refusing to do procedure

[AndyDufrane]

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so quick question, if one former interventional physiatrist refers a patient to an interventional physiatrist for evaluation for injection, and interventional physiatrist after conducting clinical hx, exam, and review of imaging decides an injection is not warranted or there is no specific anatomical pain generator that would be amenable to injection, and declines to perform procedure, and patient goes back to referring provider and complains, what to make of this situation, what is the proper protocol for both parties?

 

[specepic]

so quick question, if one former interventional physiatrist refers a patient to an interventional physiatrist for evaluation for injection, and interventional physiatrist after conducting clinical hx, exam, and review of imaging decides an injection is not warranted or there is no specific anatomical pain generator that would be amenable to injection, and declines to perform procedure, and patient goes back to referring provider and complains, what to make of this situation, what is the proper protocol for both parties?

In that situation, I would usually pick up the phone and call the referring doc rather than just send a note. Why dont you give us a little more info about the pt and what was ordered? I very commonly either do no procedure or a diff one than what was ordered based on my eval but always state in my note why. You do risk burning bridges with referring docs doing this. PCPs usually dont care but specialists, esp surgeons prob will.

 

[lobelsteve]

so quick question, if one former interventional physiatrist refers a patient to an interventional physiatrist for evaluation for injection, and interventional physiatrist after conducting clinical hx, exam, and review of imaging decides an injection is not warranted or there is no specific anatomical pain generator that would be amenable to injection, and declines to perform procedure, and patient goes back to referring provider and complains, what to make of this situation, what is the proper protocol for both parties?

I've never heard of such a thing.


Agree with above. Call him up. I often change procedure based on my eval of the patient as most folks will send patient for ESI and they will not have radicular pain. We can do MBB or SIJ or just start them on exercises. But to refuse a procedure and not have the patient happy about it makes no sense.

 

[RUOkie]

And the converse also applies. As a non-interventionalist (who used to do ESIs/facets etc), if I send a patient to a colleague for a specific procedure and either a different procedure is done, or if none is done, I expect a phone call. If I don't get an explanation as to WHY, I find a different interventionalist for my future patients. If I get a call, and we discuss it, then no worries.

Often we non interventionalists want a procedure done for diagnostic purposes because we've known the patient for a while and that does not always come out in a single visit.

 

[specepic]

Good point above, assuming you trust the referring doc you may want to consider doing the referred procedure first, then saying in your note what your plan b would be if that doesn't work. If you did not communicate well with referring doc and pt then you need to own some of the fallout

 

[AndyDufrane]

well, here is the deal, the referring provider is in our group, but the set up is not just that I do procedure and send back to referring provider,the expectation is that I follow up with the patient afterward not just for the post injection follow up appointment, but basically take over, and take over there care all together, so its not simply getting procedure and going back to referring provider, and these patients usually have crappy insurances that other interventionalists will not take, usually show up with no lumbar MRI films, I even had one case show up with failed back with arachnoiditis on L MRI report asking me to do L ESI, so I get the feeling that I am getting dumped on for patients the referring provider is looking to unload since I am the new guy, or am I looking at this situation the wrong way?

 

[101N]

well, here is the deal, the referring provider is in our group, but the set up is not just that I do procedure and send back to referring provider,the expectation is that I follow up with the patient afterward not just for the post injection follow up appointment, but basically take over, and take over there care all together, so its not simply getting procedure and going back to referring provider, and these patients usually have crappy insurances that other interventionalists will not take, usually show up with no lumbar MRI films, I even had one case show up with failed back with arachnoiditis on L MRI report asking me to do L ESI, so I get the feeling that I am getting dumped on for patients the referring provider is looking to unload since I am the new guy, or am I looking at this situation the wrong way?

You are getting dumped on. Smile and say thank you🙂

 

[bedrock]

well, here is the deal, the referring provider is in our group, but the set up is not just that I do procedure and send back to referring provider,the expectation is that I follow up with the patient afterward not just for the post injection follow up appointment, but basically take over, and take over there care all together, so its not simply getting procedure and going back to referring provider, and these patients usually have crappy insurances that other interventionalists will not take, usually show up with no lumbar MRI films, I even had one case show up with failed back with arachnoiditis on L MRI report asking me to do L ESI, so I get the feeling that I am getting dumped on for patients the referring provider is looking to unload since I am the new guy, or am I looking at this situation the wrong way?

Isn't this the job you are leaving? If not, you might want to.

1-no matter where you work, nobody should be sent to you for a procedure without an MRI. You just tell your front desk, "don't schedule anyone for a consult without an MRI" The referring doc will have to order it first.

2-The rest depends on your situation. I would try to drop the poor insurances. As I had posted recently on the pain thread, I recently stopped talking all Medicaid and my life is dramatically better. Same thing goes for medicare under 60yrs old, which means they are disabled, often for ridiculous reasons, and they usually have medicare+medicaid, meaning you only get paid 80% of medicare.

