I need to vent...politics of private practice

zenman · Jul 17, 2014

Blow it off and let your doc take care of it. Go have a glass of wine and worry about more important stuff.

Advanced Practice Columnist / Guide · Jul 17, 2014

My take on this is that specialty referrals for whatever reason should be initiated by the PCP. The PCP referred this patient to you for management of his ID issues. As a courtesy, you would call or write a letter to the PCP explaining your ID plan and any other recommendations regarding his care (i .e., Pain Service or Neurology referral). The PCP is the gate-keeper in a sense and in keeping with the spirit of that relationship, I see why he felt slighted. I would talk to the physician you work with and see what he thinks and go from there.

hubcaps · Jul 18, 2014

Thanks for the response Juan. I totally understand what you are saying. I just felt that the PCP was more focused on his self interest than the patient. He wasn't mad that I made the referrals, but rather that they were not part of his network. Also, I have taken care of many of his patients and this was the first time this had happened. How can you accuse me of poaching if it happened once?

I'm very careful about over stepping my bounds. Our practice has many patients who ask for treatment that is outside of ID, and we always tell them to see their PCP. I felt that this situation was different because his pain was very likely related to his HIV. Also, the patient came to us. If I thought the pain was due to other causes (e.g. trauma), then I definitely would have told him to see his PCP. Should I have just told his PCP to make a referral to a neurologist? Maybe, but his group doesn't have ID and therefore very unlikely that the neurologist manage patients with HIV. Could I be wrong? Of course. But my group for sure has a neurologist that deals with HIV related symptoms. I did not want to delay treatment because this patient has a history of inconsistently taking his medications and as a result has developed significant resistance. I was afraid that he was going to stop taking his medications if his pain issue was not address.

I would have a totally different reaction if the PCP was advocating for his patient rather than his own group. I know that I am a bit naive/idealistic (i.e. wanting to just care for patients and not caring about the business side). I'll admit that I made a mistake that I did not check the PCP's group/network, which is not easy given a 20 min time slot for my patients. FYI, googling the PCP reveals his own private practice, but not the larger network that he is part of.

hubcaps · Jul 18, 2014

Zenman,

Thanks. Enjoying a nice glass of beer right now.

Advanced Practice Columnist / Guide · Jul 18, 2014

I work in an academic setting with a closed medical group model. But even here, I would have been pulled aside and given a friendly lecture on why the primary team should be addressing all referrals and not me as a specialist if this were me. The reaction, however, wouldn't be passive aggressive like the way this PCP reacted. I am also in no position judge his motivations, just the actions you made and described.

Not to beat a dead horse, but what has always worked for me is keeping two-way communication open with primary teams. Always communicate your plan to referring sources and elicit confirmation that they are in agreement with that plan as a courtesy. This, like I said previously, is the spirit with which specialty referrals should operate. Hope your day is better next time.

hubcaps · Jul 24, 2014

Quick update. The PCP called one of my docs and he said he would no longer refer any of his patients to us. This was based on one patient. After reviewing the situation, my doc's agreed with what I did. They said they would have done the exact same thing. As I mentioned earlier, my decisions for referral were based on my expertise as an ID provider. My docs did not think I was overstepping my bounds. Myopathies and neuropathies can be related to HIV and their treatment. I wanted to rule out HIV related myopathies/neuropathies. Juan, I appreciate your response, but I somewhat disagree with your response. I don't think primaries should be addressing all referrals. In my experience, I've seen patients with chronic illnesses being managed primarily by their specialist. In my previous career as a peds CVICU/PICU RN, our kids with congenital heart defects were primarily managed by their cardiology team. They saw a pediatrician, but everything had to go through cardiology. I could say the same thing about our pulm, hem/onc, renal, etc. kiddos. Patients with chronic illnesses have unique needs that PCPs are not often aware of. In my opinion, the PCP is NOT always the gatekeeper.

My manager said that unfortunately we have to cater more to the physicians than the patients. My original rant was with the politics and business of healthcare today, so Juan I think you missed my point.

core0 · Jul 24, 2014

Quick update. The PCP called one of my docs and he said he would no longer refer any of his patients to us. This was based on one patient. After reviewing the situation, my doc's agreed with what I did. They said they would have done the exact same thing. As I mentioned earlier, my decisions for referral were based on my expertise as an ID provider. My docs did not think I was overstepping my bounds. Myopathies and neuropathies can be related to HIV and their treatment. I wanted to rule out HIV related myopathies/neuropathies. Juan, I appreciate your response, but I somewhat disagree with your response. I don't think primaries should be addressing all referrals. In my experience, I've seen patients with chronic illnesses being managed primarily by their specialist. In my previous career as a peds CVICU/PICU RN, our kids with congenital heart defects were primarily managed by their cardiology team. They saw a pediatrician, but everything had to go through cardiology. I could say the same thing about our pulm, hem/onc, renal, etc. kiddos. Patients with chronic illnesses have unique needs that PCPs are not often aware of. In my opinion, the PCP is NOT always the gatekeeper.
My manager said that unfortunately we have to cater more to the physicians than the patients. My original rant was with the politics and business of healthcare today, so Juan I think you missed my point.

