Private practive PM-Call or no Call

[schmee90]

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I am in a job were we have no inhouse call. We do procs at a surgery center start early finish around 2. Our clinic is open until 6 pm, and surgery center has RNs who call patien next day. I knock on wood have never had a major complication such as a epidural hematoma, infection, etc. All cervical ESI are scheduled before noon.

I do mostly bread and butter procs and SCS trials. There is discussion on wheter we need to be on call for after hours due to an emergency primarily related to procedures.

What are other peoples practices like in terms of call vs no call? Is there an added liablity with our group not having after hour call that you can respond to.

 

[willabeast]

It depends on how good the people who the patient contacts post procedure are at dealing with post procedure issues. When I was practicing a PMR group took call for everything (and were paid to do it). In over 20 years there was one problem they failed to pick up on. A cervical epidural abscess in a diabetic with renal insufficiency after I did a cervical epidural with a catheter. I don't know why the on call doc missed the diagnosis but the patient was smart enough to contact me and I figured it out pretty quickly over the phone. There was no litigation that I am aware of. I do think the doc doing the procedure is the best person to diagnose post procedure issues but I do not think it is strictly necessary if you have a well educated E.R. to at least triage stuff that can wait until next morning, but good enough is not always best.

 

[schmee90]

It depends on how good the people who the patient contacts post procedure are at dealing with post procedure issues. When I was practicing a PMR group took call for everything (and were paid to do it). In over 20 years there was one problem they failed to pick up on. A cervical epidural abscess in a diabetic with renal insufficiency after I did a cervical epidural with a catheter. I don't know why the on call doc missed the diagnosis but the patient was smart enough to contact me and I figured it out pretty quickly over the phone. There was no litigation that I am aware of. I do think the doc doing the procedure is the best person to diagnose post procedure issues but I do not think it is strictly necessary if you have a well educated E.R. to at least triage stuff that can wait until next morning, but good enough is not always best.

Interesting...Do you mind me asking what the symptoms where that an on call doc said wait, and you said no you need to go to the ER? Also how did the patent get ahold of you after hours?

I am just thining if this is gonna be a big headache with other peoples patients. I take a lot of time talking to patient on what to expect risks benfit etcs, give them a handout which i review....my colleagues, or at least one of them says we are seeting you up for an injection for your pinches nerve my ma will help you. Not much anticipatory stuff..ie am i gonna get blasted with all his patients asking why their RFA hasnt started working in the night of the inejction

 

[mille125]

In my state you have to have a way that patient's can reach out per insurance contracts.

If you are doing any procedure but especially SCS trials, there has to be a way that patients can call you if there is an issue. Someone has to take these calls even if it is an answering service forwarding messages to you. You don't want to hear about these things the next day.

Having no one taking these calls really is not proper. You need to talk to your group.

 

[Dr. Ice]

We take call for pain patients only as part of hopd. We used to take all spine service call for surgery too. They are now very easy calls. Sometimes I forget that I’m even on

 

[willabeast]

Interesting...Do you mind me asking what the symptoms where that an on call doc said wait, and you said no you need to go to the ER? Also how did the patent get ahold of you after hours?

I am just thining if this is gonna be a big headache with other peoples patients. I take a lot of time talking to patient on what to expect risks benfit etcs, give them a handout which i review....my colleagues, or at least one of them says we are seeting you up for an injection for your pinches nerve my ma will help you. Not much anticipatory stuff..ie am i gonna get blasted with all his patients asking why their RFA hasnt started working in the night of the inejction

This happened at least 15 years ago. Patient very reliable, I had worked on her low back in past. All I remember is patient contacting me saying her arm was getting weaker after a cervical epidural I did using a catheter snaked up to the pathology from C7-T1 or similar. No other symptoms. I ordered a stat ESR and it was off the charts. I always have a baseline ESR on everyone so I knew this was a significant change. I told her to go to the ER (husband driving) and alerted the ER. They got an MRI and called ortho spine who took over management. Or ortho spine ordered the MRI. Once patient got to the ER it was completely out of my hands.

