So, the hospitals, the docs making the rounds, some of the nurses, that is who I have felt did not communicate and caused errors. I may be wrong. Now, on the other hand, when my husband was admitted to a hospital where his private internist had privileges, we seemed to do just fine. He was quite diligent. However, we chose a hospital for surgery where his private internist was not a part of the loop, and I think those folks who just go from room to room and don't know all the history are kind of dangerous. Especially during an emergency. I live in a state with tort reform. I am going to have to file a complaint with the board just to find out what really happened just so the next family doesn't go through what we went through and I still have this sick feeling in my gut that the blame will be placed at the feet of the surgeon. I want the system fixed, not anyone's scalp, but I think the hospital is trying to "frame" the surgeon and I do not get it because we are only asking for answers, not trying to sue, which we cannot do anyway because it would cost a fortune, we would theoretically be paying an attorney 100k to get 50k and spending the other 50k that we lost in hopes that it would improve the system. Jeesh. I hope this rant is even intelligible.

Anonymous said...

Dr. Schawb,

Just so you know, over the years I've had consultations with three different general surgeons. All have been nothing but professional. Interestingly, their reports were brief and to the point, directly addressing the reason for the consultation, and no more than 3 paragraphs in length.

Dr. Rob said...


Enrico is right - this is hyperbole on our parts. Neither of us disrespect our colleagues like this in reality. This has, however, spurred a great discussion about what is important on both sides of the formula.

I certainly appreciate that often patients are sent to specialists without any explanation whatsoever. I am sure I have done it at times - although I try not to.

I also don't feel I am more important than my specialist friends. I am just annoyed when I see the system favoring the procedurist so much over the "thinker."


Anonymous said...

""a general surgeon is an internist who can operate."

Sorry Sid, I haven't met a surgeon with a good internist knowledge base of internal medicine in 20 years of practice. You are deluded if you think a surgical residency prepares you for internal medicine practice (just like the visa versa).

Sid Schwab said...

anon: consider context. In terms of managing perioperative medical issues, I know lots of surgeons better at it than office-based internists. Intensivists? Different story. Of course, when I trained such an animal didn't exist. More recently one of my former profs looked ready to punch me in the nose when I told him they do a better job in the ICU than I do, nowadays.

Nor is the visa entirely versa: I don't kid myself that I know enough about internal medicine to be an internist. But I know more about it than internists do about surgery: and I don't mean DOING surgery. I mean understanding what it is and what it does. And I'm sure we'd all agree that if a community had to choose only one sort of doctor to provide its body of needs, they'd be better served by a general surgeon than an internist. Or maybe we wouldn't. Anyhow, as I've already said, the post was written in part by my tongue. And this is a blog, not a sworn statement.

Anonymous said...

I do care if a surgeon are an asshole to our patients. I also care if the surgeon is an asshole to anyone, including nurses, PAs, techs, surgical housestaff, custodial staff, other healthcare providers. A surgeon who takes pride in the fact that he/she is an asshole is not someone that I would refer my patients to because to me someone like that does not deserve to hold another person's life in his/her hand.

Sometimes I seek out surgical residents and I ask them who are the asshole surgoens and how surgeons behave in the OR. If Surgeon A abuses housestaff or throws tantrums in the OR I will not refer patients to him/her. Someone like that probably is not cool and collected, which is how I want my own surgeon to be.

There is NO reason anyone could or should be an asshole at work, period. It's unfortunate that surgeons have to work so many hours in a day, and have to train so many years, but those are issues that the medical community and our society have to address as a separate matter. Much of the 5 year surgical training program is spent in torturing residents, e.g., forcing them to perform scutwork because the hospital is too cheap to hire cheap help. In some teaching hospitals, nights are spent in wheeling patients in and out of the ER. Where is the educational value in that?

And, there is no reason anyone should work a 14 hour day. It's unsafe and it's unfair to patients who deserve the very best of our mental and manual abilities. Airline pilots do not fly more than x number of hours, so why do we not have similar rules for doctors? In my opinion, operators of any kind of life-treatening instruments should not overwork to the point that they are so over extended that they feel like they have the bragging rights to act like assholes.

And by the way, the old "adage" of "surgeons are internist who can cut," in 2007 term, is as egotistic and ridiculous as internists who still say that "internists are doctors who think and can cure without cutting people open."

Sid Schwab said...

Joanna: thanks for dropping by.

Alijor said...

reading this right after Dr. Rob's letter is hilarious! I can imagine some kindergarten teacher looking concerned; "let's all hold hands now..."

Sid Schwab said...

Alijor: now THERE'S the response I was looking for!

Anonymous said...

"And I'm sure we'd all agree that if a community had to choose only one sort of doctor to provide its body of needs, they'd be better served by a general surgeon than an internist"

Actually I disagree. I think a community would be best served by a well-trained FP. That is all many small towns in this country have. Do you honestly feel comfortable with OB and peds sid? The fact is surgical issues in this "small community" are referred to larger towns with surgeons.

med sub-specialist.

Sid Schwab said...

I only included general surgery and internal medicine in my statement, because that's the comparison by which I was in soup with some commenters. Between those two, I stand by my opinion.

Cathy said...

the two of you need to buddy slap each other and repeat after me....

"I'm OK, you're OK!"

shrimplate said...

As a nurse I have sometimes witnessed these sorts of doctor-to-doctor concerns.

Nothing depresses us more than being sucked into such problems, and nothing makes us happier than seeing doctors talk to each other instead of to us.

Nothing, that is, except maybe free pizza. And Starbucks in the morning. Preferably with bagels and strawberry cream cheese. I could go on...

The whole "referring physician/specialist/nurse" triangle can sometimes devolve into the dynamic of "talking in triangles" that is sometimes associated with dysfunctional family communications.

A mother tells her child "Go tell your father that I'm not speaking to him until he does such-and-such" kind of thing.

Hey, it happens, and nurses (the good ones anyways,) can always finesse this stuff, but we just can't enable it. There isn't time.

Merci beaucoup mes amis.


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