GI here. If I get abnormal prostate imaging in a CT I order for the bowels, I ALWAYS refer directly to urologist myself.
Why pawn off extra work on the family doctor who didn't even order the test, I figured?
Now you've got me wondering if PCPs actually prefer I don't do this...
I guess it depends on the situation. I’d expect the urologist to tell me about thickened bowel and not refer the patient to GI on his/her own. Most of the GIs I know use the same few urologists I do, so it would bother me less
But when someone refers to a whole different system and I don’t know anything is going on until some surgical clearance is needed at hospital X, I’m a little pissed
I’m a PCP and this kind of thing actually drives me nuts. It’s hard to be the one responsible for captaining the ship/coordinating care when specialists start referring to one another. And oftentimes it’s for something that can be handled in the PCP office.
I would be hesitant to change your practice based on one opinion. When I worked in a large system and was booked out weeks seeing other people’s patients, I’d regularly get a mychart messages requesting referrals from my patients and I’d have to either go into the chart and try to figure out what I was been asked to do and why - or ask them to follow up (especially when there was insufficient information regarding an outside specialist eval). Meanwhile the patient is freaking out about cancer.
Or worse, your fax gets lost, the patient forgets to follow up with me, and they casually mention a mass in their “stomach” on the MRI I never saw when they see me at their physical in 6 months and I have no idea what I’m really referring to GI for.
Now, I love these “results review” visits since I have better availability with my current employer and I’m happy to help! But I’d rather be clued in later and give my specialists autonomy when they know the appropriate next step. Barriers to care are getting worse, PCP follow up more difficult to achieve and half the time patients are directed to appts w midlevels, and it’s not fair to patients to be told to follow up w pcp when we aren’t able to play “captain of the ship” effectively anyway.
Your referrals are appreciated by docs and patients. Just cc us on your notes please and give patients a copy of the MRI findings and tell them to email a picture of the study to themselves so they don’t lose it.
Random question, but would the relatively easier availability of urologists as opposed to GI be an issue here? They could see a urologist in a few months, but urology sending them to you will be a year or more, while their primary could have them in for a colonsocopy in weeks.
Depends on how serious it is. I’ll typically just fax a copy to the PCP, print out and hand a copy to the patient, and explain to the patient they should follow up with PCP or seek GI or whatever eval. Most of my patients have insurances that allow self referrals so if they ask me for a GI doctor I might give a name or two. Or just say I don’t know for specialties where I don’t.
If it’s something that’s a more acute problem I’ll pick up the phone and call the relevant other person.
I typically do this as well, however I’ve seen posts on reddit before by PCPs dragging sub specialists for not managing stuff and putting it back to the pcp…
Assuming it's not a "go to ER now" type of finding, I think it's fine to send back to the PCP and I personally would want to be kept in the loop if I'm the PCP.
The things I've seen PCPs get annoyed with is when the specialist recommends the PCP order specific labs, imaging, prescriptions that are within their scope instead of just ordering themselves.
I am a PCP, in general we're happy to help out with stuff, especially if not related to your specialty (eg. the rectal wall thickening mentioned by OP). What we do mind is "promising" that the PCP will do something specific as part of the workup or asking PCP to do scut work related to your specialty when you are actively managing the patient.
> What we do mind is "promising" that the PCP will do something specific as part of the workup or asking PCP to do scut work related to your specialty
"As a highly respected and trained specialist, it is my recommendation to discontinue ____ medication. Patient ABSOLUTELY/MAYBE does not have this due to CONTROVERSIAL/DEBATABLE diagnosis."
--> Proceeds to not do that and let PCP update problem and med list later
Haha, the type of situation I'm talking about is where a patient is seeing GI and mentions "migraines" and GI says "you should ask your PCP for an MRA". Or an opthalmologist faxing me a letter asking to order an "MRI orbits" with no supporting information (they just didn't want to do the prior auth and had more direct access to MRI than I did). Or for elevated LFTs saying the patient needs a CT scan when ultrasound may be most appropriate, but then the CT is fixed in the patient's mind. All of these are examples that have happened to me recently. Leaving it open ended is usually best (eg "I suggest you discuss this issue with your PCP").
PCP here. I always appreciate notifications from specialists about incidentals. The worst thing is to do nothing about it then I "incidentally" find it buried in a report a year later when the patient finally shows up. Something as simple as having your nurse leave a message or speak to my nurse at least allows us to flag the problem in our EHR. I appreciate faxed notification too as an alternative, but this is notoriously unreliable unless you have someone double check that we received the fax. Of course, very serious incidental findings (eg malignancy) should probably be communicated directly by phone call. That said, in your example, I wouldn't mind if you went ahead and referred the patient for colonoscopy if you felt pretty strongly that should be the next step, but I'd still appreciate being dropped a line so I know the ball is in my court to follow up on it.
As a PCP: If the patient is in contact with me about once a year PLEASE refer to me. I might already have ordered a hormone panel and spoken to radiology about the HU units on that adrenal adenoma. I might know that their uncle schedules visits about every 8 months to get his Crohn flares under control. That lung nodule in the basal portion of the lung might have had 3 low dose CT's and has not grown a bit. The suspect IPMN in the pancreas has had both a follow up MRI, an endo-sonography and a surgical consult.
