When in Primary Care should referral to PM&R occur?

[MSKalltheway]

I'm on outpt medicine right now and after seeing some clinic pts today it got me thinking about when to suggest referral to PM&R. When I get asked the magic question "what do you want to do", should I suggest PT, or physiatry first? Should PT be first line and refer to physiatry if its refractory? Should only more complicated situations go to physiatry?

I figure this would be a good question to ask now as a way to help plant some seeds, and for later obviously when (hopefully) I'm in practice to educate PCP's on how to refer properly. I thank you all for your responses ahead of time.

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[Llenroc]

Back pain, assuming the PCP at least has done a basic exam and a trial of NSAIDS. Also, suspected carpal tunnel syndrome, stroke patients, management of any disability, etc.

 

[PMR 4 MSK]

When they need a more definitive Dx than "lumbago" or "cervicalgia", and/or when then fail to respond to first line therapies such as NSAIDs and PT. Anyone can write for PT, we just do it with more eloquence and verbosity.

 

[Finally M3]

Preferably with any semblance of a workup and treatment. Even a plain ol' OPPQRSTAA would be nice sometimes.

I've been getting a rash of "Patient reports back pain" buried in a H&P, with an assessment of: "Lumbago" and plan of "Spine Center".

 

[oreosandsake]

hey Miss Kathy

as you know i've had issues with my spine since I was in hs.

a few weeks ago I went to my pcp who I highly respect and like, which incidentally was trained at a school that has a pretty good pmr program, with the cc of "I feel like the health of my spine is continuing to get worse. I want to see a spine specialist. also, I think I may need SI joint injections, it hurts here all the time (point finger)"

his response was to suggest an ortho consult, to which I responded, "No no. I've already had the back surgery. I dont want more of that."

and he sorta' had this confused look on his face.

so i continued, "I want non surgical orthopedics. you know? isn't there a physiatrist in my IPA?"

him: "a what?"

me: "a physiatrist. physical medicine and rehab doctor. I want to see someone to talk about the health of my spine. do you know a spine specialist?"

him: "oh. <pause for 3 seconds> we usually refer to ortho"

I spent a little more time trying to tell him that I didn't want the sole opinion from someone that's training was centered around the OR, but it didn't seem like I was going to get anywhere.

so I didn't get a script to see the pm&r doc like i wanted. I think he really didn't know who in the IPA insurance group to refer me to, which is sad. (yikes, please tell me there's one in my group that's good w/ msk)

he ordered bloodwork for autoimmune disease which came back negative.

and I still have yet to see a physiatrist.

but back to your Question, (which i think is a great Q, )

I'm wondering if it would it make sense for pcp's to refer to physiatrists when msk complaints are refractory to RICE?

 

[PMR 4 MSK]

I'm wondering if it would it make sense for pcp's to refer to physiatrists when msk complaints are refractory to RICE?

Any time a doc says "Hmmm, what should I do next?" with regards to a MSK pt, referall to PM&R should be considered. Otherwise, as you indicated, they send everything to ortho or neuro.

Sell PM&R to them as a hybrid of ortho and neuro.

 

[MSKalltheway]

Bump.

I'm doing a morning report on monday for my FM rotation on stroke in a young adult. Would it be appropriate for me to suggest PT only for a stroke patient with minor deficits, while more severe deficits should warrant a referral to PM&R? Or should all stroke go to physiatry as a general rule?

Sure, a shameless plug for the specialty, but I do what I can!

 

[MSKmonky]

Any time a doc says "Hmmm, what should I do next?" with regards to a MSK pt, referall to PM&R should be considered. Otherwise, as you indicated, they send everything to ortho or neuro.

Sell PM&R to them as a hybrid of ortho and neuro.

YOU see!!!! Neurmomuscular Orthopedics!!! why does nobody see the gain in this name-change??!! It will definitely give the specialty more spotlight and credit! C'mon people (refer to "New Name Suggestions" thread)

 

[dc2md]

haha. keep pushing for it MSKmonky!! i still like keeping Physiatry (b/c it's too hard to change that name), but adding "neuromuscular orthopedics" instead of PM&R. although, i always hear non-physiatry residents refer to us as "pmr" instead of physiatry. anyway, i'm off topic here.

MSKalltheway,
I think referral to Physiatry is a shameless plug (haha), but also the right choice. A Physiatrist will be familiar with treating any neurogenic bowel or bladder in this patient. Or any spasticity with baclofen/zanaflex/valium/etc. Or any specific muscle weaknesses that need addressing via PT. We followup with the PT better. We can manage any need for orthotics (for wrist or foot drop for instance). And I'd say we're definitely better at treating any neuropathic post-stroke pain the patient may have. We're much more likely to order speech therapy for the patient with language/speech/cognitive issues after the stroke.

So why did this young person have the stroke?? Was it hemorrhagic or ischemic? Patent foramen ovale? Cocaine-induced hypertensive bleed?

 

[MSKalltheway]

I think referral to Physiatry is a shameless plug (haha), but also the right choice. A Physiatrist will be familiar with treating any neurogenic bowel or bladder in this patient. Or any spasticity with baclofen/zanaflex/valium/etc. Or any specific muscle weaknesses that need addressing via PT. We followup with the PT better. We can manage any need for orthotics (for wrist or foot drop for instance). And I'd say we're definitely better at treating any neuropathic post-stroke pain the patient may have. We're much more likely to order speech therapy for the patient with language/speech/cognitive issues after the stroke.

