How much proteinuria are we talking? If its nephrotic-range, then how are you gunna do a renal biopsy on primary care? What’s more, are you up to speed on the latest treatments for all those autoimmune nephropathies?
The real question is why you would be screening patients for proteinuria. Lets say theres elevated protein on a UA and you perform a UAcr... in young people you need to ensure you have a proper sample (early morning upon awakening) to rule-out orthostatic proteinuria.
This can be a legitimate referral, you just need to first ensure that the lab finding is real and significant.
AST/ALT rarely requires additional workup in asymptomatic individual, unless AST/ALT >150 IU/L (or 3× the upper-limit of normal)
ALP rarely requires additional workup in asymptomatic individual, unless ALP >200 IU/L (or 3× the upper-limit of normal).
Hyperbilirubinemia is only caused by a few things, and depending on the other labs, it really narrows things down.
I think
internists should know how to workup these problems completely on their own, and only refer when the patient needs a liver biopsy or after a diagnosis is made that requires specialist management (e.g. primary biliary cholangitis, autoimmune hepatitis, etc.). Otherwise its pretty unacceptable to consult someone without having done all the level 1, 2 and 3 testing (level 1 being hepatitis C, lipids, hepatobiliary ultrasound), level 2 (hepatitis B, AMA, ASMA, immunoglobulin levels, iron studies) level 3 (ceruoplasmin, A1At level, Celiac stuff, TSH). Once you've done all of those and still don't have an answer, then it's time for a percutaneous biopsy. An exception would be if you found ductal dilatation on ultrasound and need an MRCP.
It depends on the degree of thombocytopenia. For unexplained thrombocytopenia I think
internists should be able to rule-out underlying liver disease first.
Unless you have rheumatologists available, you will have to take a swing this stuff (e.g. in rural areas).
This isn't particularly difficult or nuanced.
Working up an undifferentiated patient with seizure-like spells is kind of a high-risk thing, though I still think
internists should be able to do this to an extent. It is nuanced enough that referral is still probably necessary even in rural practice. If it is just managing a solidly diagnosed epilepsy on 1 or 2-drug therapy then that isn't too difficult (though still a bit more complicated than the above examples).
The psychiatrist who diagnosed and managed the problem should be doing this.
This is something every
internist should be able to do.
100 units isn't "really high". But once you get up into the 200 range (by Total daily dose), then you are dealing with concentrated insulin formulations, and I think that is best managed by an endocrinologist unless you have experience with it.
Unless you have the expensive software to manage the data from the pump downloads and have intimate understanding of CGMs and the like, then this should be managed by endocrinology, if for no other reason than the equipment required to safely manage these patients.
This is pretty easy and something every physician should know how to do since benzo overprescribing is so common. There are example taper schedules here -
benzo.org.uk : Benzodiazepines: How They Work & How to Withdraw, Prof C H Ashton DM, FRCP, 2002
(and these are only necessary for the really sensitive patients). The key is to switch to an equivalent dose of Valium which is more easily broken up into smaller doses.
Most internists or family physicians won't be prescribing anti-psychotics in the first place (at least for psychiatric disorders). If you are comfortable enough doing so in the first place, then it's not unreasonable to be expected to know how to change to something else when insurance requires.
This is literally just using Medicare rules (
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms484.pdf) to see who qualifies (which can be performed by anyone in the office, even a secretary). That being said, the latest evidence seems to suggest that unless you have severe resting hypoxemia (<=88% at complete rest) supplemental o2 probably doesn't improve mortality, reduce hospitalizations, or improve QoL. We know from the LOTT trial that moderate resting hypoxemia (89-93%) with or without exercise desats (<90% on 6MWT), supplemental oxygen does not improve long-term mortality, reduce hospital admissions, improve quality of life, or even walk distance.
Thanks
Except for repeatedly using the word "internist," he pretty much answered the same as the rest of us.