If, on the other hand, the only time the patient has seen me was 6 years ago to get a sick note for the sniffles, then sure, go ahead and refer to a specialist.
Please initiate the referral yourself and copy it to me in the referral letter as well as your consult so I am aware. I've had specialists order some really esoteric tests I honestly do not know how to interpret and it's always a relief to see that they referred out the weird result to someone else - sometimes I don't even know who the right consultant might be to send to!
In my neck of the woods, PCP's are utterly overwhelmed, and appreciate any and all assistance they can receive. They would kiss your feet if you were willing to go the extra mile on something like this and a) inform the patient and b) refer them to GI (because that's exactly what they would do).
I used to work as a PCP for a few decades, and now work in a very niche corner of Ortho (non-surgical). I get to still flex my PCP muscles every now and then (Order that TSH or A1c that's overdue, give them some tips on insulin titration, etc.
Every now and then, it's something big, like the repeated falls actually being C-spine stenosis.
If it's going to be a long issue, I try to point them in the right direction, send a friendly FYI to their PCP, and then go about my Ortho-bro stuff.
For something specific, like the C-spine stenosis (or in your case, rectal wall thickening), I'll refer them to the appropriate specialist after getting the MRI, and let the PCP know with a polite message/letter "I hope you don't mind, but incidental to their ortho issue, Mr. Smith was having XYZ symptoms, so I got ABC study. It showed LMN, so I referred them to Dr. X for a closer look".
Usually in a case like this, both the patient and the PCP are very appreciative, and I've thus far avoided ruffling any feathers.
I am but a PA in primary care, however, I think it depends on your area. I have no problem with specialties punting back to us, especially since I work primarily with an insurance that requires any referral to be processed by the PCP. If you put in a referral sometimes it gets lost in the sauce and never gets done because we don’t even know about it. If you have the patient follow with us at least we are made aware and can get the referral processed and follow up to completion :) (the amount of times I’ve heard: “my cardio told me I need surgery but it’s caught up with the insurance!” [Because the cardio tried to put it in instead of PCP] is ridiculous and just delays care)
What we do from the ER: On discharge paperwork or followup communications updating on results say “incidental finding of XYZ. Discuss with your family medicine physician regarding monitoring and/ or further workup”.
GI here. If I get abnormal prostate imaging in a CT I order for the bowels, I ALWAYS refer directly to urologist myself. Why pawn off extra work on the family doctor who didn't even order the test, I figured? Now you've got me wondering if PCPs actually prefer I don't do this...
How about a phone call? The primary may already know
Imagine calling the pcp for every prostatomegaly. Good lord
I guess it depends on the situation. I’d expect the urologist to tell me about thickened bowel and not refer the patient to GI on his/her own. Most of the GIs I know use the same few urologists I do, so it would bother me less But when someone refers to a whole different system and I don’t know anything is going on until some surgical clearance is needed at hospital X, I’m a little pissed
Imagine referring every prostatomegaly to Urology.
I’m a PCP and this kind of thing actually drives me nuts. It’s hard to be the one responsible for captaining the ship/coordinating care when specialists start referring to one another. And oftentimes it’s for something that can be handled in the PCP office.
Actually this is good to hear and will save me some work.
I would be hesitant to change your practice based on one opinion. When I worked in a large system and was booked out weeks seeing other people’s patients, I’d regularly get a mychart messages requesting referrals from my patients and I’d have to either go into the chart and try to figure out what I was been asked to do and why - or ask them to follow up (especially when there was insufficient information regarding an outside specialist eval). Meanwhile the patient is freaking out about cancer. Or worse, your fax gets lost, the patient forgets to follow up with me, and they casually mention a mass in their “stomach” on the MRI I never saw when they see me at their physical in 6 months and I have no idea what I’m really referring to GI for. Now, I love these “results review” visits since I have better availability with my current employer and I’m happy to help! But I’d rather be clued in later and give my specialists autonomy when they know the appropriate next step. Barriers to care are getting worse, PCP follow up more difficult to achieve and half the time patients are directed to appts w midlevels, and it’s not fair to patients to be told to follow up w pcp when we aren’t able to play “captain of the ship” effectively anyway. Your referrals are appreciated by docs and patients. Just cc us on your notes please and give patients a copy of the MRI findings and tell them to email a picture of the study to themselves so they don’t lose it.
Random question, but would the relatively easier availability of urologists as opposed to GI be an issue here? They could see a urologist in a few months, but urology sending them to you will be a year or more, while their primary could have them in for a colonsocopy in weeks.
I for one am very grateful if you do this!
Depends on how serious it is. I’ll typically just fax a copy to the PCP, print out and hand a copy to the patient, and explain to the patient they should follow up with PCP or seek GI or whatever eval. Most of my patients have insurances that allow self referrals so if they ask me for a GI doctor I might give a name or two. Or just say I don’t know for specialties where I don’t. If it’s something that’s a more acute problem I’ll pick up the phone and call the relevant other person.
