When are you okay with losing a patient?

[DILLIGAF]

Advertisement - Members don't see this ad

Hello all!

This is something I was discussing with another local doctor a few days ago, and thought it might make for interesting discussion....and I am especially eager to hear from any of the OMD's or OD's that are in larger practices about it. Anyway, here is what sparked this:

62 yo WF, a diabetic for 20+ years. The practice has been seeing this woman for 15 of them, and comes in for a 6 month f/u. She has had stable non-prolif DR for 6 years, and this visit showed a few new hemes, a few of which were much higher up in the retina (flames) than on previous visits. I wanted to know how established they really were, extent, etc, so I referred her to a local OD/OMD joint group for a FA.

Well, they kept her. After 2 weeks, I had a few calls made that were not returned. Eventually, I got an email that stated what had occurred in the visit (I.E. pt reported for a FA, thanks for that), and no interpretation of the test. I saw her son a month of so later, who told me that his mother was instructed to go only to them from now on to manage her diabetes.

Now, obviously this case is a little over the top, but it made me wonder...when is it ok to turn the patient over to a specialist for good?

For me, it goes a little like this:
PDR ---> when I see neovasc, it's retina guy time of course. If it is stage 3 or above, if I ever get vitreal bleeding, or if I see clear beading. (That one, it seems to me, is a little bit foggy. In my time, beading equals soon to be PDR, so its out of here.)
GLC ---> Really only when going out for surgery, and even then I expect to see them back. Also, GDx testing or other very high-dollar tests. Is this normal? An OMD friend of mine tells me he gets referrals from several OD's if notching or NFL defect is seen at all. Why? Is THAT normal?

Any input for any other conditions would be appreciated. Basically, when can a patient leave for good, and you still be okay with it?

 

[thiaeyemd]

I am an oculoplastic surgeon and honestly I have no interest in keeping any patients that are referred to me from an OD or other ophthalmologist. Ideally someone is sent over with a problem, I treat it and send it back. I don't do comprehensive ophthalmology so maybe that is why. I am in a multispecialty group and even then I send the patients back. Sometimes a patient will come to our office and say "well to be honest I am unhappy with my doc so I would like to see someone here" I tell them that my practice works on referrals and if they see someone here it hurts my practice and I ask them to do me a favor and see their referring doc back once.If they are still unhappy then they can do what they want. If you think about it, why would I be interested in keeping the patient? How is doing one comprehensive exam worth losing a lifetime of referrals from someone.

I do know that glaucoma specialists tend to complain that OD referrals are usually sent very late in the game when a patient's nerve is .99999 and their field is absolutely terrible. Surgery in that case may be helpful to save a little vision but the house is already mostly burned down. Plus the nerve can get snuffed from surgery..I could see how they may want to follow the patient after for a long time. I am not a glaucoma specialist but I could see that point. I think once you are at a stage of getting a trab or tube, it may be better for the surgeon to follow them. I know if that was my mother (who does have glaucoma) I would want that. She sees a glaucoma specialists in the city and I dont follow her at all even though I could. The reason... I wouldn't want a waste of 1 day between me seeing a field change and then sending it out, the field repeated by the glaucoma specialist and then getting booked for surgery etc. or if she has had a trab and her pressure is creeping up and I repeat the field etc.. At the point someone is thinking about doing surgery a ton of NFL is lost...if it was me I wouldnt want to waste any time in the transfer of care losing more NFL on maximum therapy..Just my opinion...

I don;t think most retina specialists want to watch NPDR etc...that is really boring and low yield for them. Sort of like when I get a referral for someone with blepharitis...like what am I going to do with this? Whichever this group is either a. doesnt realize it was your patient and was referred or b. the patient told them that they didn't want to see you anymore and the son was sugarcoating or c.are a wierd exception and illogically feel it is better to lose a career worth of referrals so they can follow one patient.

