All Branch Topic (ABT) Read the DHA IPM 18-001

[DD214_DOC]

I'm glad I stumbled onto this document. If you haven't seen it or even read through the entire thing, I suggest you do. It explains the recent changes and everything that will change is completely laid out in detail.

It's very sad to read, but also important -- especially for those who are nearing their ADSO and have yet to make a final decision to stay or leave.

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[Mace1370]

I tried man, I really did. Care to provide the highlights?

 

[Perrotfish]

I'm glad I stumbled onto this document. If you haven't seen it or even read through the entire thing, I suggest you do. It explains the recent changes and everything that will change is completely laid out in detail.

It's very sad to read, but also important -- especially for those who are nearing their ADSO and have yet to make a final decision to stay or leave.

I read the entire thing. Other than a handful of new buzzwords (product line leader?) and the requirement to implement Genesis it looks like what we are already doing. Are you seeing something I am missing?

 

[John1513]

Please enlighten! Cliffs Notes please

 

[DD214_DOC]

Please enlighten! Cliffs Notes please

Sorry for the suspense. I've been super busy the past week or two.

So I skimmed the PCMH-related sections and focused on what applied to specialty clinics and behavioral health, however everything looked pretty similar from what I could tell. I think the PCMH's have already implemented most of it, but it seems the specialty and behavioral health clinics are lagging behind.

Simply put, it's a big, "F you!", to clinicians and puts into writing processes that reduce us to simply assembly-line producers of RVUs with zero control over what we're doing. Important tid-bits to take away:

A) All scheduling, referrals, and template management will be consolidated to a centralized system within each MTF. Referrals to specialty care are routed through RM/this system and appointed by this centralized system. The local specialty clinics have zero control or input on this process. This means no more clinic-level triage of referrals to filter out what isn't necessary, what should remain in a PCMH, or what should be directed to another specialty.

B) Initial specialty referrals are expected to be appointed before the patient leaves the MTF from the appointment that generated the referral. They want a patient to leave primary care with a specialty appointment date and time in hand. To accomplish this, see centralized management above. They also mandate specific access requirements, such as at least 2 available specs within 28 calendar days.

C) Centrally-managed templates. Zero input on your own schedule. Templates are created and adjusted-as-needed by someone in admin. They also have the ability to convert appointment types to MEET PATIENT NEEDS without any restrictions. If a patient needs a SPEC and all you have that week is two open FTRs, one of them gets converted to a SPEC.

D) "Patient-centered appointing". This is a new term I've not seen elsewhere, and one that irritates me. Basically, with the changes outlined they want patients to be able to call and schedule an appointment whenever and for whatever they want. Clinics still have the ability to schedule a follow-up when the patient finishes an appointment before leaving, but no longer can outside of that. Each clinic time is also mandated to reserve a certain percentage of their total appointment slots for online-booking through TOL.

The interesting part of this is also the related expectation that a clinic RN will be assigned with scrubbing all scheduled appointments at least 2 or more days in advance. The purpose, as defined, is to decide which appointments scheduled could actually be addressed through a TCON or some other non face-to-face encounter in order to free up that appoint and be available for something more complex.

E) So much more, and I'm out of time for right now...

Essentially, everything changing is connected. I have to admit, it's a very efficient but cold and heartless system, and they really did think of everything in the document.

Sadly, not once in the document is anything related to quality of care ever mentioned. Outcome metrics are even specified in the document and do not include anything about patients actually getting better. The focus is on the timeline between initial referral and appointing, and number of patient encounters per, "provider". Maybe RVUs are going away?

 

[HighPriest]

It doesn’t sound efficient at all. This is the problem with measuring efficiency solely as time-to-care. (Which admittedly is an issue both within and outside of the DoD). If a patient is eating up an appointment slot that they don’t need because they’re in the wrong office, or being sent inappropriately to the network, or because they have a primary care issue that the PCP just doesn’t want to manage, that’s not efficient.

I could see how it -could- be efficient, if the people scheduling the appointments and making the templates were qualified, trained, and motivated. But this is the DoD, so there’s zero chance that’s they’ll be any of those things.
And there’s a limit to how many people a specialty clinic can see, so what it sounds like is that they’ll fill every square inch of clinic time with the tidal wave of nonsense consults that represent 40-50% of everything that comes through CHCS, and when they run out of space, they’ll start sending cases to the network. So instead of being able to triage a little bit to even begin to try to maintain your skill set, the actual meat cases that do come through will be drowned out by all the potatoes, and a lot of them will go to the network.
Plus, and I can tell you from experience because the first MTF I worked at had a central scheduling facility, the people doing the scheduling will probably not actually know what it is each specialty does, which will also result in patients lost to the network. For example, we didn’t have a pediatric surgeon but CHCS did have a pediatric surgery consultation. So the central office at the MTF would just send 100% of those to the network, even though I would have been able and happy to take things like branchial cleft cysts or TDCs.

So I see this as a great way to make it even harder to maintain skills. For sub specialists, at least.

 

[DD214_DOC]

It doesn’t sound efficient at all. This is the problem with measuring efficiency solely as time-to-care. (Which admittedly is an issue both within and outside of the DoD). If a patient is eating up an appointment slot that they don’t need because they’re in the wrong office, or being sent inappropriately to the network, or because they have a primary care issue that the PCP just doesn’t want to manage, that’s not efficient.

I could see how it -could- be efficient, if the people scheduling the appointments and making the templates were qualified, trained, and motivated. But this is the DoD, so there’s zero chance that’s they’ll be any of those things.
And there’s a limit to how many people a specialty clinic can see, so what it sounds like is that they’ll fill every square inch of clinic time with the tidal wave of nonsense consults that represent 40-50% of everything that comes through CHCS, and when they run out of space, they’ll start sending cases to the network. So instead of being able to triage a little bit to even begin to try to maintain your skill set, the actual meat cases that do come through will be drowned out by all the potatoes, and a lot of them will go to the network.
Plus, and I can tell you from experience because the first MTF I worked at had a central scheduling facility, the people doing the scheduling will probably not actually know what it is each specialty does, which will also result in patients lost to the network. For example, we didn’t have a pediatric surgeon but CHCS did have a pediatric surgery consultation. So the central office at the MTF would just send 100% of those to the network, even though I would have been able and happy to take things like branchial cleft cysts or TDCs.

So I see this as a great way to make it even harder to maintain skills. For sub specialists, at least.

This is exactly what I was going to add, so thanks for saving me some time!

My opinion is that, like yours, it won't work. It's designed as a very cohesive and interdependent system, based upon the assumption that each piece will actually function the way it was intended. For example, maintaining good ATC in specialty clinics relies upon the PCMH model to actually retain the types of cases it's supposed to retain. We know that doesn't happen. When I had control over my clinic, I setup the triage process to filter out the nonsense and actually refused referrals we should not have received to begin with. I sent the low-complexity straightforward things that any PCM should be able to manage or initially diagnose and treat on their own, back to the PCMH. They would simply just immediately refer it back out to the network, or refer it back to us again and again until it got through.