 

[BoardingDoc]

I always have a baseline ESR on everyone so I knew this was a significant change

What??? Every patient you inject gets an ESR beforehand if they've never had one? That seems... aggressive.

 

[kstarm]

Our group takes call and it is very rare to get called- maybe once or twice a year. (There is 5 of us all doing procedures throughout the week) we have a relatively low volume of stims and other advanced procedures. For a number of years the PMR service took the interventional calls as they were on already and they were of course not happy about that. I would find it aggravating if a patient had a complication and I could not reach the group that caused it. I just would not refer to them if they are not going to take care of their patients. The most essential thing that we try to in part on our residents is the feeling of responsibility for the patient. Unfortunately it is not something always easy to teach and is usually more of an innate personality characteristic.

 

[willabeast]

What??? Every patient you inject gets an ESR beforehand if they've never had one? That seems... aggressive.

All I can say is it definitely was worth it for me to get an ESR on everyone. Amazing what you pick up, CRPS that turned out to be infections, beaucoup occult rheumatological diseases, occult malignancies. And it saved money sometimes. Neurology sent me a CRPS once that had an ESR over 200. Sent her to the E.R., she turned out to have a flesh eating bacteria of lower extremity all the signs of infection masked by the TNF inhibitor drugs she was on. Someone once told me "you either need an ESR or a doctor". Not sure what he meant by that but if I am dumb so be it, the ESRs definitely helped me practice safe medicine. Fibromyalgia sent to me who had PMR. Occult infectious endocarditis. Cannot remember the consulting diagnosis on that one. But a good thing no needle!

 

[Ducttape]

your practice should always be available for your patients.

but i dont believe that you have to personally be at a patient's beck and call. if a patient has a major issue, a service or the ER should be able to get a hold of you or a partner.


of note to only me, the term "beck and call" seems to have originated in 1611 in a poem.

 

[specepic]

All I can say is it definitely was worth it for me to get an ESR on everyone. Amazing what you pick up, CRPS that turned out to be infections, beaucoup occult rheumatological diseases, occult malignancies. And it saved money sometimes. Neurology sent me a CRPS once that had an ESR over 200. Sent her to the E.R., she turned out to have a flesh eating bacteria of lower extremity all the signs of infection masked by the TNF inhibitor drugs she was on. Someone once told me "you either need an ESR or a doctor". Not sure what he meant by that but if I am dumb so be it, the ESRs definitely helped me practice safe medicine. Fibromyalgia sent to me who had PMR. Occult infectious endocarditis. Cannot remember the consulting diagnosis on that one. But a good thing no needle!

Getting inflamm labs on select cases is great. Yes you can pick up occult Rheum issues (in particular) in a chronic pain population.

Ordering for ALL pts is not something I would support

 

[schmee90]

This happened at least 15 years ago. Patient very reliable, I had worked on her low back in past. All I remember is patient contacting me saying her arm was getting weaker after a cervical epidural I did using a catheter snaked up to the pathology from C7-T1 or similar. No other symptoms. I ordered a stat ESR and it was off the charts. I always have a baseline ESR on everyone so I knew this was a significant change. I told her to go to the ER (husband driving) and alerted the ER. They got an MRI and called ortho spine who took over management. Or ortho spine ordered the MRI. Once patient got to the ER it was completely out of my hands.

The patients arm was getting weaker and the on call doc didnt send to ER for MRI workup after CESI with cath...wow

 

[willabeast]

The patients arm was getting weaker and the on call doc didnt send to ER for MRI workup after CESI with cath...wow

Maybe no weakness at the time patient spoke with on call doc. I really have no idea what transpired between them, never read the note.

 

[willabeast]

Getting inflamm labs on select cases is great. Yes you can pick up occult Rheum issues (in particular) in a chronic pain population.

Ordering for ALL pts is not something I would support

Suspect you are much smarter than me, or, your referring docs were smarter than mine. Or both. . "Either a doctor or an ESR". All patients referred to me were for procedures so an ESR made a good baseline, but at least once a year something dramatic would happen with initial diagnosis. Funny though admin never bugged me about it. But if your IQ or clinical chops are high enough I am sure you do not need an ESR crutch. I did. (retired now going on 10 years). True story...morbidly obese male sees me for something (cannot remember) requiring an injection. I get my routine ESR. It is over 220. Over the phone I quiz him and cannot figure it out so I tell him to go to an E.R. thinking ?endocarditis? The E.R. sends him home and is angry at me "he has nothing". 48 hours later he is admitted with
Fournier's gangrene.

