Why is this so difficult ...

[DD214_DOC]

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1. Medication started about 2.5 years ago had a very significant effect in reducing symptoms of concern, with a dramatic improvement in areas of function previously impaired due to symptoms. Dose of medication is considered on the lower end, with plenty of potential room to increase if needed.

2. Patient has a very long period of improvement and stability with this medication and dose that was well tolerated and maintained for the past 2.5 years.

3. Now, patient had a return of previously-controlled symptoms despite continued use of the same medication and dose.

Most logical intervention?

I: Throw up hands in confusion and helplessness and refer to subspecialist for management. Naturally.


I don't get it, and this happens a lot. Why is this so difficult to figure out? Even completely ignoring the diagnosis, medication, and dose, does logic not demand you consider the obvious?

 

[erg923]

1. Medication started about 2.5 years ago had a very significant effect in reducing symptoms of concern, with a dramatic improvement in areas of function previously impaired due to symptoms. Dose of medication is considered on the lower end, with plenty of potential room to increase if needed.

2. Patient has a very long period of improvement and stability with this medication and dose that was well tolerated and maintained for the past 2.5 years.

3. Now, patient had a return of previously-controlled symptoms despite continued use of the same medication and dose.

Most logical intervention?

I: Throw up hands in confusion and helplessness and refer to subspecialist for management. Naturally.


I don't get it, and this happens a lot. Why is this so difficult to figure out? Even completely ignoring the diagnosis, medication, and dose, does logic not demand you consider the obvious?

Psychosocial factors? Motivation? External incentives? Etoh/drugs?

 

[Shikima]

Psychosocial factors? Motivation? External incentives? Etoh/drugs?

I think it's in reference to the manner of the child being sent back to him after a substantial period of stability without a good reason.

 

[nexus73]

Patient stopped the meds?
Antidepressant poop out?
New biological or social stressors?

Assure they're in therapy, off illicit drugs, have no new medical issues, and maybe bump up the med dose?

To be fair to the referring doc, PCPs don't do 3 years of psychiatry. Or even any psychiatry necessarily, outside of the typical stuff that wanders into their clinic where they are supervised by attending PCPs, and certainly no child psychiatrists. At the end of the day it's good for job security. I don't think anyone refers to intentionally make you busier; they're out of their comfort zone.

Could also be chronic lyme dz.

 

[Shikima]

There are plenty of PCPs who diagnose and treat ADHD and can prescribe stims.

 

[F0nzie]

Those referrals are gold! You may be underestimating your knowledge and experience in child psych...a thorough psych eval may even reveal that meds are not the only treatment of choice.

 

[DD214_DOC]

Interesting responses.

For the record, nope. It was ADHD and tolerance to the medication. I slightly increased it to the next higher dose and voila, back to doing wonderful without any problems or concerns. This was my first encounter with the patient and everything had been managed by primary care up to that point.

Completely unnecessary referral that could have been both prevented and addressed 2 months earlier by common sense, or a simple email/phone call.

 

[FlowRate]

Completely unnecessary referral that could have been both prevented and addressed 2 months earlier by common sense, or a simple email/phone call.

This is one of the big things that I think is appreciated more when you've had to wait for a referral for something that was affecting function. 2 months is a long time. For anyone in any part of school, two months is a very long time.

 

[calvnandhobbs68]

This is one of the big things that I think is appreciated more when you've had to wait for a referral for something that was affecting function. 2 months is a long time. For anyone in any part of school, two months is a very long time.

I agree, a slightly more logical approach would probably have been to up the dose while referring at the same time if the PCP felt he/she was getting out of their comfort zone. That way they could have the psych eval for a more in depth evaluation if they wanted to while also hopefully trying to alleviate the symptoms instead of the kid waiting and probably doing crappy in school for two months on a suboptimal dose, especially with ADHD meds. Have the family call your office if the side effects get too wild and you can turn the dose back down...you have to write the prescription every month anyway.

 

[st2205]

Speaking in terms of waiting times, it's not uncommon to get a patient where the appropriate step is simple. Because of their long wait of getting in to clinic, however, they develop an expectation of some kind of grander or more elaborate plan to take place. They may find the simple answer off-putting and insulting to what they feel was the sacrifice and anticipation of 9 months of suffering to get into the clinic. This often can lead to patient frustration and nocebo response.

 

[smalltownpsych]

This would be a good example of where a phone call between docs would have been helpful. There is always a lot of talk about the importance of collaborative care, but if we can't bill for it, then it is not going to happen. Why can lawyers bill for their time on the phone and we can't? Not just talking to other docs, but occasionally talking to patient or family member of patient on the phone, as well.

 

[DD214_DOC]

This would be a good example of where a phone call between docs would have been helpful. There is always a lot of talk about the importance of collaborative care, but if we can't bill for it, then it is not going to happen. Why can lawyers bill for their time on the phone and we can't? Not just talking to other docs, but occasionally talking to patient or family member of patient on the phone, as well.

You can bill for this

 

[smalltownpsych]

You can bill for this

My understanding is that you can bill for it, but insurances won't reimburse and that seems to drive the market more than anything else. I have had discussions with people in the past about whether or not it is legal to bill insurances for a phone session with a patient (where you are actually providing treatment) and how one would code that, and the answer is usually that you can't.

edit to add: As I look at what I said it seems redundant to have to say that I was providing treatment to patient on phone, after all, why else would I be talking to them?

 

[DD214_DOC]

My understanding is that you can bill for it, but insurances won't reimburse and that seems to drive the market more than anything else. I have had discussions with people in the past about whether or not it is legal to bill insurances for a phone session with a patient (where you are actually providing treatment) and how one would code that, and the answer is usually that you can't.

edit to add: As I look at what I said it seems redundant to have to say that I was providing treatment to patient on phone, after all, why else would I be talking to them?

True. I work in a land where RVU's generate pretend money, so everything counts!