Enforcing this aspect of the PCMH is impossible, because we all know the majority of clinicians are civilians and you really have zero leverage to hold them accountable for not following procedure. Until the work one PCM refuses to even attempt to do starts getting dumped onto another PCM in the same clinic, instead of it getting dumped onto an already-overwhelmed subspecialist, there's no reason for them individually to change the behavior, or the clinic to have any investment in changing the behavior.

 

[HighPriest]

This is exactly what I was going to add, so thanks for saving me some time!

My opinion is that, like yours, it won't work. It's designed as a very cohesive and interdependent system, based upon the assumption that each piece will actually function the way it was intended. For example, maintaining good ATC in specialty clinics relies upon the PCMH model to actually retain the types of cases it's supposed to retain. We know that doesn't happen. When I had control over my clinic, I setup the triage process to filter out the nonsense and actually refused referrals we should not have received to begin with. I sent the low-complexity straightforward things that any PCM should be able to manage or initially diagnose and treat on their own, back to the PCMH. They would simply just immediately refer it back out to the network, or refer it back to us again and again until it got through.

Enforcing this aspect of the PCMH is impossible, because we all know the majority of clinicians are civilians and you really have zero leverage to hold them accountable for not following procedure. Until the work one PCM refuses to even attempt to do starts getting dumped onto another PCM in the same clinic, instead of it getting dumped onto an already-overwhelmed subspecialist, there's no reason for them individually to change the behavior, or the clinic to have any investment in changing the behavior.

In theory, and with regards to my personal beliefs, this is true. What I found in practice is that sending patients back to the PCP just didn't do anything. Once I had educated one PA or FP or IM doc with regards to when it was appropriate to refer a kid for tonsillitis or an adult for sinusitis, that provider would immediately PCS. Its like, as soon as they got their wings they were gone.
When I first got out of residency, I'd actually send personalized e-mails to each provider who had sent a patient to me that I denied explaining why I denied the referral and what needed to be done prior to referring. A lot of it was canned, but I'd try to give specific details when necessary. I got a lot of positive feedback, and after 2-3 months of executing that plan, I'd see results for about 1 month until new providers came in and the process started all over again. So, eventually, I just started sending the stuff I didn't want, or that didn't need to see me, out to the network. It's not that I didn't want to work. I saw 25-30 patients every day and did 500 cases/year. I couldn't possibly see all of the referrals. So deflecting consults somewhere was mandatory. And I had hoped sending them back to the PCP would help, but ultimately they mostly just went to the network.

BUT, I still had that option, and it allowed me to try to keep cases in house that might actually help me to maintain my skillset. AND on more than one occasion, I'd catch a patient who REALLY shouldn't have come to see me for patient care reasons (vertigo patients who were probably having a stroke, or sudden onset hearing loss that probably shouldn't have been a routine consult). Once you turn that over to an MSC officer or a nurse administrator, that all goes out the window.

 

[Perrotfish]

When I had control over my clinic, I setup the triage process to filter out the nonsense and actually refused referrals we should not have received to begin with. I sent the low-complexity straightforward things that any PCM should be able to manage or initially diagnose and treat on their own, back to the PCMH.

See, nonsense like this is why we need documents like the above. I'm always happy to get an email with an opinion on my management or suggestions for improvement, with the understanding that as a fellow board certified physician I may or may not choose to follow your suggestions. However it makes me absolutely livid when a provider actually refuses a referral that I sent them. Variously:

1) Some military subspecialists seem to have a pretty expansive view of what I 'should be able to manage' in my tiny undermanned hospital in the middle of nowhere. Some of are just nuts, some seem unaware of what kind of support I have (no I can't start IVIG on the floor, or arrange for a sedated MRI, we barely have Tylenol here), and some seem to be unaware than different physicians may have some areas of medicine they are less comfortable with than others (I have really, really tried to make endocrine fit in my head. I am still trying. But I'm really busy and its complicated and I don't see a lot of it in the first place and its getting referred). If I am sending them to you that means that a board certified physician is sure that I shouldn't be the one managing this.

2) The fact that I am sending them to you doesn't always mean that I can't or don't want to manage them, sometimes it just means they want to see you. I see lots of things that could have been triaged to a nurses visit, but they told the nurse they wanted to see a doctor. Similarly sometimes I have to send a chronic urticaria to allergy, a headache to neurology, or a molluscum to dermatology because the alternative was a patient complaint. I promise I keep many for every one I send out. We all do some work exclusively for patient satisfaction, subspecialists have to do the same.

3) Sometimes I can't say exactly why I am sending them. Its a feeling more than something I can quantify. This happens most often with psych (yes its currently a 'simple' depressive episode, but I'm getting a scary vibe) but I've done it for a lot of specialties. At least 4/5 times that I do that I know I'm going to be wrong and a little embarrassed, but I have done this long enough to know to respect my subconscious pattern recognition. Humor me.

4) Every civilian subspecialist in the world somehow manages to maintain functioning clinics without turning down referrals. As you said, when you turn down a referral we send it out to network. And they never say no. Even HMOs usually make the subspecialists see any referral that is put in the system, though they may have some mechanism to deal with providers who are consistently over-referring despite feedback. Why do military subspecialists think that they should be the only subspecialists in the world who are allowed to triage referrals on the basis on the consult text?

To me that document read like a laundry list of ways that military physicians have tried to get out of work. No you can't have 10 total appointments in the day. No you can't make the first three appointments of the day same day appointments so that no one ever books them. No you can't just turn down referrals. I'm not seeing a huge problem.

 

[HighPriest]

See, nonsense like this is why we need documents like the above. I'm always happy to get an email with an opinion on my management or suggestions for improvement, with the understanding that as a fellow board certified physician I may or may not choose to follow your suggestions. However it makes me absolutely livid when a provider actually refuses a referral that I sent them. Variously:

1) Some military subspecialists seem to have a pretty expansive view of what I 'should be able to manage' in my tiny undermanned hospital in the middle of nowhere. Some of are just nuts, some seem unaware of what kind of support I have (no I can't start IVIG on the floor, or arrange for a sedated MRI, we barely have Tylenol here), and some seem to be unaware than different physicians may have some areas of medicine they are less comfortable with than others (I have really, really tried to make endocrine fit in my head. I am still trying. But I'm really busy and its complicated and I don't see a lot of it in the first place and its getting referred). If I am sending them to you that means that a board certified physician is sure that I shouldn't be the one managing this.