3-If you are the new guy and this is a new position, then you need to screen your new appointments or have someone screen them for you. Check that they have an MRI, drug abuse history, major psych red flags, pain meds from multiple docs, don't have felony conviction, etc.

Your life will suck if you just see drug-seekers, psychos, or "disabled" slugs all day long. Gotta change that.

 

[AndyDufrane]

Isn't this the job you are leaving? If not, you might want to.

1-no matter where you work, nobody should be sent to you for a procedure without an MRI. You just tell your front desk, "don't schedule anyone for a consult without an MRI" The referring doc will have to order it first.

2-The rest depends on your situation. I would try to drop the poor insurances. As I had posted recently on the pain thread, I recently stopped talking all Medicaid and my life is dramatically better. Same thing goes for medicare under 60yrs old, which means they are disabled, often for ridiculous reasons, and they usually have medicare+medicaid, meaning you only get paid 80% of medicare.

3-If you are the new guy and this is a new position, then you need to screen your new appointments or have someone screen them for you. Check that they have an MRI, drug abuse history, major psych red flags, pain meds from multiple docs, don't have felony conviction, etc.

Your life will suck if you just see drug-seekers, psychos, or "disabled" slugs all day long. Gotta change that.

Yes, I am actively looking for other opportunities now in full gear, but I have stayed way too long already, hoping things would turn around but its a downward spiral, and am tired of feeling like I am in quicksand, but yeah, I have noticed, these Medicaid, or Medicare under 60 group, are patients of a different caliber, and yes, these are the vast majority that are getting referred to me for procedures, 😱

 

[Jitter Bug]

What you described is not a referral for procedure, it is a request for a transfer of care wrapped up in a pretty injection wrapping, The procedure is a peace offering, for taking the patient.

 

[AndyDufrane]

What you described is not a referral for procedure, it is a request for a transfer of care wrapped up in a pretty injection wrapping, The procedure is a peace offering, for taking the patient.

yeah, I was beginning to get the feeling there was something suspicious with these referrals,they usually had crappy insurance, needed translators, had untreated psych issues,psychos or other personality disorder, and usually conveniently nothing worked but opioids, earlier in the year, the same referring provider tried unloading his chronic opioid patients on me too

 

[bedrock]

What you described is not a referral for procedure, it is a request for a transfer of care wrapped up in a pretty injection wrapping, The procedure is a peace offering, for taking the patient.

Completely agree.

I would just start saying that all of these patients are not appropriate for procedure and send them right back. They'll get the point eventually.

 

[specepic]

Referral from another Pain or IPMR doc is a usually a dump until proven otherwise, often wrapped (as nicely noted above) in a reason like "facet blocks" or something to temp the schedulers. There are also NS groups in my area with their own PMR/Pain guys and if they send me a pt usually a dump too.

 

[Louisville04]

Referral from another Pain or IPMR doc is a usually a dump until proven otherwise, often wrapped (as nicely noted above) in a reason like "facet blocks" or something to temp the schedulers. There are also NS groups in my area with their own PMR/Pain guys and if they send me a pt usually a dump too.

Do you prescreen your consults or does someone automatically schedule them?

Can you just do the procedure and say something like "opioids not recommended in this patient." The patient probably will not want to follow up with you.

 

[specepic]

Do you prescreen your consults or does someone automatically schedule them?

Can you just do the procedure and say something like "opioids not recommended in this patient." The patient probably will not want to follow up with you.

Oh yea, I learned a while ago that taking a few minutes spent reviewing referrals pays off. Here is my current system:

- referrals from within the practice are not usually reviewed first (they know the rules)
- Local PCP referrals from within my hosp system are reviewed for triage purposes, they know the rules as well re : opioids
- Outside PCPs, and any other outside referral gets close scrutiny

 

[AndyDufrane]

Do you prescreen your consults or does someone automatically schedule them?

Can you just do the procedure and say something like "opioids not recommended in this patient." The patient probably will not want to follow up with you.

no I do not get to prescreen, are automatically scheduled, tried blocking earlier in the year to no avail, so now I make them have a separate evaluation for procedure on a separate day, then decide about proceeding with injection and if so what level, otherwise, showing up my doorstep without MRI and expecting an injection would be a recipe for disaster, and no I can't say "no opioids recommended", as I got a talking to earlier in the year about pissing off the referring providers because I don't prescribe opioids that readily

 

[AndyDufrane]

Referral from another Pain or IPMR doc is a usually a dump until proven otherwise, often wrapped (as nicely noted above) in a reason like "facet blocks" or something to temp the schedulers. There are also NS groups in my area with their own PMR/Pain guys and if they send me a pt usually a dump too.

this piece of advice is priceless, and so true as I am realizing, its almost like some sort of hazing one goes through, I really try to channel my inner alpha male, silverback gorilla persona when I talk to the referring providers who send these types of patients, but I do say thank you many times when I am talking to them

 

[RUOkie]

this piece of advice is priceless, and so true as I am realizing, its almost like some sort of hazing one goes through, I really try to channel my inner alpha male, silverback gorilla persona when I talk to the referring providers who send these types of patients, but I do say thank you many times when I am talking to them

It is really important to remember that building a solid practice is a marathon, not a sprint. It takes 1-2 YEARS (sometimes longer) before people really figure out what kind of practitioner you are. For example, I've been in this community for 11 yrs. I trained in, and purchased an US machine just about 2 years ago. I spoke to all of my referral sources, demonstrated it to them. They all thought it was "so cool".

