you are getting xrays on a gout patient? and injecting acute gout? Man, I need to get in the PP mindset I have never ordered an xray for acute gout. I already know what it is.
I mean, am I doing this wrong? I will soon be in PP (along with hospital gig). Am I supposed to get an xray on every patient? I rarely get xrays at my hospital because its a pain in the ass. Even when someone comes in for a bunion or something, I tell them what to (wider shoes, OTC orthotics that won't solve the bunion but might make the foot feel better) and then if still bothering them come back, we will take xrays and talk about next step. I just have a hard time ordering xrays when they won't change the course of treatement for that visit. Of course some of this disdain for the xray process is that the patient often gets charged a co-pay for the hospital registration (I am employed by the medical group technically) and then has to pay for a radiologist to read the xray even though they read it after I have already seen the patient.
You'll have your own in-office x-ray setup, I assume? There's no Radiology fee with those so you won't have to worry about that aspect any longer. Any patient whose chief complaint includes pain, joint pain, generalized musculoskeletal pain, will expect an x-ray. Even if you're convinced that you know what the problem is (e.g. neuroma, PF) if you don't resolve the problem within one visit they will criticize you for not having gotten an x-ray even if it wouldn't have affected the treatment course. Getting an x-ray simply to placate the patient isn't necessarily good medicine but it could keep them in your practice long enough for you to fix their problem rather than driving them to another provider to finish what you started, which is just reality of private practice in the USA where people feel entitled to Presidential level care. If they have MSK pain then I think that x-ray is justifiable though.
Regarding referrals for gout, I've found on numerous occasion that even though someone in the past told the patient that they have gout, their actual problem was a bunion or hallux rigidus. Someone simply thought "big toe joint pain -- probably gout" when the problem was something else. With chronic gout even if the patient is medically managed by the PCP you might be able to treat specific joint pain. Maybe Cuts With Fury is getting referrals for medical management of chronic gout (I'm not doubting him) but I can't recall ever being sent a patient for medical management of chronic gout. The PCP or Rheumatologist already got that covered and they sent the patient to me to address focal foot pain.
I'll estimate that less than 5% of the referrals I've seen with a gout diagnosis have ever had a joint aspiration. An urgent care doc or PCP in the past saw a red, painful big toe joint and diagnosed gout either by appearances alone or by high uric acid. If it's acute then anesthetize the joint (patient gets immediate pain relief and will love you for it), collect fluid for a crystal exam, then inject steroid for rapid relief. Prescribe colchicine or NSAIDS too if they haven't gotten it already.
I suspect that referrals for neuropathy are expecting you to prescribe protective shoes and/or orthotics. PCPs know that diabetic neuropathy can lead to limb loss so they're trying to do everything possible for the patient (or maybe to share liability, who knows). Just for the hell of it I googled "diabetes neuropathy" and WebMD states, "Ask your doctor if you should go to a podiatrist." If a patient were to ask their doctor if they should go to a podiatrist how many doctors would say no?
I've always appreciated the difference in viewpoint between salaried providers ("What a bulls*** referral -- they could've done this themselves.") to a private practice provider who does piece work ("Send them my way -- easy money.").