2) The fact that I am sending them to you doesn't always mean that I can't or don't want to manage them, sometimes it just means they want to see you. I see lots of things that could have been triaged to a nurses visit, but they told the nurse they wanted to see a doctor. Similarly sometimes I have to send a chronic urticaria to allergy, a headache to neurology, or a molluscum to dermatology because the alternative was a patient complaint. I promise I keep many for every one I send out. We all do some work exclusively for patient satisfaction, subspecialists have to do the same.

3) Sometimes I can't say exactly why I am sending them. Its a feeling more than something I can quantify. This happens most often with psych (yes its currently a 'simple' depressive episode, but I'm getting a scary vibe) but I've done it for a lot of specialties. At least 4/5 times that I do that I know I'm going to be wrong and a little embarrassed, but I have done this long enough to know to respect my subconscious pattern recognition. Humor me.

4) Every civilian subspecialist in the world somehow manages to maintain functioning clinics without turning down referrals. As you said, when you turn down a referral we send it out to network. And they never say no. Even HMOs usually make the subspecialists see any referral that is put in the system, though they may have some mechanism to deal with providers who are consistently over-referring despite feedback. Why do military subspecialists think that they should be the only subspecialists in the world who are allowed to triage referrals on the basis on the consult text?

To me that document read like a laundry list of ways that military physicians have tried to get out of work. No you can't have 10 total appointments in the day. No you can't make the first three appointments of the day same day appointments so that no one ever books them. No you can't just turn down referrals. I'm not seeing a huge problem.

I get where you're coming from. I never rejected a referral other than things like "patient with one episode of sinusitis" or "patient with two really, really, really bad episodes of tonsillitis last month with no prior history," and before I rejected it - always - I would check both CHCS and AHLTA to find out what treatment had been attempted. If the answer was "saline spray" and nothing else, that got rejected. That's just bad primary care medicine. I never rejected a consult that I didn't research first, and if there was ever a question, I would just accept the consult. If I ever rejected the consult, I always offered to have the provider call me on my cell or e-mail me, and if they did that there was a 99% chance I would just accept the consult. Even with all of that, I got about 10 consults every day that just shouldn't have been placed. I get that the primary care clinics are busy. My clinic was busy too. When I moved to an MTF that was less busy, I never rejected a consult because I could always get them in within 2-3 weeks. At my first MTF, I was booked out 45 days minimum and that was because of screening. I never had an issue with seeing a patient for what I felt was a basic problem when the PCP had at least put some thought into the treatment. What I did reject was a patient who came in with a laundry list of issues and the PCP just referred them to me because he didn't feel he had the time to get to the ENT stuff. That flies on the outside, but in the military system, when I was already overbooked and short on surgical cases, that patient really just needs another primary care appointment. There was one of me and about 50 primary care providers.

I also get that if the patient just wants to see a specialist, a referral gets placed. But, in the military system that's sometimes not a good enough reason. If at least something was tried to treat the primary care issue, then I'm ok with the "patient requested" rationale. If nothing had even been tried, I'm not ok with that. I'm not just twiddling my thumbs waiting for people to ask for me. They might complain. But unless the command structure is built of @$$holes, they ought to understand the response "the patient had a basic issue that was easily managed at the primary care level." Because generally that command is also trying to figure out how to stretch is subspecialists further.

So far as #3 goes, I can't really comment. I don't get a lot of "just give this patient a once over" consults. Occasionally for kids with developmental delay, but those always make sense to me because they need to have their ears and hearing checked at minimum.

So far as #4 goes: absolutely. You don't turn down referrals. But you do book them out further than 45 days (which when I was in was the mandatory maximum for the Army), and if the patient has to wait too long, they go somewhere else. It's also much, much, much more efficient on the civilian side, so I can see 30-40 patients in a day without my front desk breaking down into tears and locking themselves in a closet. I can do 3-4x as many cases in the same amount of time in the OR. And there's a second side to that sword, because many primary care physicians find it in their best interests not to send things to me that they could do (and bill for) themselves. So, yes, I'm happy to take your referral now because I have the time, and I'm getting paid, and I'm willing to bet that unless you work in an urgent care center you've at least tried to treat the patient in some way.

I don't think the new regulations will be a problem for primary care at all. In fact, I think they'll probably be better at getting all of the NPs to see more than 8 patients in a full day. So from that end, it may be a good thing. Same is true for lazy subspecialists. But if you're a subspecialist who is actually trying to be busy and keep his or her skills tuned up, it'll be just another barrier. Like everything else the DoD does, it'll ultimately punish those who want to work hard and be productive.

 

[Perrotfish]

. If I ever rejected the consult, I always offered to have the provider call me on my cell or e-mail me, and if they did that there was a 99% chance I would just accept the consult. .

This is definitely a better strategy that just rejecting it, though having been through a military residency 95% of the physicians that made that offer would be laying a trap. If I didn't give in after talking to them they would have gone to my department head about either an inappropriate tone of voice on the phone or the inappropriate consult. The inherent distrust that most people learn in a military residency might be keeping some providers from actually calling. Maybe a better strategy is to call the referring provider, rather than offering for them to call you? That's what we mostly do on the local level when we are trying to bounce back something the ER tries to send to the clinic (or vice versa).

Obviously you're out of this and I soon will be, just musing for the new guys.

So far as #3 goes, I can't really comment. I don't get a lot of "just give this patient a once over" consults. Occasionally for kids with developmental delay, but those always make sense to me because they need to have their ears and hearing checked at minimum.
.

So I never actually put that in the consult. For example I have sent one to ENT that I knew was objectively silly in the last two years: 1 year old with 1 month rhinorrhea. That describes every kid in daycare, I know. But the snot looked really weird, and thick, and just not like every other kid, even though I still can't think of an objective finding to put in my note to explain why I sent them. All the consult contained was '1 year old with rhinorrhea for one month', which I have no doubt caused an eye roll at my expense. But something felt weird and I have to sleep at night.

IThey might complain. But unless the command structure is built of @$$holes, they ought to understand the response "the patient had a basic issue that was easily managed at the primary care level." Because generally that command is also trying to figure out how to stretch is subspecialists further.

So maybe this is true for referrals from within the MTF, but as someone referring from an associated small hospital or clinic you need to understand that
1) There is rarely anyone above the level of department head who is an actual provider, sometimes not even the department head.
2) Non-physicians live in a world of competitive promotions and metric driven Fitreps and therefore have none of the sense of humor about negative evaluations that some physician leaders do.
3) Due to military regulations, every single patient complaint eats up at least 20 minutes of the CO's time and at least 1 hour of the department head's time as they 'officially' respond to the complaint.
The only patient complaints that anyone has ever really 'understood' at my commands are the ones where I could make a reasonable argument that what they patient/parent wanted would have resulted in an even bigger problem for the command. For example patients who want handfuls of opiates or for me to gloss over major issues on their overseas screenings. Otherwise there is a strong expectation that I will keep ICE complaints to an absolute minimum.