The question is have is how do you tell a referring doc that they mismanaged the patient without upsetting them etc.. so they don;t stop sending you referrals again?We have talked at length and most of my friends who are specialists either don't say anything or just try to sugar coat it like " Hey...I could see how you thought that" or "Its a tough diagnosis to make". I have found that the ODs are much more sensitive that the OMDs about this and I can frankly be more honest with the OMDS and tell them that they f)(*(#ed up and they don't seem to care. If I say that to an OD they are pretty much never going to send me a patient again. If someone could tell me what to say or what would be something someone said something to them in that situation they would say "Hmmm..i shouldnt have done that" instead of "Well I guess I will never send a patient to that guy again" I think it stems from the older relationship between ODs and Ophthalmologists but that is just conjecture...

 

[Visionary]

I've stated on here before that, because of the situation in my town, I really don't get referrals from optometrists. I can, however, speak to my behavior with referrals from other ophthalmologists. I always focus on the retina problem that prompted the referral or emergent visit. Any general management remains with the referring doc. In addition, I will also make the referring doc aware of potential issues that they should address, such as posterior capsule opacification, IOP elevation in a glaucoma patient, cataract progression (perhaps in relation to steroid injections I've given), need for refraction, etc.

The anecdote you share here is a great example of how to decrease your referral base. Such behavior is unprofessional. I, honestly, wouldn't fault you for never sending that doc another referral.

 

[Meibomian SxN]

Any input for any other conditions would be appreciated. Basically, when can a patient leave for good, and you still be okay with it?

Damn, that was foul. Hopefully in the future you can try to establish a relationship with an ophthalmology practice that does not engage in unethical practicing like that. That patients heme's could have been examined just as good with OCT. And I am sure the surgeons weren't going to start giving her invasive treatments for a few hemes.

I tend to refer for surgery only or surgical consults. But even with that you run the risk of patients jumping ship or other docs stealing. Best of luck!

 

[DILLIGAF]

I think eyemd brought up an interesting point that I have noticed as well, but for me it is a different factor that seems to get me disgruntled referrals....AGE!!!

In my experience, a lot of the OD's that I work with are those that came up with me in this area. I have known them for a decade or more, and I know their style, know their patient base, etc. As far as OMD's, I worked with the same core for years that was a long distance away. A few years ago, a new joint practice showed up a little closer, and I send a of ancillary testing there (with mixed results, as my original post noted) while keeping the actual surgeries to the team I have worked with for 15+ years. As a side note, I think this is the root of why I have lost a few pt's to the new kids on the block. I do not mean to sound off-putting, but the established docs I sent surgeries to for years have much more experience, much better CV's, better outcomes, etc. In short, I TRUST them. I think the new kids have taken some offense to this.

Insomuch as my original idea, it seems that I get along just fine with OMD's or OD's just fine, in my own age cohort or above....but I have had some run-ins with younger docs of both degrees. I feel that many of the younger OD's have a little bit of insecurity, and do exactly what eyemd mentioned. With this said, a few of the younger OMD's at the newer practice have a huge Superman complex, and seem to be very territorial.I.E. No OD knows more than them, about anything, ever. Other MD's are lesser peers, you get the idea....but I have come to think this may just be the personalities of a few bad apples at that place. Not sure that a few young bucks can speak for an entire profession, up or down...but it is something that I have noticed.

As for the doc I sent the woman to, I recently got her back. (She is low vision in one eye and that got botched by the people at the Goliath that stole her, came back for a scope + reading cap fit, for good I am hoping) I have found a few docs over there that are much more professional, but it has been difficult to know which doc they will actually see. (No matter how emphatic I am in writing, "please see Dr. X", they just give them to whomever) I am trying to siphon pt's away from them slowly, without it looking obvious. The old boys that are a little further away are awesome doctors, and the extra half hour drive is worth it for my patients...

I guess I can end with a more direct question that actually effects my current situation: What kind of things have happened to others when they stopped sending pt's to a certain place? How does that come back, especially in a rural area? Do most docs "rely" on a few select surgeons, or is a "surgeon a surgeon?"....(I.E. EVERY trabeculectomy I have ordered in the last ten years has gone to the same guy) I feel like I am perhaps being a little old school on that. Thanks all.

 

[Visionary]

No matter how emphatic I am in writing, "please see Dr. X", they just give them to whomever.

That sometimes happens in large practices. The docs have developed a policy that new referrals are spread between the docs (e.g., all go to Dr. A on Monday, Dr. B on Tuesday, etc.), in order to benefit all in the practice. Not saying it's right, but it may explain your experience.

