Dear specialist: Please don't dump your job on me

March 22, 2002

Specialists unload patients on this primary care doctor, expecting her to do the work they don't get paid for. And she's tired of it.

 

Dear Specialist: Please don't dump your job on me

Specialists unload patients on this primary care doctor, expecting her to do the work they don't get paid for. And she's tired of it.

By Shelly A. Kruse, MD
Internist/Fresno, CA

A prescription refill request is on my desk for a drug prescribed by an allergist for a patient we share. I'm sure it has reached me by mistake, and I tell the medical assistant to direct the pharmacist to the allergist's office. But several hours later, the same refill request shows up on my desk—this time with a note on it. The allergist is on vacation for two weeks and his office says no one is covering for him. Therefore, primary care doctors must handle refill requests for all his patients.

If that were an isolated incident, I would be mildly annoyed. But I've encountered such "dumping" many times, and I'm angry about it.

Specialists expect me to follow up on their patients, refill their prescriptions, and complete medical forms. I believe capitation of specialists is partly to blame. One cardiologist told me his group's capitation payment was down 30 percent, so the group was reducing its services by 30 percent. No wonder they were transferring stable patients with atrial fibrillation and other arrhythmias to primary care doctors!

Specialists are also writing my name on prescription refill requests to get me to do their unpaid work for them. Of course, I don't get paid for that either.

And then there is the liability issue. Drugs such as Cordarone or methotrexate have toxic side effects and require follow up and monitoring. If I write a refill for a prescription, I take on full responsibility for the drugs' toxicity, side effects, and efficacy—without any consultation payment.

Medical forms that should be filled out by specialists also land on my desk. An orthopedist sent me physical therapy forms to fill out for my patient who had had a total knee replacement. I don't have the slightest idea what postoperative physical therapy is appropriate, so I refused to fill them out.

A cardiologist who recommended that our patient take permanent disability after bypass surgery refused to fill out the five-page disability form. Instead, he told the patient to bring it to me. Another orthopedist expected me to fill out Medicare home health forms, even though I hadn't seen the patient and couldn't evaluate her need for the service.

But the most egregious dump is of the patient. A patient with a basal cell carcinoma called the dermatologist who performed the excision when the site became red and purulent. The dermatologist told him to see me instead. Two other surgeons also bounced patients with infections back to our primary care group—one with an infection around his prosthetic knee, and another whose breast reduction surgical site became infected.

In another incident, a patient who had been hospitalized for 14 days for depression called his psychiatrist 24 hours after he'd been discharged and said he was suicidal. The psychiatrist had left for the day, and the on-call psychiatrist sent the patient to me—even though I hadn't seen this guy in two years.

I've also seen an obstetrician refuse to treat a pregnant patient's urinary tract infection and a gynecologist who expected me to treat a woman's severe pelvic pain after an intrauterine procedure. Clearly these situations are an abdication of care by the specialists and pose enormous liability to both specialists and primary care doctors.

Today, we don't see much patient dumping anymore, because our group has left the HMO that capitates the specialists around here. But the specialists still send us plenty of Rx refill requests and forms, even for patients with private insurance. I spend two hours each day on that, and answering telephone messages without compensation—simply because it's part of my job.

I realize a specialist may not be aware of what his staff is doing. But I very much object to being expected to assume care for specialists' patients without being asked. Please, don't dump on me, and I will do my very best not to dump on you.

 

Have you had an experience similar to the author's? Please share the details with us. E-mail us at meletters@medec.com, fax us at 201-722-2688, or address correspondence to Letters Editor, Medical Economics, 5 Paragon Drive, Montvale, NJ 07645.

 

Shelly Kruse. Dear specialist: Please don't dump your job on me. Medical Economics 2002;6:106.