Why won't you make a timely and appropriate referral??????

[Guest guest]

I'll write this when I'm still good and frustrated, post it, and then perhaps wish tomorrow that I'd've waited till I was more rational. Patient speaks Spanish, on intake had all the classic signs of vestibular dysfunction, concussion, and post-concussive syndrome. I'm not a doctor, but it seems that often my new case intake as far as injuries go is a lot more involved than the intake that many doctors do, and that shouldn't be the case. Anyway, here we are 4 months post injury, client is still treating with her chiropractor 3 times a week, claims she's been telling her doctor about her dizziness (it's so bad that she refuses to drive because she doesn't feel safe doing so), doctor has thus far refused to refer her out to a Board Certified anything, PIP carrier is screaming for an IME, I force my way through the doctor's protective phone shield (a receptionist then a C.A.), get to the doctor only to learn that the chart is devoid of any mention of half the stuff the client indicates she's been complaining of. Now I know there's a communication barrier, but I suspect that the doctor never even bothered to ask the client half the stuff. Why? Why? Why? Surely one could play charades and figure out that someone suffers from dizziness, light-dependent balance, intolerance of noise, intolerance of light, intolerance of being touched. Anyway, doctor does relate enough of what the complaints were that, in my lay and/or legal opinion, a referral should have already been made. So here it is again: a referral to a board certified neurologist or orthopedist or other specialist early in a case when you have any symptoms of dizziness, numbness, bruising, or swelling is absolutely critical and essential. It will ensure that your bill gets paid eight months down the road and the patient is still seeing you and is sub-acute (meaning that the remaining problems are more subjective than objective--but entirely consistent with the history and course of treatment). When was the last time a PIP carrier refused to pay for an ortho or neuro evaluation? Never. When was the last time a PIP carrier refused to pay your bill because treatment exceeded a few months and you were the only doctor that patient ever saw and thus the only professional eye witness to the patient's condition when he/she was acute (and objective)? I bet it was yesterday or thereabouts. When was the last time a neuro or ortho took your patient away from you? I'd guess that if the referral was made within the first month of treatment that it hasn't happened. If it has, perhaps you don't have a working relationship with any such doctors in which case you need to develop such a relationship. If you're afraid that a doctor is going to steal your patient, then I'd recommend making the referral and taking 2 minutes to dictate a letter to the M.D. introducing yourself, introducing the patient, and explaining why you are making the referral. You may even want to throw in a snippet of what your treatment plan is. It could be as short as:

"Dear Dr. Board Certified: Thank you for agreeing to see my patient, Soar Nek. She has an appointment with you on December 2, 2005. I have been treating Soar for a couple of weeks for acceleration/deacceleration and connective tissue injuries sustained in a motor vehicle collision. I am referring her to you, because Soar has been experiencing numbness and tingling in her hands and fingers as well as dizziness. Cervical xrays demonstrated a loss of normal lordosis, some minor degenerative changes consistent with her age, but were otherwise unremarkable. My opinion is that the numbness is most likely hypesthesia caused by soft tissue swelling (she has had palpable and visible edema in her neck), but we would like to rule out anything more ominous. Her dizziness is of concern as it suggests concussion and perhaps an inner ear injury. She had a positive Rhombergs. I plan to continue to treat her with chiropractic and physical therapy as well as deep tissue massage to which she seems to have responded well. I have also diagnosed a thoracic and lumbar sprain/strain which both appear to be responding well to traditional chiropractic treatment. Thank you for taking the time to see Soar. I would greatly appreciate any treatment recommendations you might have.

If I or my office can provide you any assistance or information, please do not hesitate to call.

Best Regards, Dr. Wise and Prudent, D.C."

You send that letter to a new or unknown Board Certified anything, and I bet you that patient gets sent back to you. You demonstrated you knew what you were talking about and you exhibited the required amount of deference to His/Her Majesty, Dr. Board Certified. If you think exhibiting the required amount of deference to Dr. Board Certified is beneath you, then you're going to have a very frustrating career filled with a lot more adversity than needs be the case. Do any of you know more than one Board Certified medical doctor that does not appreciate those that worship the ground he or she walks on?? When was the last time you were a patient of a Board Certified medical doctor and didn't notice that the doctor demanded that his staff treat him/her as if they worshipped the ground they walked on? Why do some chiropractic physicians continue to refuse to make timely and appropriate referrals and spend so little time on the initial intake interview that so many symptoms that should alert one to the possibility that this patient may not be healed in 6-8 weeks get missed? Why am I mad? Because I get to deal with the outstanding balance owed to the chiropractic clinic that wasn't paid by the PIP carrier, and I get to explain to the client why they're not getting much money because most of the injury recovery has to go to the chiropractor to pay the huge outstanding balance. Grrrr. G. , speaking for no one but himself, Salem, Oregon.

[Guest guest]

Thanks for the letter. I think your comments are completely appropriate and I must confess to being slow to refer. I lost the great neurologist in my community I used to rely on for the dizzy, neurological patients who didn't improve quickly. The only other one is- well, an idiot. So I wait for the worst cases to refer, because they have to go to Portland (2 hour's drive).

