Things Specialty doctors wish GP doctors knew/would do before referring...

[KiwiKaymoku]

Currently still in school, but after one of my cardiology proffs mentioned that sometimes GP and even ER will refer out DMVD stage C dogs out for an echo with a cardiologist when the cardiologist wishes the GP/ER would take the radiograph. It got me thinking that I'm sure there are plenty of these instances where a specialty doctor wishes GP would do X, Y, or Z before the consult. So my question is, what can GP do a better job of before referring pt's out for any specialty consult service?

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[WhtsThFrequency]

Not really referral, but as a pathologist who receives specimens often from private clinics:

Don't send me giant specimens in tiny amounts of formalin. If you must ship it in a smaller container, please make an incision in the main mass so formalin can penetrate. Please stop sending me entire spleens stuffed into 500mL plastic containers with a dollop of formalin on top. Formalin penetrates at a VERY slow rate and the interior of the tissue will rot, and I won't be able to diagnose anything. This is especially important in hemorrhagic splenic masses. The minimum ratio of tissue to fixative for ideal fixation is 1:5 - 1:10. Anything less than that and you are going to have a lot of tissue rot in transit unless you incise the large area of interest

If you want margins, please tell me which part of the excised tissue is the deep margin vs other margins. Even if it is a dermal mass and you leave a little skin on top to indicate dorsal, during the contraction that happens during fixation things can get messy. Invest in some surgical ink for marking, or put a small suture in whatever margin you are most concerned about (usually the deep) and indicate it on the form.

If you think something is a soft tissue sarcoma, try to avoid shelling it out of the subq if you can. Those need WIDE margins. I will give you a "marginally excised" at best every time (and more often incomplete). Of course this is easier said than done depending on location - I definitely get it - but "shelling out" is always a big risk and don't be mad when it comes back "incompletely excised" on my end even thought it looked ok on yours.

DON'T CRUSH THE TISSUE. Please be gentle. Crush artifact is a real thing and I have gotten tissue that is totally unrecognizeable because it was squished. I will send it back to you as "nondiagnostic".

Don't scrub away at a derm lesion to clean it before you take the biopsy. You are potentially scrubbing diagnostic features off. Try to take a sample from the worst areas but also from the interface of a bad area and a good area. If you see pustules or blisters, try to get a sample that contains an intact one.

Understand that bone samples take a while. We have to decalcify it which can take days.

 

[allygator13]

Just take good radiographs. A thoracic study needs 3 views to be complete. Collimation is everyone's friend. Charge rads by the study (ie. a thoracic study is automatically 3 views and is charged a blanket fee that includes all 3 views) rather than per view, then there is no arguing with a client over taking 2 or 3 views, which is an incomplete vs. complete study. If a patient needs sedation to get quality rads, just do it. You're not helping anyone by taking poor quality images and you're charging your client for a non-diagnostic study that is going to create more questions than answers.

Only take images of the area you think has an issue. I've gotten a 40+ image study of a dog's entire body with the clinical question "general health screening." That is a. inappropriate medicine, b. unnecessary radiation exposure to your techs and patient, and c. the fastest way to piss off your radiologist.

Giving a good, concise clinical history and brief clinical question is super helpful when submitting for a teleradiology consult. We can answer your specific questions and be as helpful as we can. If you enter "?" or "thoughts?" we will give you our thoughts, but they may not be as helpful as you're hoping for.

 

[VIN-Foundation]

Neurology/neurosurgery ... but the fist two apply to any clinical service:

1. Follow the requested referral process. Don't tell clients to "just go on over and they'll see you." Right now we are just as busy as everyone else. We have appointments for a reason -- mainly because I can only get so many MRIs, anesthesias, etc. done per day.

2. Please arrange to have any relevant records and images sent by the time I see the client. My nurse spends at least an hour a day tracking down records and images.

