I declined to do a consult on a hospital patient, first time ever

[Tobra]

I am a bit conflicted about it. If they are on the hospital floor when they ask me to see someone, I can decline, even if I am on call. Different story if the ER calls me, you have to go see them then if you are on call.

The hospitalist calls me about a diabetic guy. I was at the hospital anyway, at the wound clinic that afternoon. I told him I could not see the guy if it was a freebie, because my office manager gets sort of pissed about all the free stuff I do. She wrote off a few thousand dollars worth last week that Medi-Cal should have paid me as a secondary insurance. Turns out the guy has Medi-Cal, big surprise. Medi-Cal, as a primary insurance, quit paying podiatrists like 6 or 7 years ago, and does not pick up copays and deductibles like it used to either. Went up to the floor, took a peek at the guy's foot, went back out and told him the guy definitely needs to go to the OR. Suggested he try calling the Ortho hospitalist, who can be reimbursed for providing the same service as I do by Medi-Cal, and even if the person has no coverage, they still get some sort of stipend from the hospital.

I felt pretty bad about it, to tell you the truth, and told the hospitalist to call me back if he could not get the ortho guy to take care of it. The hospital is apparently considering a change to the bylaws, making ER call into hospital call, but I don't know if that will fly. The current situation is just completely unacceptable for a number of reasons. There has also been talk of setting up something similar to what they have with the orthopedic and general surgery guys that are participating in their hospitalist program. Big downside to this is that by the time they get to the hospital, they are in bad shape, because they probably have not seen a podiatrist in 6 or 7 years. You end up dealing with a much more complex problem that requires more and longer treatment with a patient that is generally not very compliant, and does not do as instructed.

You may be asking yourself, "What is your point Toby?" Just venting really, not much of a point. This is the first time I ever said "No." Not too sure how I feel about it.

[GeorgeK]

Same here. We do quick free consults of XRay files for friends in practices in town. maybe 3 a week. We know them all. Never asked for anything. A few give us a bottle of red, or a box of chocolate once a year.

The kicker? they *bill* the time it takes them to bring the x-ray (by their secretary) and the results we give them as "work on the patient file". So they get paid for the work we do for them.

Planning on telling then "no".

[GWN7]

We had a guy who lived in the apartment block behind my station. Nice guy, wife and two kids. They were from up North and vegetables were a foreign concept. Lots of soft drinks and bags of chips. I first met him after his first trimming. That was a couple toes on one foot. He had post op complications and we shipped him back to the hospital. Over the next 3 years he had more parts removed to the point where he was going to loose his second leg to the knee. We didn't see him anymore after that. Some days the crap part of a job can get to you.

[gchappel]

A good friend of mine is a pod. Stopped covering hospital patients about 3 yrs ago for exactly this same reason. He is now so fed up with the system he is retiring early- July 1st he is done.
We are losing good docs due to the system in place, and it is likely only going to get worse.
gary

[stomachmonkey]

You took a look and proposed a solution that works for the patient and the provider.

I see no reason to feel conflicted.

[asphaltgambler]

My take on it as my wife is in the medical field. As a healthcare provider (or assistant) the 'system' is continually squeezing you to do more, with patients who do not take care of themselves, follow directions / orders and refuse to take responsibility for their own wellness care.

I understand that career is a 'calling'. But at the end of the day why try so hard when the patient won't and compensation continues to decline while potential liability goes up.

[cashflyer]

Wait, Tobra.... You're apologizing for having reservations about limiting the provision of services for which you will not be compensated?

I'm missing the point. I don't know why you feel bad about it, or why you would be apologizing.

[lane912]

you sound like a good Doctor.

[Porsche-O-Phile]

You didn't do anything wrong. Sorry to hear of the state of your profession but it isn't your fault - in fact you'd be making things worse by playing along with the "race to the bottom" / only-price-point-matters" healthcare model.

[pavulon]

Will an orthopod get paid (something) to see this patient for what is presumably an open wound?

[Nickshu]

Tough situation but you can't feel bad about it because you offered options. I too fight with my office manager b/c I give away too much free care. I fulfill my "altruistic" needs by giving away care to people I think deserve it. Problem is everyone these days thinks they deserve free care, tell me they can't afford anything, then proceed to drive out of my office parking lot in a $400K motor home. **rolleyes** The culture of finding no value in healthcare is maddening. As in "I'll pay $5000 for a vintage shotgun, but tell me I have to spend $2000 on my health and I say I can't afford it".

[HardDrive]

My wife is an anesthesiologist. She's just about done with medicine. Tired of the hours. Tired of dealing with dirtball parents looking to steal their kids pain meds. Tired of getting nickeled and dimed by the administration. REALLY tired of seeing 250 lbs 12 year olds complaining about joint pain.