 

[mille125]

I understand that when something unusual happens to us, it shapes our thought process. The very first contract that I reviewed out of fellowship had six of nine pages devoted to what happens if the employed doc gets disabled. It was the craziest thing that I had ever seen. I remember reading that they picked a doctor. If that doctor said that I was not disabled and had the right to choose my own. If it was a deadlock, the two of them chose a third doctor whose decision was binding. I quietly inquired and found out that they had two docs her were "disabled" and this costed them a pile of money. So I get it BUT...

Our patients expect us to practice evidenced based medicine. ESR is supported as a non-specific marker for inflammation but definitely not as a screening tool on asymptomatic patients. Why you might ask? It can be elevated at baseline and has low specificity. Many things like obesity, pregnancy, and even age can raise it. Its greatest utility is in monitoring specific diseases like RA or PMR in individual patients. I am not telling you what to do but for all of these reasons I have to agree with specepic and strongly discourage its usage as a screening tool or its usage in serial followup of a condition.

If I had to use something it would be CRP which is more sensitive and specific than ESR. When I do order these tests I order CRP and ESR together.

Just my 2 cents....

 

[mille125]

Our group takes call and it is very rare to get called- maybe once or twice a year. (There is 5 of us all doing procedures throughout the week) we have a relatively low volume of stims and other advanced procedures. For a number of years the PMR service took the interventional calls as they were on already and they were of course not happy about that. I would find it aggravating if a patient had a complication and I could not reach the group that caused it. I just would not refer to them if they are not going to take care of their patients. The most essential thing that we try to in part on our residents is the feeling of responsibility for the patient. Unfortunately it is not something always easy to teach and is usually more of an innate personality characteristic.

I agree that calls are rare and mostly not serious. I ignore refill calls after hours which are probably 80-90 percent of them. The others are usually also not a big deal. If you want to screen them further you can have an answering service or have an RN after hours. There are virtual assistant services that hire someone from the Phillipines for this purpose as they are on opposite time. Our local pain doc group that I know has 4 or 5 staff and 7 virtual assistants whose salary is 10/hr without payroll taxes.

I have a system where calls that are deemed urgent are routed to me as a voice message in an email.

It doesnt matter what you chose but you have to come up with something less you are playing with fire.

My office knows that they must call every procedure patient first thing the next morning and enter info in the chart about it (they must route any patient info that sounds unusual). I dont do any major procedures on Friday and stop all procedures at noon on that day with phone calls on those patients at 5pm on Friday. The day before I go out of town is considered a Friday for these purposes. Not saying its perfect but its something.

 

[mille125]

This happened at least 15 years ago. Patient very reliable, I had worked on her low back in past. All I remember is patient contacting me saying her arm was getting weaker after a cervical epidural I did using a catheter snaked up to the pathology from C7-T1 or similar. No other symptoms. I ordered a stat ESR and it was off the charts. I always have a baseline ESR on everyone so I knew this was a significant change. I told her to go to the ER (husband driving) and alerted the ER. They got an MRI and called ortho spine who took over management. Or ortho spine ordered the MRI. Once patient got to the ER it was completely out of my hands.

CESIs are scary and require our utmost attention. As I said on another thread, I do a whole lot of medical board and litigation reviews for the defense. The pain stuff is either SCS or CESI and 9 times out of 10 the doc did nothing wrong. Its humbling....

I have seen at least 4 epidural hematoma/spinal cord myelomalacia after catheters. I am not telling anyone what to do but I don't understand this practice because every epidurogram that I have shot in the cervical spine that is in the epidural space shows filling at almost every root from C2 to T1. If it doesn't show filling them that usually means that there is severe stenosis and a decision to use a catheter in that setting is not likely a wise one.

