Do Neurologists over diagnose dementia to fill up their panels?

[DrMetal]

Do you guys think Neurologists over diagnose dementia sometimes, to fill up their panels?

I've had a recent run of patients that I've referred, that I personally thought were not all that demented (maybe mild cognitive impairments, MMSE scores in ranging from 23 to 26, which can be very close to normal, especially given their age group > 75 yo).

Patients had no complaints. Family members were upset b/c of short-term memory problems, which I explained could be perfectly normal and fine. Of course, I capitulated, fearing the almighty Yelp review, and referred them to Neuro.

Sure as ****. They come back with a diagnosis of dementia (AD, PD, Lewy Body even), and on Aricept. One want to enter him in a clinical trial (the monoclonal Abs), which I advised against.

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[greatnt249]

Do you happen to notice if it's one or two particular offenders doing this, or do you have a pretty broad referral base and see this across the board?

 

[timpview]

I’ve never met a neurologist who had any trouble filling up their patient panel.

I’ve actually have never met a neurologist who was actively trying to fill their patient panel..

I’ve met plenty of neurologists who actively try and block referrals.. even those in the community.

 

[NewYorkDoctors]

maybe ask on the neurology forum?

im sure the private practice neurologists don't want to do a cheap 99213 and hear more complaining about unfixable "numbness."

though I will say the one thing I find most annoying when I see a patient for primary care is when they come back to me "asking my input on what the specialist said."
1) the specialist likely didn't send me notes. for those other subspecialists who send me notes, the patients usually don't ask my input because said subspecialist is on top of it
2) the reason I sent you out to a specialist is for said specialist to take full stewardship of that organ process. (like for my pulmonary patients I send notes to PCP and clearly state I will manage this condition exclusively but here is a long note that explains the medical thought process in case your patient asks you for your input)
3) usually this means the subspecialist did not explain things clearly enough to the patient.

 

[VA Hopeful Dr]

maybe ask on the neurology forum?

im sure the private practice neurologists don't want to do a cheap 99213 and hear more complaining about unfixable "numbness."

though I will say the one thing I find most annoying when I see a patient for primary care is when they come back to me "asking my input on what the specialist said."
1) the specialist likely didn't send me notes. for those other subspecialists who send me notes, the patients usually don't ask my input because said subspecialist is on top of it
2) the reason I sent you out to a specialist is for said specialist to take full stewardship of that organ process. (like for my pulmonary patients I send notes to PCP and clearly state I will manage this condition exclusively but here is a long note that explains the medical thought process in case your patient asks you for your input)
3) usually this means the subspecialist did not explain things clearly enough to the patient.

Possibly, but usually its because they trust their PCPs more than their other doctors.

 

[dozitgetchahi]

maybe ask on the neurology forum?

im sure the private practice neurologists don't want to do a cheap 99213 and hear more complaining about unfixable "numbness."

though I will say the one thing I find most annoying when I see a patient for primary care is when they come back to me "asking my input on what the specialist said."
1) the specialist likely didn't send me notes. for those other subspecialists who send me notes, the patients usually don't ask my input because said subspecialist is on top of it
2) the reason I sent you out to a specialist is for said specialist to take full stewardship of that organ process. (like for my pulmonary patients I send notes to PCP and clearly state I will manage this condition exclusively but here is a long note that explains the medical thought process in case your patient asks you for your input)
3) usually this means the subspecialist did not explain things clearly enough to the patient.

This “I’d like your input on this” stuff happens even to me as a rheumatologist. Lately I’ve had patients ask me what I thought about whatever procedure their urologist was doing to treat their bladder issue, whatever their endocrinologist was doing to treat their diabetes, etc. Hell if I know, guys…ask the specialist who is doing it, or find a different one you can actually trust…

 

[dozitgetchahi]

I’ve never met a neurologist who had any trouble filling up their patient panel.

I’ve actually have never met a neurologist who was actively trying to fill their patient panel..

I’ve met plenty of neurologists who actively try and block referrals.. even those in the community.

This.

Lately, I’ve had trouble getting neurologists to take on seizure patients in need of anticonvulsant monitoring. I don’t know who else they think is going to be monitoring those meds…certainly not I, the rheumatologist…

 

[NewYorkDoctors]

Possibly, but usually its because they trust their PCPs more than their other doctors.

what a novel concept lol

in NYC most community PCPs are .... at the same level of as mid levels in terms of communication, follow up, and follow through...

but yes I suppose it's a sign that the patient likes the PCP or the PCP is a good one who is an open communicator and follows throug.

 

[Angler]

though I will say the one thing I find most annoying when I see a patient for primary care is when they come back to me "asking my input on what the specialist said."
1) the specialist likely didn't send me notes. for those other subspecialists who send me notes, the patients usually don't ask my input because said subspecialist is on top of it
2) the reason I sent you out to a specialist is for said specialist to take full stewardship of that organ process. (like for my pulmonary patients I send notes to PCP and clearly state I will manage this condition exclusively but here is a long note that explains the medical thought process in case your patient asks you for your input)
3) usually this means the subspecialist did not explain things clearly enough to the patient.

