When to refer to specialist?

[SXMMD]

I am a resident in midwest unopposed program, small town. We have specialists in some areas (cardiology) but not others (endo) and it has shaped our referral patterns and training for common stuff pretty heavily. For example, folks in my program don't touch cardiac meds in chf patients because "cardio is already on board." There isn't an endo for hours out, so we tend to take on some of the more challenging diabetes cases because of lack of access. I'm not 100% convinced we do a great job with some of these patients and it is making me question when referral is appropriate despite access issues.

Curious to hear how others approach this issue in general and particularly curious to hear when a pcp should be referring out diabetes to an endo?

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[cbrons]

I am not in FM, but I am a 3rd year I.M. resident at an academic medical center but I signed a contract to do traditional (inpatient & outpatient) in a very rural setting. In residency we have access to every specialty including endocrine.

Truthfully, I would say all type 1 diabetics should go to endocrine, especially if they are on an insulin pump. The simple reason for that is your clinic probably doesn't have the software to download and check CGM data and doesn't have the experience to troubleshoot pumps.

Most type 2 diabetes I probably wouldn't send. I feel very confident managing most of this on my own, and usually by the time their diabetes is very bad, they have other comorbidities that make aggressive management of their sugars harmful (thus paradoxically making it easier to treat). The one exception to this rule is patients on super high doses of insulin who I think would be appropriate for concentrated insulin formulations. I don't touch U500 stuff at all.

All pregnant women with gestational diabetes go to endocrine. There is a lot more nuance to treating that than one would assume. Same thing with hypothyroid pregnant patients.

 

[MedicineZ0Z]

I am a resident in midwest unopposed program, small town. We have specialists in some areas (cardiology) but not others (endo) and it has shaped our referral patterns and training for common stuff pretty heavily. For example, folks in my program don't touch cardiac meds in chf patients because "cardio is already on board." There isn't an endo for hours out, so we tend to take on some of the more challenging diabetes cases because of lack of access. I'm not 100% convinced we do a great job with some of these patients and it is making me question when referral is appropriate despite access issues.

Curious to hear how others approach this issue in general and particularly curious to hear when a pcp should be referring out diabetes to an endo?

Primary care as a whole drastically over-refers. And we wonder why we have high healthcare expenses when patients have double expenses for treating one issue. And I'm not sure what you mean, do you not treat CHF at all and auto-refer out? Or do you work up, do initial management then refer out once it becomes more complex?

I am not in FM, but I am a 3rd year I.M. resident at an academic medical center but I signed a contract to do traditional (inpatient & outpatient) in a very rural setting. In residency we have access to every specialty including endocrine.

Truthfully, I would say all type 1 diabetics should go to endocrine, especially if they are on an insulin pump. The simple reason for that is your clinic probably doesn't have the software to download and check CGM data and doesn't have the experience to troubleshoot pumps.

Most type 2 diabetes I probably wouldn't send. I feel very confident managing most of this on my own, and usually by the time their diabetes is very bad, they have other comorbidities that make aggressive management of their sugars harmful (thus paradoxically making it easier to treat). The one exception to this rule is patients on super high doses of insulin who I think would be appropriate for concentrated insulin formulations. I don't touch U500 stuff at all.

All pregnant women with gestational diabetes go to endocrine. There is a lot more nuance to treating that than one would assume. Same thing with hypothyroid pregnant patients.

Agree with referring out type 1 diabetes. We don't refer out gestational diabetes or hypothyroidism in pregnant patients. I've even treated patients who refused insulin.

 

[hallowmann]

If people are already established with Cardiology who manages their medications, I try not to be another cook in that kitchen. If they're decompensated, I treat them though. If they're decompensated and brittle, I talk to their cardiologist and let them know my plan and see if they have other rec's.

I agree that generally we over-refer. We don't really refer out GODMA, but there are specific ACOG guidelines for management of blood sugars. We also don't refer out gestational hypothyroidism right away unless we aren't getting control quickly. That said, FM manages a lot more prenatal care than IM, so it makes sense that this is the case.

I agree with the consensus that DM1 generally gets a referral, and we manage most DM2, but exceptions include those DM2s that feel more like 1.5s and ones requiring high concentration insulin.

A lot will ultimately depend on access. If they can easily see Endocrinology, then I'm more likely to refer. If there's an issue with access, cost, etc. then I'm more likely to spend a bit more time on it before referral. I think communication with patients is key. A lot of patients actually decline referral, more so than I expected at the beginning of training.

Everyone finds their own comfort level when it comes to referrals. If they need a procedure that I don't do, then obviously they're getting a referral.

 

[FrustratedFamDoc]

My top 2 referrals are for GI (screenings, hematochezia) and gen surgery (bariatric surgery, hernias, gall bladders, etc). Cards for CAD, SSS, fragile CHF. Have some that go to endo for DMII but not too many. A few Rheum for biologics and some ortho for end stage joint disease.

My occasional specialist referrals pale in comparison to the cost born upon the system by the droves of unnecessary ER visits. It's simple math. You could probably pay for 5 specialist office visits for every soft ER visit. I would LOVE to see a graphic of what percentage ER self referrals cost the system each year and a further breakdown of the specific payor mix. I could pull up my ER census right now and half are unnecessary visits that could be handled by us. Guarantee the vast majority of those visits will be paying little or none of their own money.

Hospital system admin hate referrals because it sends the dollars out of the hospital network. Our goals and their goals have some overlap (healthy happy patients), but their goal is ultimately to maximize profits and grow market share.

As Chevy Chase would say, "where's the Tylenol!"