I think that you are missing Juan's point. You are living in the land of ACOs and managed care organizations. If the patient was in an ACO for example, the referrals to neurology and pain cost them money. As far as referrals, I will also disagree. There may have been other relationships that you were unaware of that you infringed on. For example when I did peds GI and we needed to refer a patient to surgery, I always called the referring physicians and would see if they had someone they preferred. Most of the time they were happy for us to refer, but sometimes there was some quid pro quo (they did H&Ps for the surgeon) that would send the patient somewhere else. If the surgeon had good outcomes in our experience that was fine.

I also agree with Juan that the PCP should be the gatekeeper. While you might know more about you subject, the PCP should have a better overall view. What if they had changed a BP med that was known to cause neuralgias. What if they had previously seen a neurologist or pain specialist and had a prior relationship. Hopefully you asked these questions but the PCP should know.

Finally, while peds specialists may manage all aspects of a patients care, it doesn't usually work that way for adults. Many insurance companies mandate the PCP handle all referrals. Also, having been on the receiving end of those patients transition to adult care, it usually works out poorly for the kids. Their lack of having a PCP gatekeeper impacts their ability to get proper adult care. Our adult congenital heart service sees patients in transition but absolutely refuses to do primary care. I have also been on the receiving end of this as a specialist. When I did HCV treatment, I essentially became the primary care for these patients as the patient would be referred back for HTN or DM treatment because the PCPs were afraid to interfere with treatment. All referrals were discussed with the PCP though.

While it may seem and probably is office politics, its the reality of medicine. Medicine works as a collaborative effort. While you were trying to do the best thing for that patient, you lost the ability to do the best thing for that referring physicians other patients. Ultimately you don't really know what brought this on. My thought would be the lost money to the referring physicians group which is a crappy reason. However, if you had called and asked if there was a preference for a referral could this communication avoided the whole problem?

Trauma Columnist · Jul 24, 2014

I work nephrology in a private practice. Although there is a nephrology ACO model our practice has NOT endorsed it. We are a large 17 MD, 5 mid levels (NPs and PAs) and we still manage most care.

JENNICURN · Jul 24, 2014

I am curious about how you got into ID? I am 10 months away from graduating from a AGPCNP program and ID is an area I am interested in. In my research it seems like a lot of NPs end up there via some Peds background, which I do not have nor will be boarded for. Any info is appreciated. Thanks!

hubcaps · Jul 25, 2014

Why would the PCP have a better overall view? We always update any changes with the patient (e.g. diagnoses and medication). I can easily argue that we can have better overall view because we understand how HIV/AIDS and their medication interfere with other medical issues and medications better than the PCP. I know of ID practices that manage all the primary care needs of their patients.

My frustration with this conversation is that I am angry that this PCP was more concerned with the finances than with patient care. I completely understand the philosophy of the PCP being the gatekeeper. I am not trying to argue/defend why he shouldn't be the gatekeeper. My view is mixed. I can understand from both perspectives. My venting comes from my frustration that I was criticized for caring for my patient. My intentions were NEVER to overstep my bounds as a provider. I had no personal/financial gain. It is very hard as a new NP to be falsely accused. PLEASE understand that I am not trying to make a point of how referrals should be made. I only wanted to say that I was trying to provide the best care for my patient from my experience and training. I was very hurt by the fact that this PCP wanted to personally attack me. I can understand if I over step my bounds. However, his words and actions have only demonstrated self interest. One "mistake" from my part does not warrant his actions of refusing to give my group further referrals. Once again, this only happened ONCE. I can't help but feel bad that all of a sudden the census in one of our hospitals have dramatically dropped.

I completely understand what you and Juan are saying, but I don't think it applies to this specific situation. I only brought up my point as an example of how some practices function, not as how things should be. I don't want to get into an argument of how thing should be done. There are different ways of practicing healthcare. This PCP did not want to talk to me. He went to my docs with false accusations of poaching patients. He did not say that ID should not be managing his neurological/pain needs. He said I was stealing his patients for my group. I could care less. I have NO financial incentive for make internal referrals.

I wanted to express my frustration with our broken healthcare system. I wanted to express that it hurts to be falsely accused when I just wanted the best care for my patient. Remember, the ID docs in my group AGREE with my actions. My initial referral for neurology was the recommendation of one of my docs.

Should I have called the PCP? Yes, that was another potential mistake that I made. The ID docs in my team alway tell me when I should communicate with the PCP. However, my docs did not think it was needed in this situation. I can understand the different philosophies of care.

hubcaps · Jul 25, 2014

Jennicurn,

feel free to PM me with questions.