The pain docs that I am defending that have done this have said in most cases that the surgeon ordered a certain level. Take a guess how many surgeons are willing to state that when we ask them to help us out? NONE.....Its funny because they all say that they suggest this but it is obviously at the docs discretion on how they perform it So in other words we go out on a limb for them but when push comes to shove they would rather saw the limb than join you on it.


Please note that this is my personal opinion and not based on any studies but I do review quite a few of these claims and have testified as an expert numerous times so take it for what its worth.......

 

[willabeast]

I understand that when something unusual happens to us, it shapes our thought process. The very first contract that I reviewed out of fellowship had six of nine pages devoted to what happens if the employed doc gets disabled. It was the craziest thing that I had ever seen. I remember reading that they picked a doctor. If that doctor said that I was not disabled and had the right to choose my own. If it was a deadlock, the two of them chose a third doctor whose decision was binding. I quietly inquired and found out that they had two docs her were "disabled" and this costed them a pile of money. So I get it BUT...

Our patients expect us to practice evidenced based medicine. ESR is supported as a non-specific marker for inflammation but definitely not as a screening tool on asymptomatic patients. Why you might ask? It can be elevated at baseline and has low specificity. Many things like obesity, pregnancy, and even age can raise it. Its greatest utility is in monitoring specific diseases like RA or PMR in individual patients. I am not telling you what to do but for all of these reasons I have to agree with specepic and strongly discourage its usage as a screening tool or its usage in serial followup of a condition.

If I had to use something it would be CRP which is more sensitive and specific than ESR. When I do order these tests I order CRP and ESR together.

Just my 2 cents....

I like ESR and I like CRP. CRP came along late in my career. Also suspect it is more $$ but maybe not. It is a baseline for procedures so I can quickly ascertain if I caused an infection or not. Along the way I found it helped diagnose quite a bit. It was VERY useful to me over my 35 year career. Worth repeating. It was very useful to me and my patients. Would it be useful to you? Maybe not. I used to have a nice paper demonstrating it's utility but I have no idea where it is now. Will try to find although it is old.

 

[willabeast]

CESIs are scary and require our utmost attention. As I said on another thread, I do a whole lot of medical board and litigation reviews for the defense. The pain stuff is either SCS or CESI and 9 times out of 10 the doc did nothing wrong. Its humbling....

I have seen at least 4 epidural hematoma/spinal cord myelomalacia after catheters. I am not telling anyone what to do but I don't understand this practice because every epidurogram that I have shot in the cervical spine that is in the epidural space shows filling at almost every root from C2 to T1. If it doesn't show filling them that usually means that there is severe stenosis and a decision to use a catheter in that setting is not likely a wise one.

The pain docs that I am defending that have done this have said in most cases that the surgeon ordered a certain level. Take a guess how many surgeons are willing to state that when we ask them to help us out? NONE.....Its funny because they all say that they suggest this but it is obviously at the docs discretion on how they perform it So in other words we go out on a limb for them but when push comes to shove they would rather saw the limb than join you on it.


Please note that this is my personal opinion and not based on any studies but I do review quite a few of these claims and have testified as an expert numerous times so take it for what its worth.......

I gave up cervical catheters for ESI after that case. But at the time almost everyone was doing them.

 

[mille125]

I gave up cervical catheters for ESI after that case. But at the time almost everyone was doing them.

You also have to remember that I only get called about the "issues' so it's skewed but a lot of them had catheters.

 

[mille125]

I like ESR and I like CRP. CRP came along late in my career. Also suspect it is more $$ but maybe not. It is a baseline for procedures so I can quickly ascertain if I caused an infection or not. Along the way I found it helped diagnose quite a bit. It was VERY useful to me over my 35 year career. Worth repeating. It was very useful to me and my patients. Would it be useful to you? Maybe not. I used to have a nice paper demonstrating it's utility but I have no idea where it is now. Will try to find although it is old.

Would like to read it

 

[willabeast]

This is not it. Will keep looking. Closer however.