 

[HighPriest]

This is definitely a better strategy that just rejecting it, though having been through a military residency 95% of the physicians that made that offer would be laying a trap. If I didn't give in after talking to them they would have gone to my department head about either an inappropriate tone of voice on the phone or the inappropriate consult. The inherent distrust that most people learn in a military residency might be keeping some providers from actually calling. Maybe a better strategy is to call the referring provider, rather than offering for them to call you? That's what we mostly do on the local level when we are trying to bounce back something the ER tries to send to the clinic (or vice versa).

Obviously you're out of this and I soon will be, just musing for the new guys.


So I never actually put that in the consult. For example I have sent one to ENT that I knew was objectively silly in the last two years: 1 year old with 1 month rhinorrhea. That describes every kid in daycare, I know. But the snot looked really weird, and thick, and just not like every other kid, even though I still can't think of an objective finding to put in my note to explain why I sent them. All the consult contained was '1 year old with rhinorrhea for one month', which I have no doubt caused an eye roll at my expense. But something felt weird and I have to sleep at night.



So maybe this is true for referrals from within the MTF, but as someone referring from an associated small hospital or clinic you need to understand that
1) There is rarely anyone above the level of department head who is an actual provider, sometimes not even the department head.
2) Non-physicians live in a world of competitive promotions and metric driven Fitreps and therefore have none of the sense of humor about negative evaluations that some physician leaders do.
3) Due to military regulations, every single patient complaint eats up at least 20 minutes of the CO's time and at least 1 hour of the department head's time as they 'officially' respond to the complaint.
The only patient complaints that anyone has ever really 'understood' at my commands are the ones where I could make a reasonable argument that what they patient/parent wanted would have resulted in an even bigger problem for the command. For example patients who want handfuls of opiates or for me to gloss over major issues on their overseas screenings. Otherwise there is a strong expectation that I will keep ICE complaints to an absolute minimum.

I did try calling providers. They were literally never available. I'd spend 20 minutes per consult just trying to get someone on the phone. And with the number of consults I got every day, it would have been at least 5-10 phone calls every day. And if I went on vacation??? Whoah buddy...So I stopped. They often answered
e-mails, and if it wasn't important enough for them to follow up, then it wasn't an important consult. I was able to follow up and do research on 20-30 consults per day as a single provider, so I expect that they're able to answer a single e-mail from my within a 48 hour period. If they ever asked me to call them, I would. And they had my personal cell number. Keep in mind that doing this probably took more time than just seeing some of these patients, but I was more worried about efficiency, skill maintenance, and not wasting my time, the patient's time, and the overhead required to see unnecessary consults. I did fine some reluctance at first to call me, but once they realized I really just wanted to talk it happened more and more often. And a 2 minute phone call usually resolved far more than a 20 minute appointment 30 days in the future about nothing.

I should also say, I more often rejected ASAP and 24 hour consults with the response that the consult needed to be re-entered as routine. My schedule had 32 patients on it the next day. I don't need to see an "ASAP stuffy nose because the patient is going on vacation in 2 days." That crap was RAMPANT, and a huge waste of time. What am I gonna do in 24 hours that you can't do in the primary care clinic? A semi-emergent septoplasty at 3am?

If you call your consultants and they're @$$holes to you for no reason, I'd bring that to my department head if not the chief of surgery. Assuming it happens recurrently. I can get irritated easily, for sure, but when I'm on the phone with a PCP I always try to remain professional. Ultimately, in the military, I never found a situation where I couldn't say no if I didn't think something was appropriate, so being a jerk or going to some clinic chief on main post to complain about a primary care doc would never be worth my time. I think the only time I ever even contemplated that was if I got a lot of patients from a single provider that were clearly mismanaged to the point of it being potentially dangerous. And that did happen twice, and they were both civilian contractors. Most military physicians (AD) are pretty well put together. BLUF: your consultants have no reason to be a jackass to you. Maybe that crap flew in residency, but it shouldn't fly afterwards. You should be trying to look out for each other. I can promise you that won't happen once you're out of the military, because that kind of consultant will be out of practice....unless you go work for Kaiser or something...

Along the lines of the command: I never had a physician in immediate charge of me. Every single guy who ever brought an ICE complaint to me was either an MSC officer or something like a physical therapist. But I also never had an ICE complaint brought against me that I couldn't easily explain, often over e-mail, and I could essentially always justify what I did in terms of being efficient and providing the best patient care possible. I have never worked as a primary care physician in the military, but at least with the commands under which I served I just don't think I'd have had trouble explaining why I didn't give someone a referral that they didn't need.

And BTW, a 1 month old with nasty rhinorrhea for 1 month could be a normal 1 month old, or it could be choanal stenosis, so I probably wouldn't have rejected that one. Just depends upon whether the pediatrician thought it was the typical snotty kid, or if they thought there was something weird about it.

 

[Perrotfish]

I should also say, I more often rejected ASAP and 24 hour consults with the response that the consult needed to be re-entered as routine. My schedule had 32 patients on it the next day. I don't need to see an "ASAP stuffy nose because the patient is going on vacation in 2 days."

This must be different in the Army. If I want an ASAP or Stat consult I have to get the provider to approve the consult, and put both the subspecialist's name and the appoinent time in the consult text, before I can even place the consult. Otherwise it gets kicked back and the subspecialist never sees it.

 

[HighPriest]

This must be different in the Army. If I want an ASAP or Stat consult I have to get the provider to approve the consult, and put both the subspecialist's name and the appoinent time in the consult text, before I can even place the consult. Otherwise it gets kicked back and the subspecialist never sees it.

In theory, they're supposed to call if they want something seen faster than 72 hours. I never got that call from anyone outside of the ER, and sometimes I never even got a call from them. In 9 years.

 

[Perrotfish]

In theory, they're supposed to call if they want something seen faster than 72 hours. I never got that call from anyone outside of the ER, and sometimes I never even got a call from them. In 9 years.

Definitely a difference in either service or region. Tricare just won't place a stat consult if I don't call and get both approval and an appointment time

It's actially a maddening rule when I'm not dealing with another MTF. Most of our network subspecialists won't take calls from outside providers, and if.I do get through their system won't let them book an appointment without the authorization (which I can't place without an appointment). If I need a stat consult often I effectively can't get it, unless I want to send them super far to a military MTF.

 

[John1513]

All very good perspectives.

From a tiny remote clinic, I would routinely get my requests for referrals to large (far away) MTFs routinely denied by some PA screening the referrals.

I didn’t understand why.

As a board certified physician, I am asking for help. It may have to do with PEB/MEB or a difficult case needing a 3rd opinion by a military specialist.

In the ecosystems of all other hospitals that I’ve trained at in the past, a consult is a sacred thing. It *must* be seen in 48-72 hrs at most.

So the concept of a PA denying my requests was maddening.

 

[HighPriest]

All very good perspectives.

From a tiny remote clinic, I would routinely get my requests for referrals to large (far away) MTFs routinely denied by some PA screening the referrals.

