“If you do NOT have a plan, you are part of someone else’s” – Terrance McKenna

Your FOCUS is to TEACH and HELP

I had a very interesting clinical, business experience today.  I have a patient whom I have been treating for a workers’ compensation injury to his lower back.  The injury occurred after a fall down some cement stairs in the prison in which he is a guard.  This patient had severe radiculopathy down the left leg and after confirmation of disc herniation with nerve root compression via MRI (the symptoms were severe enough that no EMG was needed), he underwent microdiscectomy by the spine surgeon I referred him to.  This patient now continues to have back pain, but little leg pain, which was the point of the surgery.  I continue to manage him 1-2 visits per week and he returned to work 10 months after the surgery.

He called to reschedule an office appointment with me, stating that he broke up an inmate fight (one was trying to stab and kill the other) and injured his knee to the point that he could not stand or walk on it.  He was at home and barely able to move.  The rest of the details were not important until he came back to my office.   He hobbled in and I looked at his knee and told him he needed to see an orthopedic surgeon as he had probably torn some ligaments.  I referred him to the knee surgeon that I have worked with for a long time.  This is where it gets interesting.  A few days go by and then the patient is due in my office for his regular lower back treatment. This guy is PISSED…hugely…and that is an understatement.  I had to calm him down and that was 4 days AFTER the visit with the orthopedic surgeon.

The scenario in the orthopedic office started with the physician’s assistant.  My patient had seen him and he treated him pretty poorly.  I have never met the PA and specifically sent the patient to see the MD.  The PA said he could go back to work on light duty and he would request authorization for an MRI of the knee.  There were some other nuances in the conversation, but the report was different and did not mention light duty, but stated he was totally temporarily disabled.  One important aspect is that HE DID NOT NEED PREAUTHORIZATION FOR THE MRI!  The long story is that the patient ended up going to his primary physician and was promptly referred to another orthopedic surgeon.  The next day the patient received the surgeon consultation, his MRI and is now scheduled for surgery due to a torn meniscus.    I did place a call to the orthopedic office and discussed all of this with one of the partners today; it is Saturday.  Believe me when I tell you that surgeons get upset when they lose a surgery…especially due to clinical incompetence.  This is why I have been telling you that the link you need to establish  with the MD is one of clinical competence and diagnostic skills; treatment modalities mean little to them.

Now, this is where there is opportunity.   The MD Lecture Series is going to be in full swing in the next few weeks, so what am I going to do with this situation?  I am going to leverage it to TEACH the MD that he/she has a problem and that my class offers Category I AMA credits can help train PAs in proper triaging techniques.  Surgeons start seeing patients on their own when they first start to practice, but then they get so busy that they need PAs.  Once the PAs come on the scene, surgeons have NO time to train them.  This goes for PAs in primary care, internal medicine and pain management.  What do they do with the conservative care cases?  Do they know how to refer to you?  Do they know that if they refer them to you that you will keep the patients “In the Loop?” (Please re-read that consultation.)

The relationship all begins with presenting research materials to the MD offices, getting to know them, establishing yourself as a competent resource for information and then helping them by teaching how to move musculoskeletal cases through the conservative care minefield…We can do that in ANY medical office; you need to keep at it and be consistent…Simple as that!

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