It is really only the last few months that people (even my friends) are referring patients to me specifically for US or US injections. They were all waiting to see the outcomes of the other people (my own pts who I was using it on)

 

[SSdoc33]

no I do not get to prescreen, are automatically scheduled, tried blocking earlier in the year to no avail, so now I make them have a separate evaluation for procedure on a separate day, then decide about proceeding with injection and if so what level, otherwise, showing up my doorstep without MRI and expecting an injection would be a recipe for disaster, and no I can't say "no opioids recommended", as I got a talking to earlier in the year about pissing off the referring providers because I don't prescribe opioids that readily

quit.

seriously.

if some bonehead adminstrator (or worse yet, doctor) is telling you to write more opioids than you want to, then you should quit.

 

[AndyDufrane]

quit.

seriously.

if some bonehead adminstrator (or worse yet, doctor) is telling you to write more opioids than you want to, then you should quit.

yes it was an admin, nice guy though, telling me I need to loosen up about prescribing opioids, to which I replied its not really evidence based medicine to be prescribing opioids to anyone who walks in the door, and he smiled and said but really, its the standard of care in the community, and I just left it that, but if I get terminated over not prescribing opioids, I wonder if the DEA or some other govt agency could get involved

 

[AndyDufrane]

quit.

seriously.

if some bonehead adminstrator (or worse yet, doctor) is telling you to write more opioids than you want to, then you should quit.

I am very much on the hunt for new gig now,
I am just coming to the realization, that I need to be the captain of my ship, and I can't do that if I work for someone else, simple as that, I think I drank the kool aid about the benefits of being a hospital based physician, but you can't put a price of autonomy, it really is priceless, I just have to get over my fear of trying to run my own business, otherwise, this is the reality, someone else is making way too much money off you, leeches, plus I have learned hospital admin are vile creatures,

 

[SSdoc33]

I am very much on the hunt for new gig now,
I am just coming to the realization, that I need to be the captain of my ship, and I can't do that if I work for someone else, simple as that, I think I drank the kool aid about the benefits of being a hospital based physician, but you can't put a price of autonomy, it really is priceless, I just have to get over my fear of trying to run my own business, otherwise, this is the reality, someone else is making way too much money off you, leeches, plus I have learned hospital admin are vile creatures,

its always nice to see the growing disillusionment and loss of innocence of the budding physiatrist. seriously, its almost a rite of passage. the sooner you learn it, the sooner you can move on and provide the best care you can while also pocketing your fair share. otherwise, you will be used and abused.

sure, you could theoretically take some legal action against these bozos if the sh$t hits the fan, but that isnt the greatest outcome, either. in the meantime, smile, nod, dont cause trouble, and find yourself a job with more autonomy. even if you dont get "fired" they can make your life very uncomfortable if they want to.

best of luck

 

[RUOkie]

its always nice to see the growing disillusionment and loss of innocence of the budding physiatrist. seriously, its almost a rite of passage. the sooner you learn it, the sooner you can move on and provide the best care you can while also pocketing your fair share. otherwise, you will be used and abused.

sure, you could theoretically take some legal action against these bozos if the sh$t hits the fan, but that isnt the greatest outcome, either. in the meantime, smile, nod, dont cause trouble, and find yourself a job with more autonomy. even if you dont get "fired" they can make your life very uncomfortable if they want to.

best of luck

+1!!!

Great advice there.

/threadjack Although, as a solo practitioner for 11yrs now, I don't see it lasting much longer. I think our government is going to force us into larger groups or employed models. I hope I'm wrong.
/end threadjack

 

[AndyDufrane]

+1!!!

Great advice there.

/threadjack Although, as a solo practitioner for 11yrs now, I don't see it lasting much longer. I think our government is going to force us into larger groups or employed models. I hope I'm wrong.
/end threadjack

that is really disheartening to hear, I am going to try to fight it, and find a a viable alternative to the hospital based employment, there has got to be a better alternative to this, there just has to be,

 

[bedrock]

Your choices are not just Hospital vs solo

Go work for a private practice group, pain or multi-specialty group. Much more freedom to practice how you see fit, but you need to ask the right questions when you visit.