I didn’t understand why.

As a board certified physician, I am asking for help. It may have to do with PEB/MEB or a difficult case needing a 3rd opinion by a military specialist.

In the ecosystems of all other hospitals that I’ve trained at in the past, a consult is a sacred thing. It *must* be seen in 48-72 hrs at most.

So the concept of a PA denying my requests was maddening.

I have to assume you mean inpatient consults. No one is seeing Bill with IBS in 48-72 hours in an outpatient clinic. What most consultants (and I mean productivity and workflow consultants) will tell you is that you should ideally be able to book non-emergent patients within 2 weeks. And that’s to keep people from going elsewhere, which isn’t an option in the military.
It takes me 4 weeks to see my PCP.

And, probably, that PA is following someone’s instructions. If it doesn’t make sense to you as to why they’re denying consults, call and ask. I was always happy to explain why I didn’t need to see a patient who “broke his nose 3 weeks ago and wasn’t having any breathing or cosmetic issues, but we just wanted to make sure he was ok,” or “dependent with really bad TMJ” (because she doesn’t need me she needs her dentist).

And if they’re denying MEB referrals, call their chain of command. That, annoyingly, you can’t do. Predeployment and MEB - usually stupid problems with absolutely no treatment required that you still need to see immediately.

 

[John1513]

@HighPriest Happy 4th of July!

Yes, I meant inpatient academic hospital medicine.

It was a learning curve for me, outpatient medicine/culture.

When I precept residents/med students in clinic, I’ll make sure to teach about the culture of referrals too.

 

[DD214_DOC]

I will add that I would personally review referrals identified as, “questionable”, when the nurse would staff them with me. The referrals that were, “rejected”, were ones I had spent considerable time reviewing AHLTA notes and other collateral information available, and whoever referred them would be contacted with an explanation, as well as my offer to provide consultation to assist them with the case prior to referral — which could still be possible if things don’t go as expected.

Denied referrals were more often than not from MLPs for things such as refusing to continue a minimal therapeutic dose of an SSRI someone had been on for over a year, doing well, without side effects. Literally no other concerns. Even continues to see a therapist. No question in the referral about what they want. Early on, I would take these not knowing any better, and my initial eval would literally be, “We just needed a refill due to our recent PCS and the NP said they can’t prescribe this medication because they’re an NP”. Once I touch them, PCM’s refuse to take them back. I have seen NP’s refuse to refill necessary meds for patients even with a pending appointments only to have them run out, decompensate, and end up hospitalized. A patient who could have got in sooner with me if my schedule wasn’t filled with cases I never should have been referred to begin with.

For my sub specialty, there is no network. I’m all there is.

 

[Dr. Wexler]

Denied referrals were more often than not from MLPs for things such as refusing to continue a minimal therapeutic dose of an SSRI someone had been on for over a year, doing well, without side effects. Literally no other concerns. Even continues to see a therapist.

Sounds like a "primary care provider" I work with. Has no problem ordering uncessary tests though.

 

[pgg]

Sounds like a "primary care provider" I work with. Has no problem ordering uncessary tests though.

Ah, midlevels practicing "at the top of their licenses" ... who could've predicted issues like this? Who?

 

[HighPriest]

Those two years doing triage in the ED before they became an NP really prepared them for this. It was basically a residency.

 

[militaryPHYS]

Somehow I missed this thread.

Locally we have a compromise to central booking. Central booking assures that no consult goes >24 hours before being appointed. BUT, we as a subspecialty review our consults twice a day (first thing a.m. and before COB) which allows us to continue to review/appoint/deny our own consults while staying within new DHA regulations. It has been working so far.

All of this is basically "patient-centered healthcare" where the patient comes first and is always right. It's the same trend we are seeing on the civilian side as well. Doubt we can change the flow of the river. Now we just have to smile and nod to PFC Cheeseball instead of ordering him to be a man and stop thinking he is entitled to concierge level medicine for his anterior knee pain while on his 3rd period of LIMDU.

 

[DD214_DOC]

Somehow I missed this thread.

Locally we have a compromise to central booking. Central booking assures that no consult goes >24 hours before being appointed. BUT, we as a subspecialty review our consults twice a day (first thing a.m. and before COB) which allows us to continue to review/appoint/deny our own consults while staying within new DHA regulations. It has been working so far.

All of this is basically "patient-centered healthcare" where the patient comes first and is always right. It's the same trend we are seeing on the civilian side as well. Doubt we can change the flow of the river. Now we just have to smile and nod to PFC Cheeseball instead of ordering him to be a man and stop thinking he is entitled to concierge level medicine for his anterior knee pain while on his 3rd period of LIMDU.

Unfortunately, DHA seems to have their **** together and actually anticipated your local compromise in the reference document. If I remember what I read correctly (it's been a while), there's a specific prohibition against any local-level initial review or even "second review", of referrals. The plan is to have an assigned NCM review appointments a couple days in advance to determine necessity (meaning everything will be appointed centrally and local clinics have zero control or input) and convert those patients who don't actually need an apt for their concern to a tcon, thus making available that appointment time.

 

[militaryPHYS]

Unfortunately, DHA seems to have their **** together and actually anticipated your local compromise in the reference document. If I remember what I read correctly (it's been a while), there's a specific prohibition against any local-level initial review or even "second review", of referrals. The plan is to have an assigned NCM review appointments a couple days in advance to determine necessity (meaning everything will be appointed centrally and local clinics have zero control or input) and convert those patients who don't actually need an apt for their concern to a tcon, thus making available that appointment time.

I think people have said definitely a NO GO but the actual verbage is:
1) "Review of specialty referrals prior to appointing will be the exception since this unnecessarily delays beneficiary appointing and is not the standard in civilian medical organizations"
2) "For referrals requiring a review prior to appointing, the RMC/O staff will either review or send to the appropriate MTF staff for review (e.g., Case Management RN/LPN, Utilization Management RN, or designated MTF second review provider)"

Unless I am missing the section forbidding such things, this verbage leaves it open to some interpretation. Either way, currently this only works during this pre-official DHA takeover where we are adjusting everything to meet new standards but have not yet hit the official implementation yet. I doubt it will be sustainable.

For long term planning we are putting together our own clinical practice guidelines and referral guidelines which are easily accessed by PCM's to promote high-yield reference. This was already established but never really stressed as priority. With new changes it will be the only way to communicate typical standard of care or guidelines for management of certain conditions since once the consult is placed it cannot be denied.

 

[DD214_DOC]

I think people have said definitely a NO GO but the actual verbage is:
1) "Review of specialty referrals prior to appointing will be the exception since this unnecessarily delays beneficiary appointing and is not the standard in civilian medical organizations"
2) "For referrals requiring a review prior to appointing, the RMC/O staff will either review or send to the appropriate MTF staff for review (e.g., Case Management RN/LPN, Utilization Management RN, or designated MTF second review provider)"

Unless I am missing the section forbidding such things, this verbage leaves it open to some interpretation. Either way, currently this only works during this pre-official DHA takeover where we are adjusting everything to meet new standards but have not yet hit the official implementation yet. I doubt it will be sustainable.