So why did this young person have the stroke?? Was it hemorrhagic or ischemic? Patent foramen ovale? Cocaine-induced hypertensive bleed?

Thanks for the response my dude. I def addressed the things you brought up in the talk this morning, and went the whole "one stop shop" route.

You know, we have no idea at all how it happened! no hx of illicits, or recurrent abortions. We requested records from her hospitalization, so unfortunately we didn't know the etiology or what workup was done. Looks like the gave her lovenox by her abdominal exam, but didn't come to us on anything but 325mg of aspirin. We were looking to do an ESR, coags, antiphospholipid Abs, ANA etc., but decided to wait until the records came before potentially repeating workup that was already done. Hopefully they'll send them over soon so we know what else we can do!

 

[PMR 4 MSK]

Bump.

I'm doing a morning report on monday for my FM rotation on stroke in a young adult. Would it be appropriate for me to suggest PT only for a stroke patient with minor deficits, while more severe deficits should warrant a referral to PM&R? Or should all stroke go to physiatry as a general rule?

Sure, a shameless plug for the specialty, but I do what I can!

If the pt only has mild purely gross motor deficits, PT may be able to correct them. But if there are fine motor problems, speech or cognitive problems, they'll need more. Again, depends on the comfort level of the PCP.

 

[dc2md]

....We were looking to do an ESR, coags, antiphospholipid Abs, ANA etc., but decided to wait until the records came before potentially repeating workup that was already done. Hopefully they'll send them over soon so we know what else we can do!

Totally off topic, but this is a PERFECT example of why we need a nationally-connected/integrated electronic medical records. This answer to what was done in the hospital would be lightning fast (compared to asking for med records and waiting for them to find the chart, photocopy everything, and send it to you). AND, there wouldn't be ridiculous duplication of expensive tests and need for multiple physician visits. Okay, off my tangent.

Good job with the presentation MSKalltheway. Way to promote Physiatry

 

[SSdoc33]

Totally off topic, but this is a PERFECT example of why we need a nationally-connected/integrated electronic medical records. This answer to what was done in the hospital would be lightning fast (compared to asking for med records and waiting for them to find the chart, photocopy everything, and send it to you). AND, there wouldn't be ridiculous duplication of expensive tests and need for multiple physician visits. Okay, off my tangent.

Good job with the presentation MSKalltheway. Way to promote Physiatry

is everybody else getting more patients coming in expecting that you'd already have all of their medical records (ie: an MRI from out of state or another doctor's notes).

me: do you have your MRI?
pt: no, dont you already have it:
me: no, why would i?
pt: i thought that all of my medical records were all online now. you know, like with obama's plan.
me: that hasnt happened yet. not even close, really.

 

[Ludicolo]

is everybody else getting more patients coming in expecting that you'd already have all of their medical records (ie: an MRI from out of state or another doctor's notes).

me: do you have your MRI?
pt: no, dont you already have it:
me: no, why would i?
pt: i thought that all of my medical records were all online now. you know, like with obama's plan.
me: that hasnt happened yet. not even close, really.

You should have asked if she had that medical record microchip thingy implanted in her yet.

 

[dc2md]

is everybody else getting more patients coming in expecting that you'd already have all of their medical records (ie: an MRI from out of state or another doctor's notes).

me: do you have your MRI?
pt: no, dont you already have it:
me: no, why would i?
pt: i thought that all of my medical records were all online now. you know, like with obama's plan.
me: that hasnt happened yet. not even close, really.

i love it!!! no, i haven't had any patients assume that yet.

but i can't wait until we actually have that sort of system. not looking forward to the national expense of implementing that, but it's gonna be phenomenal having those records in minutes...along with all pharm records to make sure our patients aren't doctor shopping or just plain forgetting to tell us they're on certain meds that might interact.

i'd like to see the VA EMR system that we've already put billions of dollars into, pimped out more (modernized), and given out for free to all practitioners...just pay for the maintenance.

 

[PMR 4 MSK]

is everybody else getting more patients coming in expecting that you'd already have all of their medical records (ie: an MRI from out of state or another doctor's notes).

me: do you have your MRI?
pt: no, dont you already have it:
me: no, why would i?
pt: i thought that all of my medical records were all online now. you know, like with obama's plan.
me: that hasnt happened yet. not even close, really.

All the freakin' time!

I can access many records online - if they had films done at 2 outta 3 of the local hospitals, we have direct PACS access (slow for one, fairly quick tranmission for the other). One local free-standing MRI outfit also gives us logons for their patients.

But if the records are from another doctor's office or the 3rd hospital, I get pts all the time assuming their records were sent when they weren't. One PCP clinic with 5 docs is notorious for sending nothing, then acting so suprised we haven't recieved anything. It's made me consider doing records review for most any patient, just to have them when I see the pt. I send pts home all the time with no Dx, no treatment plan until I get records. I've sorta resigned myself to it.

My favorite is when the pt says "It's in my records" Yes, but I don't have your records. "We'll it's in their, you'll just have to look."

Another recent problem is our clinic clearly telling patients that they need to presonally bring outside films with them, and when they request those films, the outside facility says they'll send them, then doesn't. ARRRGH!