Discriminating ability of the erythrocyte sedimentation rate: a prospective study in general practice​

G J Dinant <a title="Department of General Practice, University of Limburg, Maastricht, The Netherlands." href="Discriminating ability of the erythrocyte sedimentation rate: a prospective study in general practice - PubMed">1</a>, J A Knottnerus, J W Van Wersch
Affiliations expand

• PMID: 1793645
• PMCID: PMC1371717

Abstract​

Despite its frequent use, little is known about the ability of the erythrocyte sedimentation rate to discriminate between 'pathology' (inflammatory diseases and malignancies) and 'no pathology' in general practice. This has been studied by following 362 patients who presented to their general practitioner with a new complaint, for which the general practitioner considered determination of the erythrocyte sedimentation rate to be indicated. The test was performed at the local hospital laboratory and the patients were seen again after three months, in order to establish the follow-up diagnoses. By comparing the test results with the follow-up diagnoses, combined with receiver operating characteristic curves and regression analysis, the erythrocyte sedimentation rate was found to have a reasonable discriminating ability with respect to malignancies and inflammatory diseases (sensitivity 53%, specificity 94%, positive predictive value 48%, negative predictive value 91%, odds ratio 15.1). The upper limit for the normal erythrocyte sedimentation rate should be set at approximately 12 mm hour-1 for men and 28 mm hour-1 for women, and needs no correction for age. It is concluded that the erythrocyte sedimentation rate still deserves a place in the general practitioner's daily routine.


These guys figured it out.

Diagnostic impact of the erythrocyte sedimentation rate in general practice: a before-after analysis​

G J Dinant <a title="University of Limburg, Department of General Practice, Maastricht, The Netherlands." href="Diagnostic impact of the erythrocyte sedimentation rate in general practice: a before-after analysis - PubMed">1</a>, J A Knottnerus, J W Van Wersch
Affiliations expand

• PMID: 1634023
• DOI: 10.1093/fampra/9.1.28

Abstract​

Despite its frequent use and long history, little is known about the diagnostic impact of the measurement of the erythrocyte sedimentation rate (ESR) in general practice. We prospectively followed 362 patients who were seen by their general practitioner (GP) because of a new complaint, for which the GP wanted to know the ESR. The GPs recorded the most probable diagnosis, as well as their clinical judgements in terms of 'severe' and 'not severe', and the expected ESR values, before and after the determination of the ESR in the local hospital laboratory. Having compared the results before ESR determination with the results after, we conclude that ESR is valuable in reassuring the patient and the doctor when 'no pathology' is suspected rather than in confirming the presence of inflammatory diseases and malignancies.

 

[willabeast]

Not the article I wanted but pretty good.

https://clsjournal.ascls.org/content/ascls/27/2/72.full.pdf

//
CONCLUSION

The ESR is a simple, inexpensive laboratory test with

decades of chronicled clinical use. Despite its historical

importance, the ESR is often considered as inferior to

more specific assays, and thus its clinical utility is often

questioned. As evidenced in the discussed case study,

significant merit still exists for the ESR—from

eliminating unnecessary testing, to decreasing medical

expenses, to providing reassurance to patient and

practitioner alike. Thus the ESR, when used in the

proper context of patient symptoms and history,

ultimately has the power to improve patient care. In this

capacity, the ESR should be regarded not only as an

influential measure of the past, but also as a worthy

clinical tool for current and future practitioners.

REFERENCES

1. Plebani, Mario. Erythrocyte sedimentation rate: Innovat//

 

[BobBarker]

When the patients leave a voicemail after hours Ring Central transcribes it and sends me an email.

 

[mille125]

When the patients leave a voicemail after hours Ring Central transcribes it and sends me an email.

Same

 

[mille125]

I dont think they were suggesting that every patient should have a baseline ESR

 

[willabeast]

I dont think they were suggesting that every patient should have a baseline ESR

none of these were the article I was trying to find. But I think "Having compared the results before ESR determination with the results after, we conclude that ESR is valuable in reassuring the patient and the doctor when 'no pathology' is suspected rather than in confirming the presence of inflammatory diseases and malignancies." is what I am trying to say. IMHO ESR worth doing once on all comers. "Either a doctor or an ESR". Love that quote.

 

[mille125]

It seems that the American College of Rheumatology or the American Academy of Internal Medicine would recommend this if there was sufficient evidence. We would probably here about it in the anesthesia literature as well for preop screening.

