Is family medicine = refer-tologist?

[Fullmetal_Biochemist]

Got a slight skin allergy, went to a family physician, got less then 30 second check-up, and got a referral to a dermatologist ... Went to the dermatologist and got an over-the-counter medication for hypersensitivity ...

 

Nice referring skill there! I got this problem multiple times, so it's not just "one bad apple ruins the basket". I guess the term Refertology should be added to the medical dictionary

[shady]

I think it depends on the family doctor. It is probably more likely to happen in a big city than a rural area for example.

 

I recently went to my family doc for eczema and was prescribed a cream without referral

[Fullmetal_Biochemist]

I think it depends on the family doctor. It is probably more likely to happen in a big city than a rural area for example.

 

I recently went to my family doc for eczema and was prescribed a cream without referral

 

I won't get upset if it's just one or two (or even a handful) of experience. However, me + my friends + my family have plenty of those experience

 

My fiancee even told me that her family doc doesn't border say hi (just jump in, looked at the file, wrote a referral ... less then 10 second in total)

[Birdy]

I have just gone through several months of evaluation before my family doctor referred me for a surgical consult, and even then it was only because the imaging department refused her request for a certain imaging type (the DI schedulers here will refuse or change the urgency of things regardless of the doctor's opinion. Drives me nuts) so she couldn't find out more.

 

Because of how much I moved, I've had somewhere around ten family doctors, plus I've seen many in walk-in clinics when I haven't been under the care of one. Some refered a lot, some didn't, and I'm a somewhat complex patient. Obviously I'm not yet in med, but I don't think it's proper to go making blanket statements about specialties, given how much individual practice seems to vary.

[seeking1]

OP, I have a one-word unsatisfying answer for you: depends.

[Fullmetal_Biochemist]

OP, I have a one-word unsatisfying answer for you: depends.

 

You have the potential to become a great politician lolz, just kidding

[dmleo]

Most and good family docs don't spend less than 30 seconds a patient even if its a drug refill or checking an allergic response. Your fiance's doctor also is not a good representative either if he/she is actually spending less than 10 seconds like you say. You clearly exaggerate this.

 

Find a different doctor if its true and no, family medicine is not equal to refer-tologist.

Talk to any family doctor in rural medicine who runs everything from conception to palliative care.

[rmorelan]

there are temptations to be refer happy of course - you can see more patients as complex ones are sent to others, often you are sending them to your colleagues that don't mind the business (boring maybe for the dermatologist in your example but quick and very likely the correct diagnosis was made). You can argue in many cases it ensures a quick correct diagnosis (rural docs are very self reliant, and thus experienced but I don't envy the shear volume of material they have to master and keep up with. You would have to hope a specialist in a sub area would know that area still very much so better). Patients often appreciate the second opinion as well.

 

and rashes can be very deceiving

[GrouchoMarx]

I am unfamiliar with the fee guide for family physicians, but I have a question.

 

Is it more economically viable to refer out patients? Does a ten second referral appointment charge the same fee as a ten minute evaluation and management appointment?

[ArchEnemy]

I am unfamiliar with the fee guide for family physicians, but I have a question.

 

Is it more economically viable to refer out patients? Does a ten second referral appointment charge the same fee as a ten minute evaluation and management appointment?

 

It really depends on which funding model the family physician has adopted. If you really are interested, i would like to "refer" you here (pun intended )

[GrouchoMarx]

It really depends on which funding model the family physician has adopted. If you really are interested, i would like to "refer" you here (pun intended )

 

Referring still seems to be the most economically viable option in any of those systems.

 

In FFS, you'd get paid more assuming the time/appt does not change the remuneration.

 

In blended, it could go either way depending on the patient mix.

 

In salary, it would shorten your day such that the gross income would not change but the hourly rate would.

 

Can it be assumed that referral robots are doing it partially or wholly for income?

[thebouque]

Cain, would you say that some pathologists are referologists as well?

[GrouchoMarx]

Cain, would you say that some pathologists are referologists as well?

 

The practice patterns are different. Where a patient in a family medicine clinic will likely have multiple evaluations after the first presentation, a pathologist will look at the slide once most of the time, and nobody else looks at it after that. Pathologists would expectedly be a bit more liberal in referring out cases due to the evaluation being final, and I would consider this good practice, not over-referring.