3. We do NOT prefer to wait until a patient with an acute spinal cord injury loses pain perception before we go to surgery. And don't tell me that's what you learned in school -- I know because I taught you 🙂

 

[SocialStigma]

Surgeon (small animal) here:

- For all orthopedic referrals, please take sedated orthogonal radiographs focused on the region of interest. Don't take images with both fore/hindlimbs in it together without a marker that indicates which leg is which. Receiving 10 images where the patient is obliqued/twisted/limbs are overlapped is unhelpful and the client ends up being annoyed at us that we can't see what we need to see.
- Please provide dimensions and some description of soft tissue masses (including clinical progression), as it helps us prioritize which surg onc cases need to be seen more urgently. Often masses are just described as "large subcutaneous mass on abdominal wall" but that could mean 5cm or 30cm and there's no description of whether it is still freely mobile vs. adhered etc.
- Perform FNAs and/or incisional biopsy of all skin/SQ masses prior to referral. At least 70% of my skin/SQ mass referrals have had literally no workup and when I recommend starting with an FNA at the time of the surgery appointment, the owners are a) mad that they drove 2 hours to see me when it's something their vet could've done already, and sometimes b) say that they wouldn't pursue surgery if it was cancer. The referral visit could have been eliminated completely in these cases if the owners knew that the mass was neoplastic.
- If you are referring a case for surgery but it has other comorbidities (eg. significant kidney disease, loud heart murmur, etc) that have not been worked up, it would be ideal to have all those addressed/worked up prior to the surgery consult. Most surgeons will not be comfortable anesthetizing a dog with a grade 4/5 heart murmur that has not had a cardiac workup, so it would be better for the patient to have a cardio referral prior to the surgery referral. It just delays the patient going to surgery if I'm the one submitting a cardio referral when I see them for a surgery consult.

 

[Trilt]

I'm not a specialist. But I'm an ER vet now after about five years in GP, and I don't care what you do in general but dear god CALL THE ER PRIOR TO SENDING A PATIENT FOR TRANSFER.

Talk to me. Tell me the patient story and needs. Get an estimate (and pass it along to the owner!) and an update about whether I have the things that the patient requires.

I don't bite, I'm totally fine with you leaving an assistant on hold if it takes me a few minutes to get to the phone so you can do other things, I just absolutely hate when people just send clients with sick sick patients that they've started treating and don't prepare them at all for the transfer - it ends with, at best, awkward conversations for me, and at worst, euthanasia for a patient who has had to suffer that much longer because of the delay. 🙁

Spoiler: This turned into a bit of a rant sorry

Literally in my last couple shifts I've had:
"Suspected Addisonian" - I took one look at the labs and recommended just rechecking them - yup, lab error, easily could have been done at the rDVM if they talked to me about the numbers prior to transfer, instead I get to gently manage the owners being pissed they got sent to the ER and charged another exam and lab fee.

"Needs Blood Transfusion" - I have no blood in my fridge. I have one donor dog remaining on my list, and your patient is a 60lb IMHA with a PCV in the tweens... this ain't the place for this patient (who also got no estimate, didn't realize blood transfusions weren't an outpatient procedure, etc...)

"Heart failure cat" - yes I can tap the cat's pleural effusion. I absolutely understand that being a lot more stressful to do if you don't have ultrasound and don't do it often. But please have a discussion about the guarded prognosis for most causes of pleural effusion, the need for hospitalization/medication even in "good" causes, and if the cat is turning purple at your clinic I really would prefer you poke them so the 45 minute drive doesn't kill the cat. Because sometimes it does, and that situation is horrific for everyone involved, most of all the cat. 🙁

 

[Vannandy]

Oncology here.

1. Please take thoracic radiographs with a radiologist interpretation prior to referral if there is concern for a neoplasia with high metastatic potential and poor prognosis. The number of referrals we've received just to have a chest full of pulmonary metastasis is astonishing.

2. In-house interpretation of cytology means nothing to me. If you take the time to take aspirates submit them for a clinical pathologist to review. Feel free to stain one slide so you have an idea of what it may be or confirm cellularity. I will not prescribe chemotherapy without a cytologic/definitive diagnosis. We will repeat aspirates, wait for cytology results, ultimately delaying treatment for the patient.