For long term planning we are putting together our own clinical practice guidelines and referral guidelines which are easily accessed by PCM's to promote high-yield reference. This was already established but never really stressed as priority. With new changes it will be the only way to communicate typical standard of care or guidelines for management of certain conditions since once the consult is placed it cannot be denied.

I'd have to look through the document again, but while it does read as you indicated, it adds the stipulation that such reviews be a rare exception. I think after the DHA takeover, specialty and related clinics won't even be seeing their referrals. It will all be centralized and outside of their scrutiny, and templated schedules will just simply fill up with SPECs.

We tried the same thing with PCMs, and it didn't work. They're already overwhelmed and trying to survive as it is, and I'm quite certain a fair number of PCMs -- especially MLPs -- rely on specialty referrals as a time management strategy. It's quicker to just throw in a referral with minimal information and move on to the next patient. There's little reason for this to change, because it's going to become even easier with centralized appointing for PCM's and any other physicians or providers to shift around the workload but never actually accomplish anything.

 

[Perrotfish]

I think people have said definitely a NO GO but the actual verbage is:
1) "Review of specialty referrals prior to appointing will be the exception since this unnecessarily delays beneficiary appointing and is not the standard in civilian medical organizations"
2) "For referrals requiring a review prior to appointing, the RMC/O staff will either review or send to the appropriate MTF staff for review (e.g., Case Management RN/LPN, Utilization Management RN, or designated MTF second review provider)"

Unless I am missing the section forbidding such things, this verbage leaves it open to some interpretation. Either way, currently this only works during this pre-official DHA takeover where we are adjusting everything to meet new standards but have not yet hit the official implementation yet. I doubt it will be sustainable.

For long term planning we are putting together our own clinical practice guidelines and referral guidelines which are easily accessed by PCM's to promote high-yield reference. This was already established but never really stressed as priority. With new changes it will be the only way to communicate typical standard of care or guidelines for management of certain conditions since once the consult is placed it cannot be denied.

Aren't you a general Orthopedic surgeon at a small MTF?

 

[militaryPHYS]

Aren't you a general Orthopedic surgeon at a small MTF?

Yes. ?

 

[Perrotfish]

Yes. ?

And you're turning down referrals without seeing them? Is your workload crazily higher than a most small MTF Orthos?

 

[militaryPHYS]

I think after the DHA takeover, specialty and related clinics won't even be seeing their referrals. It will all be centralized and outside of their scrutiny, and templated schedules will just simply fill up with SPECs.

Completely agree. That's why I am writing up the new CPG's and referral guidelines with an untrained contractor/GS/nurse in central booking in mind so that they can easily reference the required images/tests/etc. to be ordered prior to the actual clinic visit. Otherwise, yes we are seeing the patients but we are also wasting a clinic appointment because then I need to send them out for an xray, injection, MRI or something else before I can actually solve a problem.

 

[Perrotfish]

Completely agree. That's why I am writing up the new CPG's and referral guidelines with an untrained contractor/GS/nurse in central booking in mind so that they can easily reference the required images/tests/etc. to be ordered prior to the actual clinic visit. Otherwise, yes we are seeing the patients but we are also wasting a clinic appointment because then I need to send them out for an xray, injection, MRI or something else before I can actually solve a problem.

Is radiology in a different building? Is there a reason you can't order tests and then have them come back to clinic like PCMs do? Or alternatively why you can't scrub your schedule yourself to make sure you have the tests and imaging you want?

 

[militaryPHYS]

And you're turning down referrals without seeing them? Is your workload crazily higher than a most small MTF Orthos?

Of course! when a PCM puts in a referral to ortho at our hospital for sciatica/lumbago/foot drop/etc it gets denied and rerouted to Neurosurgery because we have them here and that is how our MTF is set up and perhaps the GMO at an outlying clinic doesn't know that. When a consult is placed after the first visit for knee pain with no red flags, no therapy, NSAIDS and obvious the provider did not exhaust resources...

Even though you may be amazing at owning your patients and only placing perfect consults, many are not.

Is radiology in a different building? Is there a reason you can't order tests and then have them come back to clinic like PCMs do? Or alternatively why you can't scrub your schedule yourself to make sure you have the tests and imaging you want?

Xrays, sure. We do it all the time. MRI's, Guided Injections, etc. take anywhere from 2 to 4 weeks so if our goal is to make life easier on the patient then they shouldn't have to attend redundant unnecessary appointments. I am probably the more understanding of this and agree that there are many instances where it is easier to be established with a specialty earlier, but it is not absolute. There is a middle ground. And yes, thanks, I do scrub my clinics but these are already patients who's consults had been approved and likely have the appropriate primary care work up which would include MRI. I personally don't order advanced studies based on someone else's assessment on a condition they obviously aren't comfortable seeing. Not good medicine.

 

[Perrotfish]

Xrays, sure. We do it all the time. MRI's, Guided Injections, etc. take anywhere from 2 to 4 weeks so if our goal is to make life easier on the patient then they shouldn't have to attend redundant unnecessary appointments. I am probably the more understanding of this and agree that there are many instances where it is easier to be established with a specialty earlier, but it is not absolute. There is a middle ground. And yes, thanks, I do scrub my clinics but these are already patients who's consults had been approved and likely have the appropriate primary care work up which would include MRI. I personally don't order advanced studies based on someone else's assessment on a condition they obviously aren't comfortable seeing. Not good medicine.

If you're saying you're pushing the appointment out a month while you wait for the test that makes sense. I don't see why this would involve the consult being rejected, though.

Of course! when a PCM puts in a referral to ortho at our hospital for sciatica/lumbago/foot drop/etc it gets denied and rerouted to Neurosurgery because we have them here and that is how our MTF is set up and perhaps the GMO at an outlying clinic doesn't know that. When a consult is placed after the first visit for knee pain with no red flags, no therapy, NSAIDS and obvious the provider did not exhaust resources...
.

If you're rerouting to a more appropriate provider that's not an issue. If you're turning down a consult from a GMO/midlevel/IDC for knee pain because you don't like the work up... dude.

You're probably working much less than what any new civilian Ortho would consider full time, probably less than even the PCMs downstairs. The only conceivable justification for not seeing a consult someone sends to you is that you are so hopelessly overwhelmed that everyone who comes in pushes someone else out. Based on your previous posts that's not you. The GMO probably has 1 year of a Ob-Gyn residency and the IDC doesn't even have a college degree. Neither of them should be seeing knee pain at all. They definitely don't need to exhaust their resources before you agree to see the patients they're not comfortable with. See your consults.