You're like Yogi, smarter than the average bear.

 

[DrMetal]

Do you happen to notice if it's one or two particular offenders doing this, or do you have a pretty broad referral base and see this across the board?

No, I haven't investigated it to that extent.

I’ve never met a neurologist who had any trouble filling up their patient panel.

I’ve actually have never met a neurologist who was actively trying to fill their patient panel..

I’ve met plenty of neurologists who actively try and block referrals.. even those in the community.

Yeah, I can see that in busy places.

maybe ask on the neurology forum?

im sure the private practice neurologists don't want to do a cheap 99213 and hear more complaining about unfixable "numbness."

though I will say the one thing I find most annoying when I see a patient for primary care is when they come back to me "asking my input on what the specialist said."
1) the specialist likely didn't send me notes. for those other subspecialists who send me notes, the patients usually don't ask my input because said subspecialist is on top of it
2) the reason I sent you out to a specialist is for said specialist to take full stewardship of that organ process. (like for my pulmonary patients I send notes to PCP and clearly state I will manage this condition exclusively but here is a long note that explains the medical thought process in case your patient asks you for your input)
3) usually this means the subspecialist did not explain things clearly enough to the patient.

Sad thing is, I feel like I don't have much recourse once the "diagnosis" has already been made. Sad to see the family go overboard, restricting their driving, activities, etc, meanwhile they score a 27/30 on my MMSE? Adult son is upset b/c his dad can't remember who won the World Series last year.

 

[greatnt249]

Adult son is upset b/c his dad can't remember who won the World Series last year.

Neither can I, honestly. That being said, I can see it being more concerning if baseball is the father's lifeblood or something and he was the type to be able to quote player stats left and right.

 

[NewYorkDoctors]

You're like Yogi, smarter than the average bear.

thanks? i guess?

anyway i do the whole nice and sweet thing with patients. but it becomes really inane when the same thing gets repeated by the patient in the course of the same office visit five times despite being being an actor and playing the nice/sweet/compassionate role and literally the patient is repeating him/herself in a circle. Back to square 1 it seems half the time.

 

[Angler]

thanks? i guess?

Yeah, it's a compliment!

 

[DrMetal]

maybe ask on the neurology forum?

It's a good thought. But they'd likely tell me to just get the MRI, start ASA/Statin.

 

[ObsequiousAplomb]

This post is a little confusing.

You don't think the patient is demented, but you do think they have mild cognitive impairment to the degree that you consulted a neurologist. Maybe you did this because of your suspicion, maybe it was because the family is telling you that there is something wrong with the patient. The family is commenting on obvious cognitive errors the patient is having, to the point it bothers you. As a doctor, you recall that dementia is often recognized by caregivers and not the patients themselves.

The neurologist sees the patient, despite your wishes that they ignore your consultation referral. The neurologist determines it is good to start a medication that is only useful when started early. The patient starts the medication.

Somehow, you are surprised that your consultation was taken seriously. You take to an Internet forum to ask if other doctors know of specialists lying to fluff up their panels.

 

[collegestud2013]

Do you guys think Neurologists over diagnose dementia sometimes, to fill up their panels?

I've had a recent run of patients that I've referred, that I personally thought were not all that demented (maybe mild cognitive impairments, MMSE scores in ranging from 23 to 26, which can be very close to normal, especially given their age group > 75 yo).

Patients had no complaints. Family members were upset b/c of short-term memory problems, which I explained could be perfectly normal and fine. Of course, I capitulated, fearing the almighty Yelp review, and referred them to Neuro.

Sure as ****. They come back with a diagnosis of dementia (AD, PD, Lewy Body even), and on Aricept. One want to enter him in a clinical trial (the monoclonal Abs), which I advised against.

Outpatient Neurology is in short supply across the board; unless they're in a saturated area, usually they don't even need to do this to get a full panel; it often takes months to get in as new patient to an outpatient Neurologist, especially if's for something relatively minor and chronic (eg headaches). Don't know about dementia being overdiagnoses, but suspect neurocognitive disorders as a who a probably underdiagnosed, especially less severe cases like mild cognitive impairment.

 

[Sushirolls]

No, I haven't investigated it to that extent.



Yeah, I can see that in busy places.



Sad thing is, I feel like I don't have much recourse once the "diagnosis" has already been made. Sad to see the family go overboard, restricting their driving, activities, etc, meanwhile they score a 27/30 on my MMSE? Adult son is upset b/c his dad can't remember who won the World Series last year.

Send the patients to a fellowship trained neuropsychologist, and get neuropsych testing. They will be able to delineate the level of functional impairment. If you really care that much, but to @ObsequiousAplomb post, they started a med that works best early on, is that an issue?

Or skip the neurologist consult, put down MCI, and start the meds yourself and wait until things worsen before Neurology or Neuropsych and the Dementia diagnosis.