Hospital's priorities are usually not aligned with how we pay hospitalists. In fact, the two are often in direct conflict with each other. In my last post, I argued that...
Many physicians complain that they make too much money. One of the main sources of all of this unwanted money is from consults by referring physicians. In order to reduce one’s income, one very effective solution is to offend your referring physicians so that they send their patients to other doctors, thus causing them to make too much money. The good news is that electronic medical records make it easier than ever before to offend referring doctors. I’m going to show you how any specialist can use the EMR to achieve that ultimate goal of a lower income.
In the old days, it was harder to be confusing. We used to dictate our referral letters and it was just way too easy to dictate phrases like “Helicobacter pylori”. This led to referring physicians understanding exactly what you were talking about. With the electronic medical record, it is now much easier to just type “HP”. The result of this is that the referring physician reading your letter now has to figure out, “Does he mean Helicobactor pylori? Or hypersensitivity pneumonitis? Or Hewlett-Packard? Or hypertropic prostate?” Abbreviations are a great way to confuse the readers of referral letters, especially those abbreviations that you make up. So, if the patient has pedal edema, put in your note “The patient had AS” – you’ll mean they had ankle swelling but the referring physician will think you meant aortic stenosis and order a cardiac catheterization! Try to put 1-2 abbreviations in each sentence for optimal effect.
When we dictated letters, this was really hard to do because dictating an interminably long letter took a lot of your time. With the EMR, we can now insert 10 pages of irrelevant results into a referral letter with a single mouse-click! There is nothing like making the reader of your letters wade through the last 30 potassium levels dating back to 2009 to tire them out. Many EMRs allow you to import all of the meaningless lab and test results into tabular format that is next to impossible to comprehend – a sure way to get the pesky referring physician to stop referring you more patients.
A great trick I learned from one of our physicians is to vary where you put your impression & plan in your referral letters. Let’s face it, the referring physician could not care less about your review of systems, physical examination, etc. All they really want to know is what you think is going on and what either you are going to do about it or what you want them to do about it. So, the referring physician will automatically skip all of the irrelevant material and go straight to your impression and plan. By sometimes putting the impression & plan at the beginning of your note and sometimes putting it at the end of the note, you can keep them guessing about where to look. If you really want to disorient them, try sometimes putting your impression and plan in the middle of your referral letter! As an analogy, just think of how confused you’d be if the National Hockey League scores were sometimes in the sports section of the newspaper, sometimes in the arts & entertainment section, and sometimes in the middle of the classified ad section. The only danger is that if your referring physician likes playing “Where’s Waldo”, then he or she might actually enjoy the challenge of finding your impression & plan.
Try writing your progress notes and referral letters in the same language that your teenager uses to text. Use letters like “u” instead of typing “you” and “r” instead of “are”. You can even abbreviate entire phrases like “IMO” for “in my opinion” and “HTH” for “hope this helps”. Whenever possible, drop verbs out of your sentences. Don’t capitalize anything. And remember, punctuation marks are for sissies.
If you don’t like the question that the referring physician asked you, do what politicians do in a political debate – answer a different question! So, if you get consulted because of a patient’s chest pain and you are completely clueless about what is causing it, then find something else that you can work up, like their plantar fasciitis. There is nothing like “Dear Dr. Jones, Thank you for referring your patient to me for evaluation of crushing substernal chest pain. On exam, I find heel tenderness. My impression is that he has plantar fasciitis and so I will order an MRI of his ankle.” Although it is possible that the referring physician will think you are a genius for figuring out that plantar fasciitis causes referred pain that can mimic angina, it is more likely that they just won’t understand your letter. Another great way to get them to stop sending you patients.
When a referring physician sends you a patient, try to write your note in such a way to be as critical of their initial work-up as possible. If you get a consult for anemia, try inserting phrases such as: “Unfortunately, the patient’s physicians have not ordered screening colonoscopy as recommended by the American Cancer Society.” Or: “This is a textbook classic case of beta thallasemia minor that any 2nd year medical student should recognize.” If these are too subtle, try something more direct like: “The decision to order an iron level without doing a ferritin level was a really stupid idea.” I actually got a letter with a phrase like that in a consultant’s letter to me and so I never sent a consult to that physician again – if it worked for him, it can also work for you!
A very effective way to alienate the referring physician is to depersonalize them by using phrases like “PCP” and “OSH”. So, if Dr. Smith, who practices at Mercy Mother of Suffering Sorrows Hospital refers a patient to you for consultation, don’t use Dr. Smith’s name in the letter, instead just put PCP for primary care physician. This will depersonalize the referring doctor and emphasis the fact that you consider him or her to be irrelevant and beneath you. There is nothing like starting your letter by saying “Dear Dr. Smith, Thank you for referring the patient to me. She has shortness of breath and her PCP found a new heart murmur.”. In addition to depersonalizing the referring physician, you can also depersonalize that physician’s hospital. Although Dr. Smith may consider Mercy Mother of Suffering Sorrows Hospital as the center of his medical practice universe, you can remind him that his hospital is just a generic small hospital and THE Ohio State University Medical Center is the true center of the medical universe. Using OSH for outside hospital is a very useful strategy. Try writing something like: “The patient had a cardiac echo at an OSH.” Just think of how irritated you would be if you asked for a consultation and the consultant sent you a letter referring to you as PCP and your hospital as the OSH.
By using some of these simple strategies, you too can reduce your income by cutting off the flow of consults from referring physicians. And your electronic medical record makes it easier than ever before to do it.
May 6, 2017