You obviously have latitude to practice as you want within reason. It obviously helped you in some specific cases. But I don't think that we should be giving this kind of advice to this thread that also contains some residents and fellows in training.

It would also be hard to know what constitutes a "baseline" As you know even patients with connective tissue diseases, have fluctuating ESR levels that are sometimes hard to predict.

I am fine with us agreeing to disagree on this.

I am sure that Ducttape is going to weigh in on this if he is following these posts.

 

[willabeast]

It seems that the American College of Rheumatology or the American Academy of Internal Medicine would recommend this if there was sufficient evidence. We would probably here about it in the anesthesia literature as well for preop screening.

You obviously have latitude to practice as you want within reason. It obviously helped you in some specific cases. But I don't think that we should be giving this kind of advice to this thread that also contains some residents and fellows in training.

It would also be hard to know what constitutes a "baseline" As you know even patients with connective tissue diseases, have fluctuating ESR levels that are sometimes hard to predict.

I am fine with us agreeing to disagree on this.

I am sure that Ducttape is going to weigh in on this if he is following these posts.

There is a world of difference between academic teaching programs and non academic. I have sometimes wondered if I am allergic to academic medicine. For any residents reading this, my suggestion is follow orders explicitly and follow the straight and narrow at least until you pass your boards. Any other path will hurt you.

 

[Ducttape]

i looked.

i found no such article that advocates for routine use of ESR as a screening tool on all patients. some did discuss using it as a screening tool specifically for monitoring of inflammation or for specific diseases associated with inflammation (such as prosthetic infection or autoimmune disorder)


of note, the Choosing Wisely Initiative sponsored by ABIM in 2012 recommended that when for screening for inflammation, the CRP is a better test than ESR.



sorry it took so long. i looked through about 1000 articles.



my eyes got so blurry, i ordered myself a esr to check for eye inflammation... maybe i should change that to a crp...

 

[willabeast]

i looked.

i found no such article that advocates for routine use of ESR as a screening tool on all patients. some did discuss using it as a screening tool specifically for monitoring of inflammation or for specific diseases associated with inflammation (such as prosthetic infection or autoimmune disorder)


of note, the Choosing Wisely Initiative sponsored by ABIM in 2012 recommended that when for screening for inflammation, the CRP is a better test than ESR.



sorry it took so long. i looked through about 1000 articles.



my eyes got so blurry, i ordered myself a esr to check for eye inflammation... maybe i should change that to a crp...

the article was written a long time ago, perhaps in the sixties, definitely no later than the seventies. I think the group of patients all had pain that were studied. Maybe I did not throw it out when I retired. I did compare ESR with CRP when it first came out. I preferred ESR because the lab results seemed more consistent with the ESR test.

 

[mille125]

i looked.

i found no such article that advocates for routine use of ESR as a screening tool on all patients. some did discuss using it as a screening tool specifically for monitoring of inflammation or for specific diseases associated with inflammation (such as prosthetic infection or autoimmune disorder)


of note, the Choosing Wisely Initiative sponsored by ABIM in 2012 recommended that when for screening for inflammation, the CRP is a better test than ESR.



sorry it took so long. i looked through about 1000 articles.



my eyes got so blurry, i ordered myself a esr to check for eye inflammation... maybe i should change that to a crp...

That isn't surprising because as I said earlier CRP is more specific and more sensitive than ESR.

 

[giddyup]

I am in a job were we have no inhouse call. We do procs at a surgery center start early finish around 2. Our clinic is open until 6 pm, and surgery center has RNs who call patien next day. I knock on wood have never had a major complication such as a epidural hematoma, infection, etc. All cervical ESI are scheduled before noon.

I do mostly bread and butter procs and SCS trials. There is discussion on wheter we need to be on call for after hours due to an emergency primarily related to procedures.

What are other peoples practices like in terms of call vs no call? Is there an added liablity with our group not having after hour call that you can respond to.

In my group it’s myself and three other interventional plus 2 general pmr. We split the call so it’s 2-3 mos a year. About 10 or so calls a month, mostly BS. Mild inconvenience.