3. Please evaluate a concerning mass with cytology/aspirates prior to performing a routine lumpectomy. A cytologic diagnosis will help determine the surgical dose. For example, if it comes back as a high grade/grade 3 mast cell tumor and a marginal mass excision performed, we're probably talking about another surgery regardless. Same thing with soft tissue sarcomas (i understand they don't always exfoliate well but 9/10 we get a suspicion for mesenchymal neoplasia on aspirates).

4. If you have a dog with multiple enlarged peripheral lymph nodes please do not start them on empiric doxycycline if there is a low suspicion for tick-borne disease. Rule that out. Run a 4DX and do a blood smear, check platelet counts. Look for evidence of vasculitis. Also please do not start them on an NSAID lol.

5. If there is an incidental oral mass appreciated during a COHAT/dental prophy please take photos. The oral cavity heals very quickly and it is hard to know exactly where the mass was if there isn't evidence of local recurrence by the time they reach referral.

6. Call and consult with your local oncologist if you are unsure about a certain neoplasia. We understand GPs have to be a jack of all trades and don't expect you to know all considerations of prognosis or treatment options. We are more than happy to consult and guide the conversation with owners. It is a waste of everyone's time if there's a cervical mass and the owner has no money for a CT scan which is going to be required for further workup and treatment interventions. Cancer treatment is expensive but the reality.

7. Advocate for pet insurance for all your patients. We want to treat cancer. Finances are a serious consideration for many. Lymphoma has an 80-90% complete remission rate and it pains me that many don't proceed with treatment (of course in conjunction with other considerations) because of finances. Both my dogs are fully insured in the event they ever have expensive veterinary costs.

8. Being a veterinarian means having a commitment to continued learning. There are some wonderful GPs that perform wonderful workups prior to referral. Many times I find many do not and refer with inappropriate workups and empiric antibiotic trials. The lack of CE or continued learning on challenging/new cases is a disservice to the patient and owners resulting in delayed treatment interventions. Graduating and passing NAVLE doesn't automatically make you a good clinician. I certainly wasn't. Experience and the continued commitment to learning is what makes a great doctor. And it takes a team to provide the best quality of medicine for your patients. That includes learning when to reach out to others in your field when you don't know the answer.

Side comment: I've seen this also from ER doctors and specialists referring. Please understand the limitations of medical oncology. Medical oncology is not withholding a secret chemotherapy that will save a dog from an active hemoabdomen from a splenic mass if the owners don't want to proceed with surgery. Neither is the BCS 2/9 cat with abdominal effusion and suspected pancreatic mass. Transferring to Oncology just to euthanize and have the difficult conversation is not fair to the patient and client (example: cat who received 2 blood transfusions overnight just for the owner to learn of the poor prognosis from oncology and euthanized or diffuse pulmonary metastasis not communicated from ER overnight to the owner only for us to euthanize in the morning). If one does not know much about a certain neoplasm that they may encounter through ER please contact your Oncology Service. We are more than happy to share the considerations, workup, and potential prognosis for the patient.

 

[that redhead]

No longer in GP but enjoying this thread. Ever since @WhtsThFrequency made a comment years ago about no one ever filling our their clinical history section, I always do my best to give as much detail as possible. (Maybe too much, sorry path squad!)

 

[WhtsThFrequency]

No longer in GP but enjoying this thread. Ever since @WhtsThFrequency made a comment years ago about no one ever filling our their clinical history section, I always do my best to give as much detail as possible. (Maybe too much, sorry path squad!)

I will take even the most overzealous paragraphs over a hastily scribbled "dog has lesion" any day, haha.

People tend to just do a mental hand-wave and think oh, well pathology will see it under the microscope and know what it is.....but in reality sometimes it's super difficult for us to distinguish between similar processes and the extra information does help - i.e. how long as the animal had the problem, does it wax and wane, what treatments have been tried, has it gotten worse/better with said treatments, etc.

 

[allygator13]

I will take even the most overzealous paragraphs over a hastily scribbled "dog has lesion" any day, haha.

