Secondary Polycythemia

[DoctorDontStop]

New attending here. Hoping to get some advice from those of you practicing for a while. I just started a job in a somewhat rural setting. I get a lot of Heme referrals from PCPs, pulmonologists, etc for patients for polycythemia. These are almost always known tobacco abuse cases, COPD, etc. We were always taught in training to treat the underlying cause, but the referring docs and patients expect to be treated with therapeutic phlebotomy. Some of them have had this issue for years and previous hematologists would just do phlebotomies to correct the number and keep everyone happy but this seems counterproductive. Perplexed about what to do as my suggestions for smoking cessation and inhaler compliance is falling on deaf ears.

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[RainerMaria]

Unless symptomatic I wouldn’t typically treat a number in secondary polycythemia. If they had clear polycythemia sx like erythromelalgia, pruritis or other presumed sequelae could offer therapeutic phlebotomy to goal HCT 55 or lower but it is not well supported by evidence so I think even UpToDate it is a weak recommendation.

But I think it is regional / practice dependent as some will. There is a post on the mednet from 2020 where a hematologist from JHU said he would offer to reduce risk of thrombosis based on number

But I too was trained this way… treat underlying disease not the number. But If you are getting pressure to treat, we’re facing a national blood shortage. Why not just suggest the patient donate blood rather than waste resources (both blood and infusion time)?

Ref:

UpToDate

www.uptodate.com

 

[RustBeltOnc]

This is a very common situation. Unfortunately, in the primary provider space, only old school internists understand the difference between primary and secondary polycythemia. The OP's recommendation is sound, even if it is not well received. My recommendation is to continue to do the right thing.

 

[HemeOncHopeful19]

Just wait until you get the people going to "low T clinics" who want therapeutic phlebotomy to keep their numbers normal, I've seen that once or twice so far.

I usually just explain the reasoning "this patient's polycythemia is a physiologic reaction to ______, and there is not very good data supporting phlebotomy in the absence of symptoms etc."

 

[DoctorDontStop]

Already getting those unfortunately. I try to get them off “T” but again…..deaf ears.

 

[NewYorkDoctors]

Don’t forget OSA . Recommend to see sleep medicine

 

[gutonc]

I get these from time to time. And it's usually the full monty, obese, on testosterone, smoker with OSA who won't use CPAP. Since they're in the office and "want an answer" I check a ferritin, EPO and MPN panel to rule out an underlying primary cause and then tell them to quit smoking, stop the testosterone, use their CPAP and if their PCP is really worried about treating a number, they can donate blood once a month.

My advice typically falls on deaf ears as well, but as long as they don't have ET or another MPN, I don't really care and they can go whine at the "men's clinic".

 

[HaemOnculus]

There is some loose guidance from the BMJ(https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.15647). I typically recommend donating blood or phleb them down to a HCT somewhere between 52-55% after telling patients that doctors are pretty much making it up. I usually leave them be if it is cardiopulmonary as that is likely an appropriate physiologic response.

 

[NewYorkDoctors]

as with all "high maintenance patients," I am sure the PCP knows the medical issues and (i would hope) gave it one shot to explain to the patients. In in our current day and age, patients do not trust primary care doctors anymore and want "specialists" to manage everything. These same "high maintenance" patients subsequently lament how there is no one "master super doctor quarterback Dr House but nicer" for them. It's a vicious cycle.

anyway in the community, PCPs like to refer these "softball" patients thinking "hey the specialist will make some easy money."
What they fail to realize is
1) this only applies to community based private practice doctors who collect money and not RVUs. there is no incentive to see these low complexity low RVU patients otherwise
2) there are other more needy patients with legit issues that need that time block
3) there are other ways to make money besides seeing "high maintenance" patients who do not come with any CPT codes other than 9920X + G2211 (if medicare) who seem to have already made up their mind about what they want from the visit

If the PCP ever sent me a "Talk Only" patient like this for pulmonary, I would be more understanding and helpful if the PCP relayed some message to me (not in the chart but via text or call or something) that he/she tried to reason with patient but patient "only wants to see a specialist."

 

[sloh]

Just wait until you get the people going to "low T clinics" who want therapeutic phlebotomy to keep their numbers normal, I've seen that once or twice so far.

I usually just explain the reasoning "this patient's polycythemia is a physiologic reaction to ______, and there is not very good data supporting phlebotomy in the absence of symptoms etc."

Good post. This is so common haha. There’s actually evidence to suggest that for these patients, undergoing phlebotomy just results in a physiologic reflexive increase in RBC production.

 

[gutonc]

Good post. This is so common haha. There’s actually evidence to suggest that for these patients, undergoing phlebotomy just results in a physiologic reflexive increase in RBC production.

I'm definitely stealing that verbiage. I may in fact have just made a dotphrase out of it.

 

[dozitgetchahi]

as with all "high maintenance patients," I am sure the PCP knows the medical issues and (i would hope) gave it one shot to explain to the patients. In in our current day and age, patients do not trust primary care doctors anymore and want "specialists" to manage everything. These same "high maintenance" patients subsequently lament how there is no one "master super doctor quarterback Dr House but nicer" for them. It's a vicious cycle.

anyway in the community, PCPs like to refer these "softball" patients thinking "hey the specialist will make some easy money."
What they fail to realize is
1) this only applies to community based private practice doctors who collect money and not RVUs. there is no incentive to see these low complexity low RVU patients otherwise
2) there are other more needy patients with legit issues that need that time block
3) there are other ways to make money besides seeing "high maintenance" patients who do not come with any CPT codes other than 9920X + G2211 (if medicare) who seem to have already made up their mind about what they want from the visit

If the PCP ever sent me a "Talk Only" patient like this for pulmonary, I would be more understanding and helpful if the PCP relayed some message to me (not in the chart but via text or call or something) that he/she tried to reason with patient but patient "only wants to see a specialist."

Also,

4) at least in rheumatology, these “softball” patients the PCPs send aren’t actually easy money…they tend to be some of the most time consuming and draining consults. My idea of an “easy money” rheumatology referral is gout or osteoporosis…PCPs seem to think it’s fibromyalgia or osteoarthritis, both of which are neither easy nor a good source of money (in fact, they are usually a huge drain of time, energy and effort which I’m always trying to unload from my clinic as soon as possible).

That said, I don’t think the PCPs even think that they’re serving me up “easy money”…I think they’re just shipping out problems they don’t feel like dealing with, wrapped up with a “positive ANA” cherry on top so it gets through the filters…