 

IHC tends to be limited in smaller centres, which would make them more likely to send out cases that require it. I have not seen a pathologist send out every GI biopsy the same way a family doc could refer out every patient that walks in the door. Could they?

 

How is it in Quebec under the L4E model? Are pathologists there less likely to refer out because they want to meet the 1.5 FTE quota?

[Fullmetal_Biochemist]

Referring still seems to be the most economically viable option in any of those systems.

 

In FFS, you'd get paid more assuming the time/appt does not change the remuneration.

 

In blended, it could go either way depending on the patient mix.

 

In salary, it would shorten your day such that the gross income would not change but the hourly rate would.

 

Can it be assumed that referral robots are doing it partially or wholly for income?

 

"Your question will be referred to a Referologist for further and proper answer(s); meanwhile, for today consultation, please swipe your health card"

[ArchEnemy]

Referring still seems to be the most economically viable option in any of those systems.

 

In FFS, you'd get paid more assuming the time/appt does not change the remuneration.

 

In blended, it could go either way depending on the patient mix.

 

In salary, it would shorten your day such that the gross income would not change but the hourly rate would.

 

Can it be assumed that referral robots are doing it partially or wholly for income?

 

I believe FP are not remunerated for reviewing the specialist report/images. Hence, referring patients out constantly may or may not be ideal for their practice.

[Hockeynut]

Not a med student here but I would like to include my own opinion on this matter. Growing up in a rural setting and now living in Montreal I've seen both sides of the evolution of family physicians. The modern FP is essentially just a warm body to refer to a specialist. This is from a vast amount of personal experience, beyond that this is how they teach nowadays. When your not an expert on the matter just refer to someone else within the healthcare team. This is a completely ok system for major centers where there is a large number of specialists/FP. In a rural setting this is absolutely abhorrent. Old school FP in the North are some of the best, most well rounded/read individuals I've ever met. It's insane the breadth of knowledge they have. That being said the new age physicians come into town and aren't confident/ don't know and refer patients out to specialists. This is really hard as people wait months until a specialist comes up north to hold a clinic or must travel 400-1100 kms to see a specialist which during the winter, isn't exactly a fun idea.

 

In my mind FP are being trained to refer to specialists, as his is the way the current healthcare system has been designed. This really puts those who live in a rural setting at risk.

[leviathan]

When you're not a staff physician, resident, or even medical student, I wonder how you've come to these conclusions about the training of family physicians, Hockeynut.

 

Family physicians receive very good training throughout med school and residency combined to manage the bulk of problems that come into the office. The tendency to refer is more a product of the competence of that physician and their comfort level, rather than the training itself.

[Arztin]

I shadowed a family doc a few weeks ago a whole day. During that entire day, he referred only one patient to an orthopaedic surgeon because she had hip problems. He treated all the other patients by himself. Therefore, he gave me the impression that family docs can actually do a lot.

 

Edit: he did send another patient to the hospital to get some labs though.

[BK47]

When you're not a staff physician, resident, or even medical student, I wonder how you've come to these conclusions about the training of family physicians, Hockeynut.

 

Family physicians receive very good training throughout med school and residency combined to manage the bulk of problems that come into the office. The tendency to refer is more a product of the competence of that physician and their comfort level, rather than the training itself.

 

^This. 100% agree

 

Family docs do get good training. A new grad fresh out of residency might refer stuff along at a higher rate compared to someone who is older but as they get farther out and more competent/comfortable/they have seen more, they have a better idea of what they can realistically manage on my own. Further to this point, just by virtue of being in practice and seeing what specialists have said/done about things they have sent along, they get a better idea of how to manage some of those things w/o even involving the specialist next time around.

 

When I did my family medicine rotation the family doc I worked with (who was fantastic) told me it definitely takes a few years after finishing residency to really get comfortable being on your own. He's an older guy who is an excellent doc and he told me when he was younger he definitely referred along a lot more than he sees today.

 

And on the general subject, I don't think family doctors are simple 'refer-ologists.' They have their scope of practice which will cover a lot of things depending on their own comfort level. Naturally there are things which will fall outside the scope because of their training and they have to refer on (e.g. patient needs a colonoscopy... patient needs an operation...). Family MDs, at least all the ones I've worked with, do not simply refer everything along. I think it's actually a tough skill to know when you ARE out of your depth and have to refer along, vs. 'no, its not that serious, I can probably manage this / maybe all the patient needs is reassurance.'

