American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, January 14, 2010

An open letter to consultants

Thank you for agreeing to see my patients. I send them to you with confidence that you can help me in the overall care for them.

Maryann Gets a Letter by feverblue via FlickrWhile I understand that you had a few extra years of training above me, and certainly have extensive knowledge in the area of your expertise (that is why I send people to you in the first place), I would like to share with you a few important points about our relationship. Understanding these things will help you better care for the patients I send your way and will greatly help me get what I want from the consultations I send to you

I am not a moron. I typically try to anticipate what you will do for the patient and order all appropriate tests before sending them to you. There are almost always has been a number of visits and several tests ordered that may greatly help you in managing the problem for which I send you the patient. When I send you a patient, I typically want a specific question answered. Please ask yourself: "What does Dr. Rob want me to answer?" and answer that question for me.

My patients are not morons. Overall, my patients are very nice and reasonable people. Even those with very strange histories are seldom coming in to simply waste their doctor's time. Rest assured that I won't send you a consult that simply gets a patient off of my hands. Please listen to what they have to say, and if you are confused as to what is expected, please call me and I will explain what I want from you.

You represent me. Please understand that when I refer a patient to you, their experience with you will reflect back on me. I sent them to you for a reason, and if they think you are incompetent or that you are a jerk, it makes me look bad.

These patients consider me as "their doctor," not you. I am the one who is ultimately responsible for their care, not you. If they are dissatisfied with you, they come to me and I will send them somewhere else. I am trying to take care of their medical care as a whole, so please communicate to me what I need to know to better their overall care. You play a very important role, but not the central role in their care. That is my job. Your job is to help me do my job to the best of my abilities

I can send my patients elsewhere. Most of my patients require a referral for them to see you. On top of that, most want to know my opinion of specialists. I essentially have complete control over whether my patients see you or not. This means that a major part of your job is to keep me satisfied. If I don't like the care you give my patients, I will send them to someone who gives me what I want. This is not a veiled threat, it is the reality of the relationship between primary care and specialty physician. I control a portion of your pipeline, so it is good business to keep me happy.

Please be brief. I really don't care about 90% of the stuff you put in your letters. Just answer my question and put it in a letter. I know you have to appease the E/M gods to get paid properly, but I really don't want to read that stuff.

Please communicate. It is useless for me to send patients to you and not get the consult note back. Make sure you get my name right (notes are often sent to the wrong office) and get it to me in a timely fashion. Like it or not, your job is to help me manage the patient, not the reverse. It is no help to have patients see you and not know what went on.

I understand that this is a somewhat odd relationship, since I am paid far less than you and yet am the central player. Truthfully, it galls me a bit that you get triple my income while I play the lead role and you support me in my job. Yet I realize that this is not your fault and that overall you value my role in the health care system. I promise to do what I can to make your job easier. Please help me in my quest to do what is best for my patients.

Dr. Rob

[This post appeared in Musings of a Distractible Mind in July 2007. Since that time, my frustration with my interaction with specialists has grown, not improved. Our system seems to discourage communication when it should be promoting it.]

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Blogger Michael Kirsch, M.D. said...

Dr. Rob, This is an excellent post. I am one of those specialists who survives by attending properly to patients and their primary care physicians. Your philosophy of specialty consultation is not typical of what most of us are seeing in the field. Primary physicians consult for many reasons, most of which were not included in your post. When I receive a GI consult from a primary physician who has already given thought and attention to the issue, it is a refreshing experience. Your post describes ideal practice, but the universe that I inhabit isn't quite this smooth.

January 14, 2010 at 12:11 PM  
Blogger Dr. Rob said...

So just move to Augusta and I will send you my patients and we can both be happy.

Yes, I know that there is a big problem with docs' communication skills on all levels. Our system creates a lot of this both ways. I communicate easier with you than I do my colleagues in town.

January 14, 2010 at 5:37 PM  
Blogger Michael Kirsch, M.D. said...

There's a glimmer of hope. With the speed that telemedicine is progressing, you might be able to be one of my referring physicians, sooner than we think!

January 14, 2010 at 8:53 PM  
Blogger Toni Brayer, MD said...

Awesome post and you are brave to write it. I think things might even get worse now that there is no "consultant code". No longer can a urologist focus on one tiny area of the body (maybe "tiny" is the wrong term)and get paid 4X what I get for a complete cognitive work up.

January 19, 2010 at 1:32 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

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The Blog of Paul Sufka
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

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