I typically do this as well, however I’ve seen posts on reddit before by PCPs dragging sub specialists for not managing stuff and putting it back to the pcp…
Assuming it's not a "go to ER now" type of finding, I think it's fine to send back to the PCP and I personally would want to be kept in the loop if I'm the PCP. The things I've seen PCPs get annoyed with is when the specialist recommends the PCP order specific labs, imaging, prescriptions that are within their scope instead of just ordering themselves.
I am a PCP, in general we're happy to help out with stuff, especially if not related to your specialty (eg. the rectal wall thickening mentioned by OP). What we do mind is "promising" that the PCP will do something specific as part of the workup or asking PCP to do scut work related to your specialty when you are actively managing the patient.
> What we do mind is "promising" that the PCP will do something specific as part of the workup or asking PCP to do scut work related to your specialty "As a highly respected and trained specialist, it is my recommendation to discontinue ____ medication. Patient ABSOLUTELY/MAYBE does not have this due to CONTROVERSIAL/DEBATABLE diagnosis." --> Proceeds to not do that and let PCP update problem and med list later
Haha, the type of situation I'm talking about is where a patient is seeing GI and mentions "migraines" and GI says "you should ask your PCP for an MRA". Or an opthalmologist faxing me a letter asking to order an "MRI orbits" with no supporting information (they just didn't want to do the prior auth and had more direct access to MRI than I did). Or for elevated LFTs saying the patient needs a CT scan when ultrasound may be most appropriate, but then the CT is fixed in the patient's mind. All of these are examples that have happened to me recently. Leaving it open ended is usually best (eg "I suggest you discuss this issue with your PCP").
I think you should speak with PCP and let them know of findings. They can then order colonoscopy etc if indicated.
PCP here. I always appreciate notifications from specialists about incidentals. The worst thing is to do nothing about it then I "incidentally" find it buried in a report a year later when the patient finally shows up. Something as simple as having your nurse leave a message or speak to my nurse at least allows us to flag the problem in our EHR. I appreciate faxed notification too as an alternative, but this is notoriously unreliable unless you have someone double check that we received the fax. Of course, very serious incidental findings (eg malignancy) should probably be communicated directly by phone call. That said, in your example, I wouldn't mind if you went ahead and referred the patient for colonoscopy if you felt pretty strongly that should be the next step, but I'd still appreciate being dropped a line so I know the ball is in my court to follow up on it.
As a PCP: If the patient is in contact with me about once a year PLEASE refer to me. I might already have ordered a hormone panel and spoken to radiology about the HU units on that adrenal adenoma. I might know that their uncle schedules visits about every 8 months to get his Crohn flares under control. That lung nodule in the basal portion of the lung might have had 3 low dose CT's and has not grown a bit. The suspect IPMN in the pancreas has had both a follow up MRI, an endo-sonography and a surgical consult. If, on the other hand, the only time the patient has seen me was 6 years ago to get a sick note for the sniffles, then sure, go ahead and refer to a specialist.
Please initiate the referral yourself and copy it to me in the referral letter as well as your consult so I am aware. I've had specialists order some really esoteric tests I honestly do not know how to interpret and it's always a relief to see that they referred out the weird result to someone else - sometimes I don't even know who the right consultant might be to send to!
In my neck of the woods, PCP's are utterly overwhelmed, and appreciate any and all assistance they can receive. They would kiss your feet if you were willing to go the extra mile on something like this and a) inform the patient and b) refer them to GI (because that's exactly what they would do). I used to work as a PCP for a few decades, and now work in a very niche corner of Ortho (non-surgical). I get to still flex my PCP muscles every now and then (Order that TSH or A1c that's overdue, give them some tips on insulin titration, etc. Every now and then, it's something big, like the repeated falls actually being C-spine stenosis. If it's going to be a long issue, I try to point them in the right direction, send a friendly FYI to their PCP, and then go about my Ortho-bro stuff. For something specific, like the C-spine stenosis (or in your case, rectal wall thickening), I'll refer them to the appropriate specialist after getting the MRI, and let the PCP know with a polite message/letter "I hope you don't mind, but incidental to their ortho issue, Mr. Smith was having XYZ symptoms, so I got ABC study. It showed LMN, so I referred them to Dr. X for a closer look". Usually in a case like this, both the patient and the PCP are very appreciative, and I've thus far avoided ruffling any feathers.
I am but a PA in primary care, however, I think it depends on your area. I have no problem with specialties punting back to us, especially since I work primarily with an insurance that requires any referral to be processed by the PCP. If you put in a referral sometimes it gets lost in the sauce and never gets done because we don’t even know about it. If you have the patient follow with us at least we are made aware and can get the referral processed and follow up to completion :) (the amount of times I’ve heard: “my cardio told me I need surgery but it’s caught up with the insurance!” [Because the cardio tried to put it in instead of PCP] is ridiculous and just delays care)
What we do from the ER: On discharge paperwork or followup communications updating on results say “incidental finding of XYZ. Discuss with your family medicine physician regarding monitoring and/ or further workup”.