Ann Goldeen, Astoria

Why won't you make a timely and appropriate referral??????

I'll write this when I'm still good and frustrated, post it, and then perhaps wish tomorrow that I'd've waited till I was more rational. Patient speaks Spanish, on intake had all the classic signs of vestibular dysfunction, concussion, and post-concussive syndrome. I'm not a doctor, but it seems that often my new case intake as far as injuries go is a lot more involved than the intake that many doctors do, and that shouldn't be the case. Anyway, here we are 4 months post injury, client is still treating with her chiropractor 3 times a week, claims she's been telling her doctor about her dizziness (it's so bad that she refuses to drive because she doesn't feel safe doing so), doctor has thus far refused to refer her out to a Board Certified anything, PIP carrier is screaming for an IME, I force my way through the doctor's protective phone shield (a receptionist then a C.A.), get to the doctor only to learn that the chart is devoid of any mention of half the stuff the client indicates she's been complaining of. Now I know there's a communication barrier, but I suspect that the doctor never even bothered to ask the client half the stuff. Why? Why? Why? Surely one could play charades and figure out that someone suffers from dizziness, light-dependent balance, intolerance of noise, intolerance of light, intolerance of being touched. Anyway, doctor does relate enough of what the complaints were that, in my lay and/or legal opinion, a referral should have already been made. So here it is again: a referral to a board certified neurologist or orthopedist or other specialist early in a case when you have any symptoms of dizziness, numbness, bruising, or swelling is absolutely critical and essential. It will ensure that your bill gets paid eight months down the road and the patient is still seeing you and is sub-acute (meaning that the remaining problems are more subjective than objective--but entirely consistent with the history and course of treatment). When was the last time a PIP carrier refused to pay for an ortho or neuro evaluation? Never. When was the last time a PIP carrier refused to pay your bill because treatment exceeded a few months and you were the only doctor that patient ever saw and thus the only professional eye witness to the patient's condition when he/she was acute (and objective)? I bet it was yesterday or thereabouts. When was the last time a neuro or ortho took your patient away from you? I'd guess that if the referral was made within the first month of treatment that it hasn't happened. If it has, perhaps you don't have a working relationship with any such doctors in which case you need to develop such a relationship. If you're afraid that a doctor is going to steal your patient, then I'd recommend making the referral and taking 2 minutes to dictate a letter to the M.D. introducing yourself, introducing the patient, and explaining why you are making the referral. You may even want to throw in a snippet of what your treatment plan is. It could be as short as:

"Dear Dr. Board Certified: Thank you for agreeing to see my patient, Soar Nek. She has an appointment with you on December 2, 2005. I have been treating Soar for a couple of weeks for acceleration/deacceleration and connective tissue injuries sustained in a motor vehicle collision. I am referring her to you, because Soar has been experiencing numbness and tingling in her hands and fingers as well as dizziness. Cervical xrays demonstrated a loss of normal lordosis, some minor degenerative changes consistent with her age, but were otherwise unremarkable. My opinion is that the numbness is most likely hypesthesia caused by soft tissue swelling (she has had palpable and visible edema in her neck), but we would like to rule out anything more ominous. Her dizziness is of concern as it suggests concussion and perhaps an inner ear injury. She had a positive Rhombergs. I plan to continue to treat her with chiropractic and physical therapy as well as deep tissue massage to which she seems to have responded well. I have also diagnosed a thoracic and lumbar sprain/strain which both appear to be responding well to traditional chiropractic treatment. Thank you for taking the time to see Soar. I would greatly appreciate any treatment recommendations you might have.

If I or my office can provide you any assistance or information, please do not hesitate to call.

Best Regards, Dr. Wise and Prudent, D.C."

You send that letter to a new or unknown Board Certified anything, and I bet you that patient gets sent back to you. You demonstrated you knew what you were talking about and you exhibited the required amount of deference to His/Her Majesty, Dr. Board Certified. If you think exhibiting the required amount of deference to Dr. Board Certified is beneath you, then you're going to have a very frustrating career filled with a lot more adversity than needs be the case. Do any of you know more than one Board Certified medical doctor that does not appreciate those that worship the ground he or she walks on?? When was the last time you were a patient of a Board Certified medical doctor and didn't notice that the doctor demanded that his staff treat him/her as if they worshipped the ground they walked on? Why do some chiropractic physicians continue to refuse to make timely and appropriate referrals and spend so little time on the initial intake interview that so many symptoms that should alert one to the possibility that this patient may not be healed in 6-8 weeks get missed? Why am I mad? Because I get to deal with the outstanding balance owed to the chiropractic clinic that wasn't paid by the PIP carrier, and I get to explain to the client why they're not getting much money because most of the injury recovery has to go to the chiropractor to pay the huge outstanding balance. Grrrr. G. , speaking for no one but himself, Salem, Oregon.