 

[mclem222]

I send things out to different OMDs and basically get the patient back after whatever the issue I sent it for. I have rarely had a problem. I did have one guy I sent out for a SLT and the glaucoma specialist told the patient he didn't need it and didn't have glaucoma and sent him back..Kinda annoyed me...

 

[JMK2005]

I send things out to different OMDs and basically get the patient back after whatever the issue I sent it for. I have rarely had a problem. I did have one guy I sent out for a SLT and the glaucoma specialist told the patient he didn't need it and didn't have glaucoma and sent him back..Kinda annoyed me...

Instead of being annoyed, I would think it be an opportunity to discuss with the glaucoma specialist about differences between your and his management.

 

[mclem222]

I did...The guy was a -15 myope with IOPs in the teens, C/D 0.7 and normal HVF. I had him on travatan to bring his IOP to about 9-10 but he didn't want to be on the drops anymore so I thought an SLT would buy him some time. The OMD said he thought it was physiological cupping and didn't need the procedure.

 

[ABaverage]

I did...The guy was a -15 myope with IOPs in the teens, C/D 0.7 and normal HVF. I had him on travatan to bring his IOP to about 9-10 but he didn't want to be on the drops anymore so I thought an SLT would buy him some time. The OMD said he thought it was physiological cupping and didn't need the procedure.

With IOPs in teens and normal HVF.. it doesn't seem that you would need to put a patient on Travatan. What would you do to prevent referring a patient out on weak grounds? Perhaps an OCT next time to access the RNFL? C/D is large, but that doesn't dx glc. Perhaps he has always and will always have a 0.7.

 

[JMK2005]

I did...The guy was a -15 myope with IOPs in the teens, C/D 0.7 and normal HVF. I had him on travatan to bring his IOP to about 9-10 but he didn't want to be on the drops anymore so I thought an SLT would buy him some time. The OMD said he thought it was physiological cupping and didn't need the procedure.

The transition glaucoma suspect to glaucoma is not clear cut. Myopic nerves makes it even more difficult difficult.

I've been taught to talk in positive terms about the referring doctor. Good for everyone involved.

On the flip side, if I am referring out, I tell the patient that it is for an evaluation and leave the treatment options open-ended including observation. This lets the specialist render his own opinion and not look like the bad guy if he chooses not the treat.

If a patient expects an SLT and doesn't get one, it leads to disappointment even if it may be in the patient's best interest.

 

[Zorro12]

I did...The guy was a -15 myope with IOPs in the teens, C/D 0.7 and normal HVF. I had him on travatan to bring his IOP to about 9-10 but he didn't want to be on the drops anymore so I thought an SLT would buy him some time. The OMD said he thought it was physiological cupping and didn't need the procedure.

Cases such as this are no wins for the OMD. On the one hand you want to keep getting referrals, but on the other hand you need to do what you feel is in the best interest of the patient. Contrary to what is written in the throw aways SLT is sometimes not a benign procedure. If the OMD feels the patient had physiologic cupping that is his opinion, and rendering an opinion is the job of the specialist.

You sent a patient to a glaucoma specialist who said the patient didn't have glaucoma and it "annoyed" you. Instead of being annoyed maybe you should re-evaluate what you are doing for the patient and consider that the person that stares at visual fields and optic nerves all day may be right. Patient's stated IOP is in the teens. Lets say 16 for fun. You have set a target IOP of 9-10, or close to a 40% drop in his Tmax. What prospective randomized trial gives the evidence base to set this target in a person who does not have glaucoma and has normal IOPs? A target of 9-10 is unrealistic and is usually only needed in patients with the most advanced damage. If you don't get 9 with one med do you Rx 2? 3? 4? If only on one prostaglandin analogue the patient (or insurance) is paying $100 a month, which adds up over a life time. If I had seen the patient all of this would be going through my head. Of course coming out my mouth would be, glaucoma grey area blah blah blah everybody has a different threshold to treat blah blah would go back to Dr. X blah blah wouldn't worry blah would observe off gtts if it were me blah blah. But you would get the patient back. My/our practice rule is referrals all must see their referring OD/MD at least once and we don't set up a follow-up with us unless it was planned in advance with the referring doc, or if it is a problem for us to deal with until treatment is complete.