Infectious dx or FM doc for herpes diagnosis?

[Meibomian SxN]

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I have a patient who is presenting with a possible herpes diagnosis. Does this referral go to infectious disease or would their family practitioner handle this with competency without need for subspecialist referral?

I ask out of ignorance because when I the patient gave me his FM doc's card it said specialty in sports medicine.

 

[deleted87716]

If their PCP can't handle herpes, they need to find a new PCP.

 

[JackADeli]

I have a patient who is presenting with a possible herpes diagnosis...

If their PCP can't handle herpes, they need to find a new PCP.

Meibomian, can you specify exactly what type of pathology your patient is presenting with to you as an optometrist? I may be reading into this too much. I think the OP, as an optometrist may be talking in the realm of a more serious form of Herpes.

If not, I agree with BD, a primary care physician should be able to handle/manage garden variety oral or genital herpes. But, if complex, I still ~agree with BD that a primary care physician worth anything will be able to coordinate any appropriate referrals and specialty care above and beyond the garden variety.

 

[Meibomian SxN]

Meibomian, can you specify exactly what type of pathology your patient is presenting with to you as an optometrist? I may be reading into this too much. I think the OP, as an optometrist may be talking in the realm of a more serious form of Herpes.

If not, I agree with BD, a primary care physician should be able to handle/manage garden variety oral or genital herpes. But, if complex, I still ~agree with BD that a primary care physician worth anything will be able to coordinate any appropriate referrals and specialty care above and beyond the garden variety.

The patient does not have any corneal involvement at this point but has cold sores around the mouth that resemble HSV, but not cluster like. No nodes felt, no cold like symptoms etc, but the patient said he has possible rashes on his genitals that looked similar.

As this is not my field I asked who his PCP was and he showed he a card saying "Family Medicine doctor specializing in Sports Medicine."

Of course the Family Medicine doc can refer to a specialist also but to avoid multiple unnecessary referrals, do FM docs who specialize in sports medicine culture and test for HSV properly or do they simply refer to someone else?

Again, I realize the training of doctors is as only good as they practice.

 

[VA Hopeful Dr]

The patient does not have any corneal involvement at this point but has cold sores around the mouth that resemble HSV, but not cluster like. No nodes felt, no cold like symptoms etc, but the patient said he has possible rashes on his genitals that looked similar.

As this is not my field I asked who his PCP was and he showed he a card saying "Family Medicine doctor specializing in Sports Medicine."

Of course the Family Medicine doc can refer to a specialist also but to avoid multiple unnecessary referrals, do FM docs who specialize in sports medicine culture and test for HSV properly or do they simply refer to someone else?

Again, I realize the training of doctors is as only good as they practice.

Hard to say. Sports Medicine folks still have to keep their FM board certification current, so technically speaking they should be able to handle it. It depends on how much of the guy's practice is sports medicine and how much is primary care.

That said, generally speaking, I wouldn't send to ID unless we're talking an encephalitis/meningitis.

 

[deleted87716]

You'll rarely go wrong referring patients back to their PCP.

If you want to know if the sports med guy does anything other than sports med, call him!

 

[JackADeli]

You'll rarely go wrong referring patients back to their PCP.

If you want to know ...call him!

👍

 

[Meibomian SxN]

Hard to say. Sports Medicine folks still have to keep their FM board certification current, so technically speaking they should be able to handle it. It depends on how much of the guy's practice is sports medicine and how much is primary care.

That said, generally speaking, I wouldn't send to ID unless we're talking an encephalitis/meningitis.

Thanks for the advice. If it was a general PCP I would not have even thought of it, but I'm not familiar with sports medicine docs. I'll just refer to them.

 

[JackADeli]

Thanks for the advice. If it was a general PCP I would not have even thought of it, but I'm not familiar with sports medicine docs. I'll just refer to them.

I guess, it is this simple, you asked who his PCP was. The subspecialty components of business card is not so relavent beyond the contact information. If he handed you a business card that listed:

Dr Z, Family Medicine doctor specializing in nuclear physics

It still wouldn't matter cause your patient is still under the care of said physician for primary care... and nuclear physics 😀

 

[Meibomian SxN]

I guess, it is this simple, you asked who his PCP was. The subspecialty components of business card is not so relavent beyond the contact information. If he handed you a business card that listed:

Dr Z, Family Medicine doctor specializing in nuclear physics

It still wouldn't matter cause your patient is still under the care of said physician for primary care... and nuclear physics 😀

Again, if the PCP was board certified in internal medicine then I would not have questioned competency....