People tend to just do a mental hand-wave and think oh, well pathology will see it under the microscope and know what it is.....but in reality sometimes it's super difficult for us to distinguish between similar processes and the extra information does help - i.e. how long as the animal had the problem, does it wax and wane, what treatments have been tried, has it gotten worse/better with said treatments, etc.

Same with radiology in many situations!

Ex. If you are concerned about foreign material in the stomach, including a little blurb about when the dog last ate is HUGE. If we don't know that piece of information, we are going to waffle that it could be food, could be foreign material. If the dog ate that day, we are still going to waffle. However, if the dog hasn't eaten a meal in 24 hours or more, we can feel better about it probably being foreign and not just normal food.

Ex. Animals with heart disease in possible CHF, very helpful to know if Lasix has been given prior to the radiographs or not, whether chronically or just an IV dose when they presented.

 

[JaynaAli]

Yes, history is super helpful and important. And some people will go on about “biasing the pathologist” but I want to know what you think it is so I can make sure I address your concern. I’ll give you a pat on the back “your clinician suspicion of a [insert diagnosis] is confirmed” in the comments if you tell me what you think it is and you’re right. And then you won’t get the dumb “correlate clinically” ending comment.

And when we’re talking history, the description of the mass is one of the more important features for me on cytology. “Mass on foot for 5 months” is great and I’ll take that over no history every day but if you tell me it’s a cutaneous red raised hairless 1 cm mass with an ulcerated area or it’s a tan, cauliflower-like 5mm lesion on a stalk or if it’s a non painful sq swelling it’s going to make me lots more confident that you actually hit what you wanted and it’s a representative sample.

Also I get histories of “abdominal mass” - is it IN the abdomen or ON the abdomen…there’s whole different differentials for cutaneous/sq lesions on the abdomen than ones within the abdomen.

History on a fluid saying “200ml removed from the chest” are useless. I can’t really even think of a time where the actual volume you retrieved was ever clinically significant to me when classifying the fluids. You know differentials for different types of effusions, so give me the info that can help us narrow it down if possible. have you done a cbc and is albumin low? Is there a history of heart or liver disease? is cancer a possibility? I realize when people sample effusions they may not know why it’s forming and they want us to tell them that, but I can be a lot more confident and definitive on the cause of your vague AF modified transudate if you tell me the liver values are increased or that there’s been a murmur for 6 months.

And if you look at a slide and think you saw something weird or that you’re concerned about, for goodness sakes SEND THAT SLIDE IN and tell us you saw something on that slide that worried you. Then we can make sure we found what you saw to address your concern and then educate you on whether or not it was significant or not. The cells might not be on the other slides.

And don’t forget that cyto sucks for canine mammary. Poke mammary masses to make sure they’re mammary and not a mast cell tumor or a lipoma, but don’t expect us to classify it or tell you if it’s a benign or malignant mammary neoplasm on cytology. That’s a job for histopath.

Also if you absolutely want a cytologic grading on a MCT because you’re planning to use Stelfonta, maybe ask for that in the history. My lab has us do that routinely if possible, but not every place does.

Try not to stain the best slide if possible when you’re looking at slides yourself. Our lab stain is more predictable which makes our jobs easier. We can and do look at diff quick slides all day so if you do stain the best one it’s fine, but I prefer slides stained in the lab every time.

FLUIDS YOU WANT CYTOLOGY ON GO IN PURPLE TOPS. Always. Please. Not white tops or red tops because the cells will clot in those. They want a white or red for culture so send those along too but give me a purple. And if you make your own slides of said fluid and you DONT send a tube, please tell us whether you concentrated it or if the slides are in concentrated direct smears. If you don’t say I can’t confidently give you a slide cellularity estimate and effectively classify the effusion.

 

[Drjc1977]

Currently still in school, but after one of my cardiology proffs mentioned that sometimes GP and even ER will refer out DMVD stage C dogs out for an echo with a cardiologist when the cardiologist wishes the GP/ER would take the radiograph. It got me thinking that I'm sure there are plenty of these instances where a specialty doctor wishes GP would do X, Y, or Z before the consult. So my question is, what can GP do a better job of before referring pt's out for any specialty consult service?

