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

[stephanie2u at optonline.net]

Hi Carla,

With all respect for your opinion about the written and unwritten rules, I think the only rules that matter are the ones that can be enforced. No matter how helpful an article with suggestions about procedure, it doesn't constitute rules. Many MDs do not play nicely with other providers--not only NPs, but also other MDs. Doctors are always trying to steal each others' patients.

There may be some way to short circuit some of their tactics:

Perhaps if you give all your patients a written policy that you will not retroactively OK referrals made by other offices since it undermines your efforts to coordinate their health care ("occasionally I/we receive calls from other providers' offices requesting [such and such paperwork]. I regret that I must decline to perform this service, since certain insurance contracts are designed to have all referrals originate from the primary care provider. This is in the patient's best interests. Please keep this in mind should you visit a specialist I have recommended to you.") , you would be able to "just say no" to the offices that are trying to coerce you into OKing their referrals. That is really obnoxious. But some of the solution could be in educating your patients about the process.

There's no reason you could not send a letter spelling out your policy on this to any specialist you deal with, when you are sending your referral letter. You might as well draw a line in the sand, if you feel strongly about it.

Can you just approve a single visit to the specialist [until they prove they can play nicely] rather than 6 or whatever your practice is? Then the patient would have to contact you to initiate a second referral and you could figure out if the specialist is trying to steal your patient from you.

Instead of assuming the patient is going to the specialist you recommend, why not give them a few names and tell them to call you up when they've made their appointment. Then do the referral paperwork. That way you know who to send your letter to. You could fax it with the "confidential" blurb on the cover sheet.

Once you've sized up some of these specialists and picked out the ones that will play by your terms, you could make it extra easy by giving the patient a form for the specialist to fill out with their impression and plan along with a SASE for your office, with a little cover note saying you are providing this form and SASE for their convenience, although you find a letter they have dictated is more informative, and preferable.

I've not been in your shoes, so I'm not 100% sure any of the above would work. I'm just throwing out some ideas. It seems like the time has come to use tactics that other professionals use and are not likely to antagonize anyone.

Stephanie Walker, FNP

----- Original Message -----
From: Carla Anderson 
Date: Monday, March 10, 2008 2:28 am
Subject: Re: [NPInfo] Physician blogs maligning NP s and PAs another issue
To: NP Info 

> Hi Stephanie,
> 
> The rules are the "unwritten" and some are "written" rules of 
> appropriate conduct, in terms of people starting a new business, 
> in terms of a good ol boys club, in terms of just doing the 
> right thing... There are many articles on the "written" rules, 
> and here is one on the AAFP website:
> 
> http://www.aafp.org/fpm/20071100/38opti.html
> 
> In this article, it says the docs will be so embarrassed if 
> they get a call, but I find they are more brazen than that..so I 
> think I WILL make a personal visit, ahead of time... There are 
> not too many choices, as a lot of the docs that are in surgery, 
> or gi, work in large groups together, and are affiliated with 
> certain hospital groups, and patients dont want to travel too 
> far out or dont have a choice because of their insurance. 
> Regarding the "secretary part", boy the games they play. They 
> have their true secretary call me and say " we need YOU , SINCE 
> YOU ARE THE PCP, to call the insurance company and make this 
> appointment that we scheduled (without your approval I might ad) 
> retroactive, because YOU dont want the patient to suffer and pay 
> extra....we want this to be in the best interest for the 
> patient...dont you?" I literally have had many patients not 
> return once they see the specialist. Or I work very hard to 
> find a psychologist that is an "expert in the field of
> ADHD/OCD/Tics in adults, for a guy that has been dealing with 
> it for YEARS. So I tell him how important it is to get the 
> right person (he has waited this long). I get an appointment 
> scheduled, do all the referral paperwork, call the patient. 
> Then two days later, the patient says he looked on line and 
> found "someone" that can see him in two days rather than two 
> weeks, so he will just go there... The list goes on and on.. 
> 
> Yes it goes to educating the patients, but there are so many 
> unique and individual cases... I had one woman who I set up with 
> a nationally renowned breast surgeon for a biopsy, and her 
> plastic surgeon boss who always threatens to fire her, got his 
> ego inolved and said to her "you should go to the doc I refer 
> you to..., we like her better"... so then I have to cancel, and 
> my credibility goes down with this doc I initially set up..
> 
> So it is a problem on both the patient and the specialist end, 
> they both need a lot of education.. I think I am going to really 
> educate, prior to the consult. The patients may think they can 
> shop around, but in my neighborhood there are not a lot of 
> providers that go out of their way for house calls, answering 
> calls on a Sunday , etc..
> 
> It comes down to being like Parenting. If the specialists will 
> form a united front with me, then the patients have structure 
> and are not confused. But if they play the patient back and 
> forth, then it creates confusion. 
> 
> I just never used to see this before, where the ortho doc 
> refers to Rheumatology, instead of back to me, no letter, 
> nothing. And the only way I found out is because I called the 
> patient. I also am in practice by myself, no doctors to back me 
> either. 
> 
> The letter/form I send is very clear. It says I am sending 
> this patient to you for a consult and/or a procedure. Please 
> send me a written explanation of your findings, and your 
> recommendations..." something like that..and I send copies of 
> all notes, labs, insurance. And then they ignore me. I had one 
> doc a colorectal surgeon who was great.
> He gave a personal call right after his visit, then sent a 
> great letter, of his procedure, and referred the patient. 
> 
> But I will fix the problem, and keep you informed. Carla 
> Stephanie Walker wrote:
> Hi Carla,
> 
> What a difficult situation you have, but I agree with AnnMarie 
> that 
> you may have some leverage. Although you gave a lot of 
> information, 
> there are some details that only you are aware of.
> 
> In your area, is there more than one specialist office for each 
> specialty, so you can boycott the more troublesome offices if it 
> comes to that, and only send patients to the ones who are cooperative?
> 
> If so, I think it is worth the trouble to contact these 
> specialists 
> personally. Obviously with 2 jobs, you have little time to make 
> a 
> personal visit, but I think it's more effective than a phone 
> conversation. It's harder for the doc to brush you off. I would 
> just 
> walk in like a drug rep and ask for 15 minutes of their time. 
> Why not 
> bring a box of candy for the office staff with your business 
> card on 
> it, or something, just like the drug reps do.
> 
> To the doctor, you could say that for some reason you are not 
> getting 
> any written reports from them after you have referred a patient, 
> and 
> do they have any suggestions, since you would like to continue 
> referring patients to them.
> 
> When you say the specialist office will tell you to play 
> secretary 
> and do all the paperwork for them--what paperwork do you mean? 
> And, 
> when you mention that they are breaking the rules, whose rules 
> are 
> you referring to--is it the insurance contract? If so, then you 
> could 
> speak with the insurance company.
> 
> Best of luck,
> 
> Stephanie
> 
> 
> On Mar 9, 2008, at 5:32 PM, Carla Anderson wrote:
> 
> > 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
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> 
> 
> Carla R. Anderson, FNP-C
> Healing Presence Family Practice, PC 
> carla_rayne at yahoo.com
> 503 819 9726
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