[Tilikum Turbo]

Friend of mine who initially got into plastic surgery to help car crash patients and people with born deformities, etc. He got so nauseated at the business as it turned completely into the vanity "business", and no longer practices.

[Tobra]

That is just how it played out for my uncle. Trained at the burn center in Galveston, got sick of boobs and facelifts. He quit and bought a place on the Connecticut River, extremely cool old house.

Originally Posted by pavulon

Will an orthopod get paid (something) to see this patient for what is presumably an open wound?

Yes, an orthopedic surgeon would be paid by Medi-Cal(Medicaid everywhere else). Probably under $100, but yes they would be reimbursed for the service.

Ortho hospitalist took him to the OR the next day.

This scheisse really pisses me off to no end, maybe that is why it bothers me so much. If I ever run into Roger Niello on the street, I am kicking him square in the nuts. I told that fuch to his face in his office, just what would happen, no psychic abilities necessary. I wonder how many more people have died or gotten pieces cut off because of this foolishness. My friend Dave is heavy into research, one of the founders of the Diabetic Foot Conference that happens in LA every year. I bet he could give me a ballpark number off the top of his shiny head and be pretty GD close.



I am pretty good at this stuff. If you lived here, and your vascular surgeon says, "You need to see somebody about that foot," I am the "somebody" they generally have in mind. There are a pretty fair number of folks walking around with two legs that love my dumb ass, both here and in Texas. Made a couple of old ladies cry when I told them I was leaving for Cali.

[Cajundaddy]

Sorry you are having a bad day Tobra. It sounds like you made a difficult decision and did the right thing by referring the patient to a Dr. that is still within the system, such as it is.

I have cousin you have probably seen at some point. Retired teacher, terrible feet, diabetes, and a house full of sweetened soft drinks and snack foods. Hard to watch this.

[aap1966]

you took a look and proposed a solution that works for the patient and the provider.



i see no reason to feel conflicted.

+1

[M.D. Holloway]

In a related incident, I did some work for a start-up and invoiced them - mind you this is for a few thousand which they agreed to up front - no hidden costs. They kept telling me that the 'check was coming'. Been 3 months. I'm not gonna expect it. Well they called last week for more work for me. "As soon as we clear up what is owed we can talk about the next project".

Health care must be the worst...

[Tobra]

Sort of like loaning money to an ex brother in law.

Had a guy about 70 come in this afternoon. Been diabetic 5 years, probably knows almost as much about diabetes as me. Has a daughter in law that is 50 and has been diabetic since she was 3. She is bipolar, schizo, whole litany of mental disorders, he has been her caregiver for quite some time. Charming gentleman from Georgia. He has been seeing an internal medicine colleague since he came here 20 years ago. He said he really liked his doctor and his policy was to do just what she told him. Sandy told him to come see me after he dumped an overloaded 90 gallon green waste barrel on his foot, so there he was. Did it two weeks ago, so maybe he doesn't know as much about diabetes as I do, but he knows who to call now anyway. He will be bringing the wife and daughter to see me too. Turned out he did not have anything all that serious, which is not what you would be thinking if you looked at the radiology report. It was describing a divergent Lis Francs dislocation, which is a very bad thing Jumped out of second story window bad.

I tried to look at the films at lunch, no dice, freakin' EMR, never freakin' fails to fail on looking at images. I don't want a thousand words. In this case it was a brief paragraph. more like a hundred. I have looked at foot films for 25 years, show me a picture. Trust me, I know what I am looking for. He just whacked his first and second metatarsal heads together. Pinched the lining of the joints really good. Not unlike having some muscle head squeeze the heck out of your hand shaking it, only with whole lot more energy and hard as ABS plastic, or whatever those things are made out of, he will be fine.

Had dinner with the parents, the kids and grandkids. Was late, because it is Friday and it is a three day weekend. Son and his wife remodeled their kitchen. Last time I saw it, it was bare cement floors, sheetrock and some pipes coming out of various places in the walls and floor. Very sweet, really beautiful granite countertops. Flecks of gold in it, glass five burner electric cooktop. I prefer cooking with gas myself, but it certainly was easy to clean up. The twins are three and half, and the baby is like 11 months. I swear that little one is the prettiest kid I ever saw in my life. Daughter and her husband just put an offer on a house about three miles from my house, which will make babysitting much more convenient. Nice place, needs work, and I would cut down the tree in the front yard, which looks a little sketchy to me.

[Rusty914s]

Hi Tobra, I love whiskey too.