[NPInfo] Physician blogs maligning NP s and PAs another issue

Sun Mar 9 14:32:00 PDT 2008

I also wish to join the ACC. I mentioned it before, and am working at my second job today, but will get back to it right away.  I have a question for the list.  I did not see the original blog, of malignment, but along those lines..I have my own practice.  I do not know if it has anything to do with me being an NP PCP rather than an MD but here is what is happening.  

   I have noticed over and over again, that I refer to Ortho, or General Surgery, or wherever,  and rather than them writing me a nice letter of Consult and sending the paient back to me, they either continue seeing the patient for weeks or months (if they have good insurance) and they are doing primary care visits, not needed for their specialty services, (billing the patients insurance at their specialty rates) ,  or they are referring patients to another specialist. They are breaking the rules.  They upset the patient and confuse them.  I do not know if they tell the patient negative things about NPs, and they do not really know me personally, this is not a personal thing.  But one patient had severe swelling, pain, feeling cold,  and numbness to her left wrist with positve phalens and tinels, and does a lot of repetitive computer work...so I sent her for an u/s to r/o dvt, then emg/nct, to eval for Carpal tunnel synrome.  Initial labs including ana, rf were negative,
 but sed rate was slightly elevated.  I put her on a steroid taper, ice (after dvt was ruled out), splinting, off work, and sent her to ortho. After I referred her to one ortho, the patient called me, and said she called another one on her own, and got in sooner, so now could I send all thepaper work there.  So I had to send another letter to the first ortho doc, apologizing, and cancelling the referral, and then sent another referral letter to the ortho doc that the patient wished to see now.

   Anyway, this ortho doc did not write me any type of letter thanking me for the consult, or did not write me any letter regarding his exam or findings.  He just referred the patient on his own to rheumatologist to r/o lupus... and then tells the patient to come back to him.. I had to find this out, by calling the patient.  This has happened several times, and then the specialist gets a letter from the next specialist, as they were the referring doc, and I get pushed out of the loop.  

  UNLESS OF COURSE, INSURANCE REQUIRES I AS PCP DO THE PAPERWORK. Then the specialist office will call me and tell me to play secretary and do all the paperwork for them.. I really feel that maligning is going on behind the scenes.  I thought about having lunch with these docs, which I will, but there are so many, especially when the patient later tells you, of a certain doc she has seen since childhood.. 

  I have the American Academy of Family Physicians website Consult Form, including the rules.. They are clearly breaking the rules, and it is clearly disrespectful.. The problem is the patient is put in the middle.. and I do feel that being an NP in private practice is part of this passive agressive move that is occuring.. I will continue to remain positive.  I think I am going to answer part of my own question right now... PRIOR  to any referral, I will call the doctor's office and ask to speak to the doctor directly.  This is when i have the most power.  At that time BEFORE THE REFERRAL,  I will let the doc know that I need to be in charge of all referrals as PCP, kept in the loop, and referred back to with findings if specialty care is not needed. I ALSO am going to tell the patient BEFORE the referral they are NOT TO CALL on their own and set up with a different provider as it causes a lot of confusion and fragmentation...The patient clearly can be in charge, and tell
 the specialist what needs to be done, as if they have good insurance they are very powerful.  And the patietns that have gone to private NP practices know, and are very loyal, but the brand new ones are easily influenced if no bond has developed. But these docs MUST REALIZE I AM A GREAT REFERRAL SOURCE and I will not use them again if they abuse this. 

  Just for this one patient I had to fill out several work excuses, medication rxs, the referral letters, the different imaging studies, and the 6 pages of Family Medical leave act that had to be faxed to both her employer and he employers insurance company.  The primary care provider (whether doc or NP or PA, needs to be the hub of the wheel, and the specalists are the spokes).  They are not the one that coordinates the annual exams, all of the meds, the testings, and making sure that all providers associated with the patient are on the same page.  Carla Anderson, FNP-Healing Presence Family Practice, Oregon

jlambertrn at comcast.net wrote:
  Karen,
I echo your thanks to Stephen and David. I agree whole heartedly with you and your thoughts and the fact that much of our knowledge/training is similar to the apprentice concept that has been working for centuries. (Sorry about the run-on sentence; my high school english teacher is probably rolling over in her grave!) As you, I too remain humbled by the amazing amount of knowledge that is out there that we (including docs) need to be on top of. I treat people with respect, and expect the same in return, docs included. For the most part, I enjoy a very collegial relationship with the other docs in the ED where I work. Occasionally, I have to call a specialist for a consult. Most are receptive to me as a NP, however you still run across the arrogant jerk every now and then. I always remember who they are when I am moonlighting in primary care as I frequently do. Does a doc really think I am ever going to refer a patient to him/her after being disrespectful or unprofession!
al towa
rds me? If the offender treats a colleague in that manner, how will he treat my patient? Nope, no referrals for you! 
As far as Panda Bear is concerned, I feel he has way too much time on his hands. His post was long, rambling and most of all B-O-R-I-N-G. One of the AMA's beefs with us has always been "they take patients away from us, and it will affect my ability to earn a living". Does Panda Bear have any clue to the difficulty a patient encounters when he/she calls their PCP on a day when they truly ill and are told that the next available appt. is in two weeks? We see these patients in the ED every day, so there goes the theory of "us" stealing "their" patients. Paaaaallleeeeeze! There are plenty of patients to go around and that is an unfounded, tired, mundane talking point put forth by the AMA and other groups. That argument impacts patients in a very negative manner. Yep, reading that blog, made me get the same feeling in my gut that I get when I have to call that arrogant ENT or surgeon, or whatever. The positive point in all of this is that I LOVE WHAT I DO, and like Peg Fitzgera!
ld alwa
ys says "Being a NP is the BEST job on the planet". So what next? We all go on doing what we always do- providing quality, evidence-based care to our patients who put their faith and trust in us every day. One patient at a time. I think it's time to join the ACC- Dave Mittman, are you listening? I have my credit card in hand. LOL.
Julie Lambert, FNP
Ocean County NJ
-------------- Original message -------------- 
From: karenfnp at comcast.net 

> Stephen and David, 
> 
> Thanks for your comments and the sample blog. As a champion, especially for 
> NPs, I like to hear what others say about us in order to facilitate 
> bridgebuilding. One aspect of health care provider training I like to stress 
> with docs and advanced practice clinician students is that so much of what we 
> learn in the medical aspect of what we do is apprentice based. We all have to 
> learn the same new info when new diagnoses, treatments and meds emerge on the 
> health care scene via CME and OJT to maintain quality evidence based practices. 
> ( To have more residency programs for PAs and NPs in speciality areas would give 
> us more credibility in specific content areas.) I like to maintain a posture 
> of humility in terms of all that we need to know these days and respect docs who 
> do the same. It looks like this "panda bear physician", per the content in this 
> blog blurb, chooses to spend energy putting NPs PAs down and reminds me how we 
> have to choose where to spend our energy in ! 
> buildin 
> g our allies in the physician community and not waste it a la "casting pearls 
> to swine" as Jesus said once. 
> 
> Karen Riesinger FNP 
> Portland, OR 
> 
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Carla R. Anderson, FNP-C
  Healing Presence Family Practice, PC  
  carla_rayne at yahoo.com
  503 819 9726