I have personally seen wide ranges of care with family practice doctors, and so I am not sure what they treat and what they refer nowadays; no disrespect to any of them.

And given the many false-negatives associated with herpes diagnosing, I prefer to refer my patients to those who are competent in their respected fields; rather than them getting lost in the healthcare chain.

 

[JackADeli]

Again, if the PCP was board certified in internal medicine then I would not have questioned competency....

I have personally seen wide ranges of care with family practice doctors, and so I am not sure what they treat and what they refer nowadays; no disrespect to any of them.

And given the many false-negatives associated with herpes diagnosing, I prefer to refer my patients to those who are competent in their respected fields; rather than them getting lost in the healthcare chain.

Ok, so I was joking about the nuclear physicis.

Your first line about board in IM is, IMHO, uninformed and likely very, very insulting.

That said, a business card is not necessarily going to tell you if someone is board certified. Someone claiming to be a family medicine doctor specializing in sports-med, generally, in most cases are FULLY TRAINED in family medicine and may or may not have added training in sports medicine.

...As this is not my field I asked who his PCP was and he showed he a card saying "Family Medicine doctor specializing in Sports Medicine."...

Whatever the case, the patient you described has a primary care physician that is by all accounts and to the best of your knowledge a family physician. Thus, he/she should be qualified to address diagnosis and/or referral of this matter. Also, as your patient has a primary care provider, it is likely for your patient to get any additional subspecialty physician care and/or referrals, he/she will need to go back to their PCP. You probably would not be avoiding undo referrals by trying to refer directly to someone other then PCP.

 

[VA Hopeful Dr]

Ok, so I was joking about the nuclear physicis.

Your first line about board in IM is, IMHO, uninformed and likely very, very insulting.

Meh, even great swaths of the MD community automatically assume that IM>FM, so I'm far from insulted that an OD thinks that as well. Most MDs, after all, assume that ODs are mostly spectacle peddlers. Heck, he's right in saying that in FM there is great variety in terms of which MD handles what and refers what out.

 

[Meibomian SxN]

Meh, even great swaths of the MD community automatically assume that IM>FM, so I'm far from insulted that an OD thinks that as well. Most MDs, after all, assume that ODs are mostly spectacle peddlers. Heck, he's right in saying that in FM there is great variety in terms of which MD handles what and refers what out.

I respect ALL healthcare providers, regardless of what their title is. But I asked my question out of my own ignorance in the difference between family practice vs internal medicine. I do know that they both have separate residencies, hence they are not the same.

Even other internal med docs try to make a distinction...
Example: http://www.advancedqueensmedicalcare.com/Herpes.html

"Please be advised, many, if not most doctors are not aware of how to properly test for Herpes.
Over the past few years there has been emerging data and testing methods that most doctors
don’t even know about. For example, swabs of presumed herpes lesions reveal a lot of false
negatives. That is, somebody that really has herpes may have a negative swab test. Many
doctors don’t realize that the IgM antibody test is essentially useless. Also, many are not sure as
to the proper timing necessary for the IgG test and swabbing sensitivities.

At Advanced Queens Medical Care, we are experts in the diagnosis and management of genital
and oral herpes. Importantly, we are often able to recognize lesions when they occur and can
often diagnose herpes when lesions are not present with advanced testing techniques. We are
actively involved in reviewing relevant academia on this disease."

 

[smq123]

I respect ALL healthcare providers, regardless of what their title is. But I asked my question out of my own ignorance in the difference between family practice vs internal medicine. I do know that they both have separate residencies, hence they are not the same.

Even other internal med docs try to make a distinction...

Of course. It's all marketing. There are IM guys out in my neck of the woods who claim to be "Lyme Disease" experts, and advocate 6 months of constant doxycycline treatment. There are other IM guys who claim to be experts in "Holistic and Wellness" experts....whatever that means. 🙄

When it comes to adults, general outpatient IM and general outpatient FM is not all that different. There is a general outpatient IM guy who is SCARILY incompetent, so you really can't generalize based on board certification.

Sending a pregnant woman or a child to a general outpatient IM, though, is a bad move. 😉

 

[VA Hopeful Dr]

Of course. It's all marketing. There are IM guys out in my neck of the woods who claim to be "Lyme Disease" experts, and advocate 6 months of constant doxycycline treatment. There are other IM guys who claim to be experts in "Holistic and Wellness" experts....whatever that means. 🙄

When it comes to adults, general outpatient IM and general outpatient FM is not all that different. There is a general outpatient IM guy who is SCARILY incompetent, so you really can't generalize based on board certification.

