I was told to not write scripts for physical therapy while working as a doctor in the emergency room because therapist will call to discuss cases and we arent built to answer primary care issues with patients we see for one visit in a year. The general idea of and ER is to "treat and street", take care of immediate issues and if not life threatening, send them back to primary care. Problem is that many people who cant afford insurance use the ER for their office doc. Even people with public aid will have ER visits paid for but primary care may be paid for but will be difficult to get into.....thus they also see the ER for primary care. Then there are the well established doctors who have very full schedules and cant pack in patients for same day appointments so send them onto the ER for what "sounds like it needs an ER visit symptom". Since I have been working in the ER I have noted that the average patient may wait 2-4 hours. This is a wait that will range from sore throat to chest pain.
One of the reasons I write is to kinda of gripe about the need for efficiency but the resitance for change. I have training in sports medicine and medical acupuncture more than most of my counterpart family practice breathren. This doesnt win me a bigger paycheck or a higher position in a hospital. Ney, I get paid the same paycheck at everyone else but I may get patients cleared of their disease state faster. More due to the fact that I combine physical medicine with conventional medicine. A regular primary care doc would probably be able to come up with the same diagnosis but an extra step or two is saved due to the fact I dont have to get another consult to help with ongoing care or treatment. (example: if ortho is needed, it will usually take about a week to get one to see a patient and that is after the right test is ordered)...that could translate to a week of lost wages or a week of a mom staying home to care for a kid that could have started physical therapy sooner.
I digress, in the ER I see alot of sprains and strains. I know how to send off and I even write specific plans and orders on the script to physical therapy. The option is always to start it and just have them follow up with primary care if they still need something after a few weeks or if the patient suffers a set back while in PT. So I save the patient, save the primary care docs office the hassel of seeing the patient after the accident or trauma and then prescribing the same script they would have written in less detail, saved the patient time at home doing nothing waiting for a call back from the primary care doc or ortho docs office, saved the work from paying for a temp to come in and do the work of the individual for his or her time off. But ....if it goes off the grain of standard procedure I shouldnt do it. Dont get me wrong, The administrator is doing the right thing by saying to hold it cause the system isnt set up to follow these people I am helping (an I am doing it at a discount since I am not getting paid for giving my expert opinion on the topic of how to care for a specific injury).
To expound on the topic, I have alot of nurse freinds who have been trained to be managers but it is just too much hassel and political red tape that even with training they step down to routine "grunt" work because the excessive frustration isnt worth the extra few dollars on the paycheck. Also a higher liability, since one that is higher on the food chain is also accountable. (more of a scapegoat when needed)
Patients know this and they will pay extra just to be in the care of a doc that knows their particulars. This concept is growing of "concierge medicine" which used to be called boutique medicine since it seemed to cater to those who needed foofoo care and hand holding. Truth now is that patients know faster care and more efficient care can be managed if the doc knows you and is willing to cut corner in caring for you, whether it is in time to see him, time to get to talk to consult or time to get out into a procedure. The catch is a family usually has to pay a "retainer fee" to be in the docs small circle. Doc usually takes 500 patients only to devote more time to each one. (this compared to the 2500-3500 patients needed per year to break even with the expenses of a 1-2 man office) Imagine a family paying an extra 1000 -1500 dollars a year on top of medical insurance bills.
I believe this is also the reason people are shying away from docs and conventional medicine due to the doc doesnt spend time to listen since he or she is so busy that they only spend the bare minimum to hear a select symptom or two and make a great diagnosis to prescribe the standard prescription medicine and have them follow up. Patients are never one medical problem now a days. With all the pressure today and 50-60 hour work weeks, dual income families, poor eating and poor health, even if they only complain about one thing, there are two more to address that have to be postponed until 1-2 weeks when the next opening is available. The proverbial 15 minute slot has to be followed or a practice with go belly up paying for all the extra people needed to take care of the paper chase that the insurance companies create to keep money in check. Well, I do what I am told and dont write scripts for PT anymore....tonight was painful because a patient whom I was treating could have used physical therapy quickly but now I had to send her back to the clinic that couldnt fit her in tonight for a simple sprain. And she will probably spend 3 days getting an appointment, then another 3 days to see a specialist, then another 3 days to get to PT. At least the nursing manager said the idea was good but it has to be approved by all primary care docs before I could do it and the other ER docs had to agree. I'll submit it to the house to be approved by the senate just to be veto'd by the higher ups......oh well! Just do your job and turn away is what my wallet says.....but my heart says help the sick! Where is Hippocrates when you need him!