 

[militaryPHYS]

You do realize that there is a difference between a consult asking for assistance in a difficult case vs. just saying "23 yo AD marine with anterior knee pain please eval for surgical intervention" Unfortunately a lot of PCMs don't spend the extra minute explaining the reason of the consult which then provides us with no useful information and it appears they are just trying to pass the buck. Then we look like the bad guys for denying such a consult. I wish the provider would just call the available 24/7 call number and ask before placing any consults. It would almost be easier. Imagine that...direct contact between providers?!

Regardless. Can we get back to useful discussion on how to accommodate for upcoming DHA changes rather than air personal grievences against specific specialties?

 

[militaryPHYS]

If you're turning down a consult from a GMO for knee pain because you don't like the work up... dude.

Basic workup for knee pain is from medical school and intern year. Xray, PT, NSAIDs, activity modification. Still has pain? MRI. That is not specialty medicine. If you don't think that that is within the scope of a GMO then I'm not sure what is. Now, if regimental surgeon said that their GMOs or PCMs are too busy to see these patients and we need to offload them on to ortho for basic workup, then sure. Roger that. Until then I would expect a GMO to do his or her job before just placing a crappy consult with no information and empty promises to the patient of cure with surgery. Again, you might be great at what you do but many primary care providers are not so don't get all hot headed when one single consult is denied for appropriate reasons.

 

[Perrotfish]

Again, you might be great at what you do but many primary care providers are not so don't get all hot headed when one single consult is denied for appropriate reasons.

There is no appropriate reason for a small MTF ortho to deny a consult.

 

[Perrotfish]

So to expand a bit. If you get a truly inappropriate consult:

1) The first time it happens, from any given provider, see it and don't say anything. However do jot it down in an excel spreadsheet.
2) If it keeps happening, from the same provider, you call the provider. Maybe its a blind spot in their care, and a phone call +/- an emailed guideline fixes it. Maybe they never got a sports med rotation and you work with the regimental surgeon and set them up with a rotation through the SMART clinic. Maybe you get a very immediate sense that they were the weak intern and now they're drowning, and you just pick up the slack and keep seeing the consults
3) If they blow you off, and it keeps happening, you email the regimental surgeon/DMS/whoever is in charge of them to discuss a plan of remediation and you cc the DSS. Attach the excel spreadsheet you have been keeping and a written description of your attempt to deal with the situation at a lower level. Let the chain of command handle it.

What is never appropriate is to send an injured Marine back to a provider that you thought was too incompetent or lazy to do an initial work up. The Marine's health is always more valuable than your time. That's why consults shouldn't ever get rejected if you have the ability to see them. If you reject them you don't look like the bad guy, you ARE the bad guy. Maybe the PCP sucks too, but that's not an excuse for you leaving the patient referred to you without care.

 

[militaryPHYS]

False. We run an acute clinic every morning for walk in ortho as needed for injured Marines. This is in addition to our regular clinics, OR schedules and 24/7 access that patients and PCMs have to discuss a potential ortho case. Don’t pretend to know how well or poor someone else is caring for injured Marines based on your online impression. Consults through CHCS are 95% good and 5% a way to provide a way for a provider to give the patient something, even if it may not be good medical practice. Please don’t pretend to think that isn’t true.

CHCS is not the place to ask a clinical question, it is a place to refer properly worked up patients. If you want me to evaluate a patient you have a question on call my phone I carry 24/7 to see if I can help with proper steps or agree that we should bring them in for a routine appointment.

 

[Gastrapathy]

And this is why DHA thinks there need to be rules

 

[HighPriest]

So, is the train of thought here that small MTF orthos never have a full clinic, or that even if they're working 16 hour days every day of the week to treat patients who could be treated at the primary care level, it's worth it because Marines need to be deploy-able? Because, if they're running half-filled clinics, I'm inclined to agree that they shouldn't be declining consults. If they're booking patients that actually need to see them out 45+ days from the date-of-consultation so that they can see a swarm of guys who just need some ibuprofen and PT, then I'm inclined to agree with militaryPHYS.

I'm not an orthopaedic surgeon, and so most of the patients I saw (with exceptions) were deploy-able whether I see them or not, but I certainly denied consults. BUT I also always had full clinics and I was booking out up to 45 days. So something had to give. If I had space, however, I would see the patient.

And, BTW, DHA thinks there should be rules because they think that access to care is the most important metric in the world, even if it's inappropriate access to care, because they don't know how to look at a metric in context.

 

[Perrotfish]

So, is the train of thought here that small MTF orthos never have a full clinic, or that even if they're working 16 hour days every day of the week to treat patients who could be treated at the primary care level, it's worth it because Marines need to be deploy-able?

The two trains of thought are that:

1) Small MTF orthos don't have a lot to do (relatively) and should never be turning down patients

And

2) Even if a clinic is full the appropriate way to deal with an inappropriate sounding consult isn't to turn it away unseen. You see the consult and then provide feedback to the provider and/or the provider's boss

 

[HighPriest]

So, yeah, if they're not busy I agree.

If they're pushing patients that actually need them out because they're inundated with inappropriate consults, I do not agree. I've been in that situation, where I can't see a chronic sinus patient who's failed appropriate medical therapy for 5 weeks because I have 15-20 patients with "stuffy nose, never tried any treatment of any kind" every day in clinic. It's unfair to the patient who needs me, and it's unfair to the patients who didn't need to have a second appointment to see me (because they also waited five weeks when they could have been treated and happy already).

In the latter case, you're doing more harm than good. I do agree that they should provide feedback with regards to what is appropriate.

 

[DD214_DOC]

/\

This right here. We are all monitored on ATC standards and other metrics unrelated to the actual quality of care being provided. Many of us, I assume, still care about quality, too.

The above reason is why I had to do the same thing with referrals to my clinic. I would regularly have to try to squeeze the actual complicated psych patient referred to me somewhere off-template in order to see them, or they would just have to wait 4-6 weeks for an initial appointment. (For my subspecialty, 5-6 weeks is actually really damn good -- the average wait for a new patient apt is about 6 months). I couldn't do this for all of them due to my other obligations. I was put into this position because of the deluge of unnecessary referrals for things like, "continuity of care", even though the patient is stable > 6 months with a straightforward treatment regimen, or because the MLP simply doesn't want to refill a psychotropic. This, in combination with the blatant refusal to assume continued treatment for even the most simple and straightforward psych patients, resulted in my access going to complete ****.

The behavior never changed, no matter the amount of education, offers to collaborate and be available for consultation, or anything else. Which I knew, because so long as we kept accepting the nonsense, there's no reason for it to stop being sent to us.

