I need to vent...politics of private practice

[hubcaps]

So today, I was accused of "poaching" patients by a PCP.

Here's some background information. I'm an ID NP and we were referred by this PCP for a pt that needed HIV care. I've been co-managing this pt with one of the docs in my practice. We started this pt on a new drug cocktail and after a few weeks he developed neuropathy/myopathies. So I referred him to a neurologist that is part of my medical practice, who has experience with HIV related neuropathies. This patient continued to complain of pain and our ID nurse gave him a pain referral. The patient eventually goes to the ED for worsening pain and I did the initial consult. I briefly introduced myself to the PCP and said that it was nice to finally meet him. He did no say much except that he would like to talk to one of the docs in my practice that day. I said that one of them would be rounding in the hospital the next day, but he said he had to talk to them that day. This made me feel very uncomfortable. If he had a question about the patient, then I would attempt to address it and if not I would have called/texted one of the docs.

So today, he ends up talking to one of my docs and said that I was poaching his patients. He said that referrals should be made to members of his group and not my group. That was not my intent. I have no financial interest with internal referrals. Also,my patient was asking me for care that was presumed to be related to his HIV. I wasn't trying to manage healthcare needs that was unrelated to his HIV. It frustrates me that my intent was to get my patient the best care and to be accused of selfish gains.

I really want to confront this doc, but it's best not to rock the boat. Do I just avoid him and defer all communication with him to my docs? The politics of private healthcare is really wearing me down, which is all new to me. My RN experience was at a large teaching institution, and my NP clinicals were in underserved areas, mostly supported by grants and fundraising. I just want to take care of my patients! Thanks for letting me vent.

[BostonFNP, APRN]

I can see your frustration and it is understandable, you were doing your best for the patient.

I also can see the PCPs frustration. It is not just about financials it's about effectively managing the patient. I would speak up as well if I referred a patient to a speciality and they stated referring that patient to other specialities without communicating with me as the PCP.

[TammyG]

When I worked with a consulting provider group, we were extremely, extremely careful not to step on toes of the PCP that referred to us. Even with med adjustments, we always called the PCP and let them know what we were doing. Some of them could care less and just said "do what you want and don't bother me." But most appreciated the call and also appreciated the opportunity to weigh in and approve the orders. It was rare that we had one that did not approve whatever we suggested. We would never order another consult ourselves, just recommend (or get approval from the PCP first). It was explained to me that proper protocol as a consulting provider is essential if you want to keep getting referrals. A lot of it makes no sense, it is just the way it is.

[scottaprn]

If I were the pcp I would be upset for 2 reasons. First of all the referral without consulting me and second of all the fact you came onto a public forum and insinuated that the referral he wanted was due to financial reasons. the second one is a very serious allegation.

I work in a specialty practice and we always check with the pcp on referrals. The pcp often will say they don't care but sometimes they do. you may find out later that the doctor ypu referred to has a skeleton in his closet you don't know about. Or maybe the pcp wants referrals inside his group so he can track down the treatment plans easier than from an outside doc. Maybe the specialist in the group have a better work in relationship for a million different reasons. For you to say the reason was financial without any proof is worse than the referral if you ask me.

and get used to the politics. they will be around long after you retire.

[BlueDevil, DNP]

I also agree with Juan and Scott. I am a PCP with a closed multi-specialty group, and it does hurt me financially when patients are referred outside the group, since I have a significant interest in profit sharing. More importantly, it hurts the pt because care becomes fragmented. I'd have been irritated too, Difference is, I'd have addressed you directly.

The doc was right to complain, since it is in his groups financial best interest to keep specialty referrals within the group. If they didn't have the specialty available, that's one thing, but if they do, by all rights, the patient should be seeing someone in their group. It is much better for the patient in the continuity of care aspect. Nevertheless, by their very nature, referrals are the PCPs call to make, not yours. They should be choosing, along with consulting the patient, whom is selected for referrals, not outside consult providers. There is a PCP in my office who's background is pain management, but an ID provider I referred a pt to probably wouldn't know that. We also have a provider with a strong ID background in our office, but a neurologist outside my office couldn't know that. This is why referrals must be left to the PCP. I expect outside consults to send me a copy of their notes, which include suggestions. I have come to expect this, because this is how it is always done! It is the protocol. I have gotten such letters from consults done at Mayo, Cleveland clinic, and Boston Children's Harvard fellows. None of them has ever presumed to make the referrals themselves. It simply isn't done. In the case of your patient, I could have kept that patients pain consult within 30 feet of the exam room, which is definitely in the patent's best interest. And yes, mine as well -which is perfectly ethical.

Unless one is neglecting the best interests of the patient, maximizing profit is nothing to be ashamed of. I don't understand why you would try to turn this into a criticism. PCPs already make less salary than their specialty counterparts, many of us depend on profit sharing to make up the difference. That isn't ignoble. If one was sacrificing the patients best interest in pursuit of profit, that is something else, but that was not the case here. Their group apparently had the necessary providers available, and no one can argue that a patient is better off without 3rd and 4th parties putting their hands in. That is how major mistakes occur. Too many cooks spoil the broth. The PCP is the gatekeeper for a reason, it is safest and most expeditious for patients.

That said, your real complaint should be that the PCP did not address his concerns to you directly. I would not tolerate that level of disrespect, and I must disagree with Zenman here, I would confront him about it. As long as NPs put up with that kind of blatant disrespect, the longer the profession is held back. "In the future Dr, if you have questions or concerns about my practice approach, you would do better to address me, not my colleagues." You sound too much like you are practicing apologetics when you refer to "my docs." You are their equal, not their subservient. Act like it and you'll be treated like it. No one would treat me that way more than once, I assure you. I admit that is hypothetical, since no one ever has. I find it astounding really.

That PCP should have the communication skills at this point in his career to explain to you why he felt your action was inappropriate (and I agree that it was), and you both could have learned something from the exchange. The real shame of it is that that learning opportunity was lost. Now all you both have managed to do is burn professional bridges, which is a huge, unnecessary, disadvantage to everyone.

Bottom line, he has poor interpersonal skills, but better communication with the PCP from your office is critical.