If a GP is not sure of a diagnosis or how to manage a given disease, then it should be referred. Another wrinkle to consider in this is the possibility of a malpractice suit. If a case goes bad, though appropriate treatment was administered but a poor outcome resulted, the lawyer can argue the case should have been referred. Unfortunately in today's litigious society, one is forced to practice defensive medicine which is more costly and to nobody's benefit except for the attorney. When I started in practice many years ago, if a case had an unfortunate end result, the client and I shook hands, The client would say, "Thanks Doc, I know you did your best." Today, I have had people in my office hoping to hit the malpractice wheel of fortune. Sometimes the GP has no real options but to refer just to cover their ass. So sad.

 

[that redhead]

If a GP is not sure of a diagnosis or how to manage a given disease, then it should be referred. Another wrinkle to consider in this is the possibility of a malpractice suit. If a case goes bad, though appropriate treatment was administered but a poor outcome resulted, the lawyer can argue the case should have been referred. Unfortunately in today's litigious society, one is forced to practice defensive medicine which is more costly and to nobody's benefit except for the attorney. When I started in practice many years ago, if a case had an unfortunate end result, the client and I shook hands, The client would say, "Thanks Doc, I know you did your best." Today, I have had people in my office hoping to hit the malpractice wheel of fortune. Sometimes the GP has no real options but to refer just to cover their ass. So sad.

To be fair, as you say in your first sentence, I think referral should always be offered in cases where the GP doesn’t know how to proceed, or doesn’t feel comfortable proceeding. But I also think it’s fair to offer referral even in more routine scenarios; some people want that specialized care and can pay for it. I understand we want to keep business if we can do it ourselves but I think the practitioner needs to really reflect on themselves and their practice and be honest that (assuming client would go for it) they’re giving the best possible care the patient can receive. For a lot of old timers, they don’t doubt their ability; not saying they should, but perhaps acknowledge that there may be better available care for a tough case and give owners the option. Not even having the option and then finding out later I could have seen a (xyz) specialist would piss me off too.

 

[cdo96]

And if you look at a slide and think you saw something weird or that you’re concerned about, for goodness sakes SEND THAT SLIDE IN and tell us you saw something on that slide that worried you. Then we can make sure we found what you saw to address your concern and then educate you on whether or not it was significant or not. The cells might not be on the other slides.

can confirm, the cytology I sent that the description said “stained slide labeled ‘slide 2-funky cells’ has several cells that are funky in appearance and irregular” gave the pathologist the slides they needed to give an official diagnosis 😂

 

[cdo96]

Not a specialist yet, but ECC resident:

If you suspect a hemoabdomen or something that is very very bad, you should at least tell the owners of your suspicions. You can absolutely tell them to refer to us for more diagnostics, but I can’t tell you the number of dogs that I diagnosed with hemoabdomen by sticking a needle in the abdomen and then immediately euthanized because the owners didn’t know (or said they didn’t know) that it was likely cancer. I call them transfer to euthanize. They suck.

Agree with trilt. Always call before sending things because I will almost always give you a rough estimate. I had one rDVM write in their record they sent over ‘ER DVM quoted 5-7K, quoted 3-4K as a more reasonable quote’. You know what I did? I euthanized the pet when they couldn’t pay the quote I gave them.

If you send a patient to ER, always send records with them. Send any previous bloodwork, even if it’s from a few years back, especially if it’s a kidney pet. Please send rads too- if you can’t send digital rads, then give the owners a CD copy that they can bring with them. Otherwise I have to repeat radiographs, spend more of the owner’s money on unnecessary tests, and that makes nobody happy.