 

[HighPriest]

The other issue is two fold:
1 - Part of the metrics upon which surgeons are judged are measured in the OR. You can't book OR cases when 50-60% of your patients don't need to be in a surgeon's office. Depending upon the specialty, there's a varying percentage of patients who are non-surgical even when they're supposed to be there. (in ENT, for example, we do a lot of medical management). So if I'm seeing my usual non-op patients, PLUS a deluge of patients who are non-op because all they needed was for someone to tell them the should start taking claritin, it can very rapidly become difficult to actually fill an OR room. When you don't do that, the Army gets pissed off. Which brings us also to:
2 - There's already a major issue with skill rot, especially in procedural-oriented services. Drowning them in inappropriate consults makes this situation worse, not better.

But, again, this only applies if the service is appropriately busy. If they're seeing 10 patients/day and turning everything else back, that's a little ridiculous. You do need to carry your load.

 

[DD214_DOC]

The other issue is two fold:
1 - Part of the metrics upon which surgeons are judged are measured in the OR. You can't book OR cases when 50-60% of your patients don't need to be in a surgeon's office. Depending upon the specialty, there's a varying percentage of patients who are non-surgical even when they're supposed to be there. (in ENT, for example, we do a lot of medical management). So if I'm seeing my usual non-op patients, PLUS a deluge of patients who are non-op because all they needed was for someone to tell them the should start taking claritin, it can very rapidly become difficult to actually fill an OR room. When you don't do that, the Army gets pissed off. Which brings us also to:
2 - There's already a major issue with skill rot, especially in procedural-oriented services. Drowning them in inappropriate consults makes this situation worse, not better.

But, again, this only applies if the service is appropriately busy. If they're seeing 10 patients/day and turning everything else back, that's a little ridiculous. You do need to carry your load.

I certainly agree with the last part. I'm the only subspecialist of my type where I am, so I am extremely busy. Another issue with the nonsense referrals -- particularly the ones basically requiring me to do nothing but refill the psych med for a patient who's been stable > 6 months or even longer without side effects -- is that E/M coding is based on medical necessity. While I would get some credit for the diagnostic eval, the refusal of primary care to take back patients that should never have been referred to begin with means I get stuck with them. This means that I cannot really code for anything higher than a 99212 or 213 without being fraudulent, and given my apt duration is set for the time demanded for complicated patients, my Average F2F Acuity is absolutely murdered .. along with my RVU. The quick fix idea then becomes, "just see more of them", which serves only to exacerbate the problem by filling my schedule with even more patients who don't actually require subspecialty care.

Round and round it goes.

 

[HighPriest]

I certainly agree with the last part. I'm the only subspecialist of my type where I am, so I am extremely busy. Another issue with the nonsense referrals -- particularly the ones basically requiring me to do nothing but refill the psych med for a patient who's been stable > 6 months or even longer without side effects -- is that E/M coding is based on medical necessity. While I would get some credit for the diagnostic eval, the refusal of primary care to take back patients that should never have been referred to begin with means I get stuck with them. This means that I cannot really code for anything higher than a 99212 or 213 without being fraudulent, and given my apt duration is set for the time demanded for complicated patients, my Average F2F Acuity is absolutely murdered .. along with my RVU. The quick fix idea then becomes, "just see more of them", which serves only to exacerbate the problem by filling my schedule with even more patients who don't actually require subspecialty care.

Round and round it goes.

Just start booking 2-3 of them at a time. Group sesh.

 

[militaryPHYS]

Agree with above. Bottom line for Small MTF Ortho:
1) we only "deny" consults that are either improperly placed (wrong specialty, etc.) or grossly inappropriate (Literally no workup completed) -- these are all few and far between
2) Our clinics are full and we see a large volume of non-op patients like High Priest was discussing above
3) For every consult denied in #1 we probably see and capture the same number of patients that have an issue that needs to be seen sooner than our ATC number (major tendon injury, "simple" finger dislocations that are actually not reduced, also shoulders for same reason, fractures outside of accepted tolerances, etc.) So if those patients are NOT reviewed and get central booked to our normal ATC they show up 2 weeks+ later and are outside of the window for proper surgical treatment and then they are screwed forever.

So the blanket statement that a small MTF surgeon shouldn't be reviewing their consults and needs to just see everything given to them by central booking is not only generalized and near sighted, it is unsafe to patients.

Completely agree there is a compromise, but just saying NO REVIEW I don't think will have the perfect effect that everyone is hoping for.

 

[Dr. Wexler]

So the blanket statement that a small MTF surgeon shouldn't be reviewing their consults and needs to just see everything given to them by central booking is not only generalized and near sighted, it is unsafe to patients.

Completely agree there is a compromise, but just saying NO REVIEW I don't think will have the perfect effect that everyone is hoping for.

I don't know why you're getting a hard time. Our local civilian orthos won't see the patient without the relevant imaging. And demand plain films beforehand even if the primary doc doesn't think they are needed. No problem.

Not limited to surgery. Local medical specialists demand certain tests before seeing the patient. Also reasonable.

Are these test always indicated? I dunno. But I'm guessing the specialists got tired of seeing patients who hadn't had any initial evaluation done at all and so they decided to make a blanket rules.

Hopefully you can get some guidelines put in that the referral management drones will follow. Must have failed at least 2 pharmacotherapies for allergic rhinitis. Must have imaging of affected joint. Just don't call it "review" I guess.

 

[teacherman84]

As someone who works in primary care and referral clinics, educating for bad referrals helps...a good relationship between specialty and primary care goes a long way.

So on other DHA changes that i hadnt heard that were talking about what im at...aside from the usual changes to GME, reducing specialties closing small MTFs

A new network for med group system/email separate from the rest of the base...coming over the next year.

Deployment buckets going away...Just having a group of deployable folks ready to go at any time.

 

[HighPriest]

There should be a good relationship. Educating on referral guidelines should happen. Primary care clinics should feel comfortable calling subspecialists and asking for direction without getting badgered. The point is, it should be a cooperative relationship. The subspecialists shouldn't be rejecting referrals simply because they don't want to see patients. If they have the time, they should be seeing things, even if they think they weren't necessarily appropriately worked up, so long as it's actually something they treat (ie: I would get TMJ consults all of the time, and I don't treat TMJ, they needed to go to their dentist). But the other side of that coin is that subspecialty clinics aren't just a dumping ground where PCPs can send patients because they feel overloaded. I was essentially never running a slow clinic with available spots. Seeing a patient for allergies who had never been prescribed any treatment of any kind was a 10-15 minute appointment slot that could have been managed at the PCP level. If they fail there, then I'm happy to see the patient. But instead I'm seeing an irate patient who waited 6 weeks to see me so that I could put him on flonase. Plus, my next patient is a 2 year old who hasn't been able to hear well for 4 months because he had to wait an extra 6 weeks to see me because my clinic is full of guys who just need flonase. There's a difference between not knowing how to manage a semi-complex issue as a primary care provider, and just dumping things on specialists because you're busy.

But there should be a dialogue there as well. From both sides.