Sending a pregnant woman or a child to a general outpatient IM, though, is a bad move. 😉

With the change in many IM residencies towards training hospitalists, I actually think that pretty soon the general outpatient realm will be mostly ours. As it stands right now, we certainly get more outpatient experience than any of the medicine residents in my neck of the woods.

 

[VA Hopeful Dr]

I respect ALL healthcare providers, regardless of what their title is. But I asked my question out of my own ignorance in the difference between family practice vs internal medicine. I do know that they both have separate residencies, hence they are not the same.

Exactly, which is why I wasn't insulted in the slightest. Our training setup is complicated even for people involved in it, must less anyone outside of medicine.

 

[deleted87716]

Again, if the PCP was board certified in internal medicine then I would not have questioned competency....

I have personally seen wide ranges of care with family practice doctors, and so I am not sure what they treat and what they refer nowadays; no disrespect to any of them.

Don't worry...I send all of my patients to ophthalmology. No disrespect intended to optometrists, but with wide-ranging scope, I'm not sure what they treat.

 

[JackADeli]

I guess the bottom line for the OP to understand is that a fully trained family medicine physician is more then qualified to diagnosis and treat oral and genital herpes and other sexually transmitted disease and other cutaneous diseases. I would also say that anyone claiming to provide primary care should also be equally qualified for such. The OP's patient provided a business card for his primary care physician. The business card just also happens to mention the PCP's interest and or ADDITIONAL focus. Sports-med does not disqualify the basic foundation, that is the physician is apparently a Family Medicine Physician. That should be good enough.

"Board certified" in IM is not magic. Presuming quality is a given because of board certified IM, Ortho, FM, Pedes, Cards, Surge, etc... would be a mistake. BC hopefully demonstrates a certain level of training and knowledge but does not guarantee competence in any field or discipline.

As an aside, when I look for a new primary care after moving/relocating/job change/etc... I generally with few exceptions look for a good FM PCP over any IM. That is my bias and preference. But I don't have herpes or any other cutaneous diseases😎

 

[Meibomian SxN]

...As an aside, when I look for a new primary care after moving/relocating/job change/etc... I generally with few exceptions look for a good FM PCP over any IM. That is my bias and preference. But I don't have herpes or any other cutaneous diseases😎

Btw: The TSA gives a good physical pat down these days and its no copay...

 

[JackADeli]

...As this is not my field I asked who his PCP was and he showed he a card saying "Family Medicine doctor specializing in Sports Medicine."....

Again, if the PCP was board certified in internal medicine then I would not have questioned competency...

...As an aside, when I look for a new primary care after moving/relocating/job change/etc... I generally with few exceptions look for a good FM PCP over any IM. That is my bias and preference. But I don't have herpes or any other cutaneous diseases😎

Btw: The TSA gives a good physical pat down these days and its no copay...

Not sure the connection of FM with TSA???😕

It troubles me. Maybe I am over-reading and picking up on a recurrent undercurrent theme in all this. Probably, that's just me. It probably shouldn't catch my attention, as the FM folks seem to give you a pass or not interpret it as I am.

 

[Meibomian SxN]

Not sure the connection of FM with TSA???😕

It troubles me. Maybe I am over-reading and picking up on a recurrent undercurrent theme in all this. Probably, that's just me. It probably shouldn't catch my attention, as the FM folks seem to give you a pass or not interpret it as I am.

TSA = patting down people's junk??? FM = checking my Px for herpes???

OK, I get it. Bad joke! Let me get offline and get ready for this snow storm 😱
Thanks again for the advice...

 

[lowbudget]

I'd be pretty pissed as a patient if you sent me to an ID doc and made me pay $100 copay for a cold sore. They better have disseminated herpes, fulminate sepsis, multi-drug resistant something, or some anus parasite from some tropical whatever if I'm gonna tap the expertise of an ID doc worthy of their training. I make my specialists work for their money.

Meibomian, you did fine. You could have referred the patient to a podiatry intern and chance are the cold sores would've gotten better.

If you ask me, whether a sports medicine physician can manage oral/genital herpes really depends on what your patient considers to be a sport.

I will say this: Meibomian is right that there's variation across what primary care doctors will/like to see, but this is fairly straightforward. If a fellowship trained sports med doctor wants to give up primary care, they would simply drop "family medicine" from their business card and simply list "sports medicine", much like a fellowship trained breast surgeon would drop "general surgery" from their business card because they no longer do colorectal work.

But sure, does a cornea transplant ophthalmologist still see general ophtho? Does a pulmonologist still do general internal medicine? I have a vascular surgeon where I am who still does general surgery. And, I know OB/Gyn's who don't do OB anymore. Go figure.