Personal pet peeve: not every sick animal, or critically ill animal needs to be euthanized. Owners will often ask you for your input, and that’s okay. They know you, they like you, and I’m the mean dr who takes their money and tells them scary statistics. You can give your input, but remember that septic abdomens, pyothorax, ventilator patients, etc CAN pull through. You don’t have to condemn an animal because it’s something you’re not comfortable treating. Maybe it’s still the optimist in me, but 99 times out of 100, I wouldn’t be doing what I am if there wasn’t a chance it could improve. Sometimes owners just need someone else to tell them they’re not crazy for trying.

 

[Vannandy]

Riding the ER train. Please don't drag things out and at the end of the week transfer on Fridays (classic transfer Friday dumps.) If your patient isn't doing well and needs hospitalization and needs to see a specialist then send them over. Weekend services are likely limited so we can't fully work cases up till Monday.

 

[cdo96]

Riding the ER train. Please don't drag things out and at the end of the week transfer on Fridays (classic transfer Friday dumps.) If your patient isn't doing well and needs hospitalization and needs to see a specialist then send them over. Weekend services are likely limited so we can't fully work cases up till Monday.

ooh yes, and also don’t wait to transfer until the end of the day. I can’t count the number of times I heard that they went to their rDVM at like 9 am and then they didn’t actually transfer until 5-7pm when their hospital was closing and all of my specialists are gone.

Once had a third degree AV block on a Friday that sat on fluids all day at the rDVM until they transferred to us at like 6 pm, got to us at 7pm, wanting a pacemaker. And then the owners were mad they couldn’t get a pacemaker that night (but actually would have been able to get one that day if they had been there like 5 hours early)

 

[cdo96]

Riding the ER train. Please don't drag things out and at the end of the week transfer on Fridays (classic transfer Friday dumps.) If your patient isn't doing well and needs hospitalization and needs to see a specialist then send them over. Weekend services are likely limited so we can't fully work cases up till Monday.

same vibes as well: had an rDVM blow every single accessible vein but the jugular, and then once they blew the last saphenous said “welp go to X hospital since we can’t help you anymore!”

don’t do that.

 

[Doctor-S]

I really LIKE reading this thread because many of these vet medicine issues are also applicable to human medicine.

With that in mind, I'll mention:

1. The rGP should review the specialist's findings, results and recommendations when consult reports arrive from the specialist. In human medicine, there is potential liability in failing to read and/or act on a specialist’s evaluation. Since the GP is the referring doctor, they're a vital member of the patient's medical team. The rGP can contact the specialist if there are additional questions about the patient’s specific diagnoses and/or medical care. Maintain open lines of mutual communication, as needed.

2. The rGP has a professional duty to provide information about the patient’s current situation, as well as supplying accurate medical records, test results, and other relevant documents to avoid duplicate effort. If the patient's notes (e.g., EMRs) are inaccurate, this will likely cause time-consuming duplication of effort. Many times, rGPs will blindly rely on other office staff to enter EMR info and history - and significant errors can (and do) occur. It is my professional policy to review important findings and notes that I suspect are inaccurate because I don't automatically believe the accuracy of everything that I read from a referring doctor - given that I have received many notes and records that have been inaccurate. When this occurs, I often have to order re-testing all over again which is time-consuming and distressful for many patients. Once again, I have no problem contacting the rGP if I have questions/concerns about anything.

 

[Drjc1977]

To be fair, as you say in your first sentence, I think referral should always be offered in cases where the GP doesn’t know how to proceed, or doesn’t feel comfortable proceeding. But I also think it’s fair to offer referral even in more routine scenarios; some people want that specialized care and can pay for it. I understand we want to keep business if we can do it ourselves but I think the practitioner needs to really reflect on themselves and their practice and be honest that (assuming client would go for it) they’re giving the best possible care the patient can receive. For a lot of old timers, they don’t doubt their ability; not saying they should, but perhaps acknowledge that there may be better available care for a tough case and give owners the option. Not even having the option and then finding out later I could have seen a (xyz) specialist would piss me off too.

Always give the client the option!

 

[battie]

Going to repeat: please call before sending to the ER. Because of significant staffing issues, my hospital is significantly limited Saturday through Monday night. As in we can't take surgical or significantly critical cases likely after 2 or 3 depending on the case.