 

[rokshana]

Endocrine here, so maybe a bit biased, but generally agree with levophed ...DM1 and difficult to control DM2 would be appropriate...MODY and LADA are under recognized and so not treated appropriately.

Any hypo/hyper thyroid pregnant person should have at least one visit with endocrine as early as possible...and if they have had a miscarriage and contemplating pregnancy again, should be seen by endo before they get pregnant.

Gestational, same philosophy as DM2 pts...if difficult to control, then should see endo.

New thyrotoxicosis, growing thyroid nodules, adrenal nodules, possible cushings, for the most part should be referred to endo, but this can vary with the comfort level of the pcps in the area...some are great, other do the wrong tests (ultrasounds for thyrotoxicosis or serial thyroid antibodies hoping they will “go down”) or jump the gun with treatment without a full work up

Even if there isn’t an endocrinologist close, you can always call to seek advice...most endos are happy to help give advice about initial testing to see if the pt really needs to see endo...when I was working on Maine, there was a phone number to ask an endo for physicians/mid levels to call since there are so few endos in Maine.

 

[hallowmann]

...Even if there isn’t an endocrinologist close, you can always call to seek advice...most endos are happy to help give advice about initial testing to see if the pt really needs to see endo...when I was working on Maine, there was a phone number to ask an endo for physicians/mid levels to call since there are so few endos in Maine.

This is a great service, and becoming more common. I'm a huge fan of states implementing these initiatives.

 

[deleted87716]

Most patients I refer out simply require services that I don't provide. Although, I do send a lot of ortho stuff out that I could probably manage just because I don't have the time to deal with it (it's almost always an "oh, by the way" during a regular follow-up visit for somebody whose chronic problems list already taxes the 15-minute visit to the max).

 

[VA Hopeful Dr]

Most patients I refer out simply require services that I don't provide. Although, I do send a lot of ortho stuff out that I could probably manage just because I don't have the time to deal with it (it's almost always an "oh, by the way" during a regular follow-up visit for somebody whose chronic problems list already taxes the 15-minute visit to the max).

I've started referring out more ortho of late because I'm sick of trying to get MRIs approved. That's become my main reason for referring out these days.

 

[Freezeout]

Most patients I refer out simply require services that I don't provide. Although, I do send a lot of ortho stuff out that I could probably manage just because I don't have the time to deal with it (it's almost always an "oh, by the way" during a regular follow-up visit for somebody whose chronic problems list already taxes the 15-minute visit to the max).

I’ve struggled a lot with this as someone doing PCSM and primary care. It’s al ost always either because we have to ask pain level or an “btw my knee hurts” when I’m done with the visit.

 

[Splenda88]

I've started referring out more ortho of late because I'm sick of trying to get MRIs approved. That's become my main reason for referring out these days.

Well, people say that the US do not ration care.

 

[Splenda88]

Endocrine here, so maybe a bit biased, but generally agree with levophed ...DM1 and difficult to control DM2 would be appropriate...MODY and LADA are under recognized and so not treated appropriately.

Any hypo/hyper thyroid pregnant person should have at least one visit with endocrine as early as possible...and if they have had a miscarriage and contemplating pregnancy again, should be seen by endo before they get pregnant.

Gestational, same philosophy as DM2 pts...if difficult to control, then should see endo.

I have no issue managing gestational diabetes. I would not feel more comfortable managing a pregnant female with hypo/hyperthyroidism; I will leave that for endo.

I guess my outpatient training is subpar then. Then again my IM program is very inpatient heavy.

 

[SXMMD]

For our heart failure we do initial workup and management, but regardless of complexity there is a tendency to refer out to get them eatablished with a cardiologist and subsequently deferral of management beyond some basics e.g. messing with lasix. Will manage on inpt side w/o cardio unless they really aren't doing well or in cardiogenic shock.

Really good to get some feedback on t1dm; we manage them (and not well imo). Might be time for a change...

Rokshana, thanks for that bit of advice
Will start to call more.

We have a sports med fellowship here so we try to keep the ortho stuff that we can here, but we also have a large orthosurg population here so we sometimes feed the consultants too, but otherwise similar referral pattern. Depends on when we could get them back to address the issue outside of the 15 other things we spoke about in 15 minutes

Thanks for the responses, keep them coming!

 

[VA Hopeful Dr]

Well, people say that the US do not ration care.

I don't follow

 

[rokshana]

I have no issue managing gestational diabetes. I would not feel more comfortable managing a pregnant female with hypo/hyperthyroidism; I will leave that for endo.

I guess my outpatient training is subpar then. Then again my IM program is very inpatient heavy.

Dude?! Seriously? Did you not read what I wrote? My philosophy about GDM is the same as DM2...not difficult to control, then quite appropriate for PCP...either IM or FM, but difficult to control, having endo or mfm handle this is appropriate...it’s not about your ego, it’s about the patient and her baby...realize just by being a specialist , I’m going to see more gdm than you...unless of course you also have a whole clinic day set aside for all your gdm or pts with Diabetes that are pregnant...

 

[MedicineZ0Z]

Dude?! Seriously? Did you not read what I wrote? My philosophy about GDM is the same as DM2...not difficult to control, then quite appropriate for PCP...either IM or FM, but difficult to control, having endo or mfm handle this is appropriate...it’s not about your ego, it’s about the patient and her baby...realize just by being a specialist , I’m going to see more gdm than you...unless of course you also have a whole clinic day set aside for all your gdm or pts with Diabetes that are pregnant...

Agree and disagree. We can make that argument about everything. Then you get overspecialization and overutilization of specialists; which is what happens in the northeast. And all that leads to is greater healthcare costs and an unsustainable system.