 

Coming from someone who will be starting a residency in Internal Medicine, I have a lot of respect for family docs. They're on the front lines and really are the gatekeepers (among many other things) of our healthcare system.

[leviathan]

I should reiterate what BK47 said as well. I can remember maybe a handful of consults that we made throughout my 6 weeks of family med rotations in clerkship. They were all appropriate referrals as well.

[bloh]

The problem nowadays lies halfway in the patient as well. They expect a referral. They've read on the internet that their indigestion could be cancer/celiac/fill in the blank and they've read that they need ______ specialist.

 

The other part is inexperience and comfort. If you haven't managed something enough times you may not feel comfortable fiddling with it. So a referral in that case, isn't necessarily a bad thing IF you learn from it. I've read amazing consult letters that were sent back to the GP that outline perfectly how to manage that (and future) patients. A good example that I've seen in my training is cluster headaches. We've all read about it and been taught it in school but how often will a GP truly see cluster headaches? Not very often. So when it finally comes to your door and you think you know what it is, there will be some discomfort in managing it on your own, especially since the management isn't without risks. The consult letter that came back with that referral was super awesome; outlined first line management, what to look for, what to use if it doesn't work and under what circumstance to referr back. That kind of experience is incredibly valuable. Unfortunately, not many specialists take the time to do that kind of teaching because it takes time and money.

[Josh Rider]

This is kind of how I see the role of the family physician based on my experiences with my own family doctor, paediatrician as a kid, and doctors that I've seen at clinics:

 

1) Annual check ups: Blood tests/urinalysis, physical examination (vitals, neuro, etc), history/conversational information, treatments for non-complicated ailments, referrals and follow-ups for testing or specialists if needed.

 

2) Short visits for acute or chronic medical issues: Flus, Colds, Strep throat, sinus infections, allergies, migraines/headaches, anxiety, gastroenteritis, rashes, UTIs, etc. Get relevant diagnostic tests and prescribe relevant treatments if a simple case and refer to specialist if he feels that it is beyond scope of knowledge/experience and requires more careful care.

 

For example, for a minor-moderate case of psoriasis, intertrigo, or eczema, a family doctor may prescribe the cream himself. If the skin condition is severe, is difficult to diagnose, or isn't responding to basic treatments, then a family doctor should refer to a dermatologist.

 

3) For patients who have multiple chronic medical conditions, a GP acts essentially as a person who can assist you at integrating your care and making sure that all of your medical conditions are being observed and treated.

[preppy038]

it DEPENDS

 

when i was on ob/gyn, there was this family MD who basically refers any ob/gyn patients.

 

i.e. he won't even do a pelvic exam because he's "afraid" -- is literally what my obs/gyn said.

 

At the same time, I worked with a family MD who did all the gyne stuff +/- invasive procedures (so he did all primary care gyne like pap smears, endometrial biopsies, primary care ob like low-risk OB care +/- deliveries etc)

 

Family MD is what you make out of it. If you're extremely skilled in IM, you could be your patient's "internist" and manage all their medical issues (whether or not that's an economically efficient practice is another issue)

 

The only thing is that for surgical issues you do have to refer for surgeries.

 

 

Bottomline: you could work as a referotologist as a family MD if that's your choice,

 

or you could work as a proficient family MD who has a broad knowledgebase and is able to handle all types of patients before referring.

 

 

Derm is a unique area because I feel as though most medical students don't get much exposure to it, so it always seems to be an iffy field for family medicine to be semi-experts in it, which may have been the reason why you were referred for an allergic dermatitis

[Renoir]

it DEPENDS

The only thing is that for surgical issues you do have to refer for surgeries.

 

Are there not some minor surgeries that can be done by FM? I'm thinking rural areas - I had my tonsils out in a rural hospital many years ago, and don't remember a surgical team being there at all.

 

I imagine there would maybe be some extra rotations or something for that to work?

[BK47]

I think family MDs can handle some basic outpatient procedures that only require local anesthetic (not GA or anything...), like a punch biopsy or maybe excisional biopsy on the back or something not too complex. Beyond that, though, I think in this day and age it would be very unusual for a family MD to do something like an tonsillectomy.

 

That being said, when I was on my family rotation the doc I worked with told me that the doctor he inherited his practice from ~20 years ago actually used to do appendectomies on his patients... So maybe back in the day it was more common for family docs to do invasive procedures.