I was asked a very interesting question the other day by a listener of the show. After he asked the question, I felt compelled to answer, because I KNOW there are so many out there feeling the same.
I promised to keep the name anonymous, but here is what was asked:
“Hello, Andrew. Love the podcast. I’m a FP PA less than a year into clinical practice and I have a question that many new grads probably deal with. My question is: ‘when to hold ’em and when to fold ’em’ for common conditions? Especially my first few months in, I wasn’t sure how far to take a workup before it was appropriate to refer to the specialist. Elevated PSA, decreased GFR, Anemia not responding to initial treatment, etc.
Along the same line, when to just order the diagnostic study vs office visit with specialist.”
First off, I want to give a disclaimer that this entire answer is my personal opinion. During practice I have dealt with two types of patients: those with insurance and those without.
The patients without insurance are paying out of pocket and cannot afford to see a specialist. Many, don’t have the paperwork to even apply for medical. So, it’s my job to do as much as possible before I say they need to seek specialized care.
On the flip side, I have patients with insurance, who can easily be referred. The problem that I commonly run into is it will take months for them to be able to get their initial consult with a specialist. So, there are things that can be done in the mean time which I know the specialist will want to see.
But, lets start with something easy. If you feel like an echo, colonoscopy, etc are needed – you should refer to a specialist. Those types of studies are typically done by the specialist anyway – making this one a no brainer.
The far majority of studies, however, are not done by a specialist. So, the next thing you have to think about is: if you order a test – will you know what to do with the result? If the answer is no, don’t even go down that path.
If the answer is yes – then you have another question: can you do anything about it? If you can’t and you would have to refer anyway, then that is your answer.
If you can, then order the test and address the outcome appropriately.
The fear many have is the possibility of missing something. This fear holds many back and forces the young clinician to “play it safe”. The reality is that the majority of things don’t need an intricate workup.
The problem is, you only know that with experience. So, what is one to do lol. Something which helped me immensely was reading the progress notes of the specialist. I would read the patient visit, treatment, and plan. Another thing I always do is ask the patient: “what did your cardiologist say” “what did he recommend.”
Don’t be scared of looking dumb. You won’t. The patient sees this as you caring – nothing more.
After a while, you start to notice patterns and things start to click.
With all that being said, this a broad question and every situation will be different – which is why I can’t give one clear answer. But, maybe it would help if we were to walk through an example…
I like the example of anemia stated in the question, because it is very common. So, let’s say a female patient comes in for a routine physical and you order labs. Her hemoglobin comes back at 10.0.
She’s anemic. You look at her MCV and it’s low. Next you notice an elevated RDW. The most common etiology would be iron deficiency anemia. So far, so good.
Let’s say you didn’t bother to take an appropriate history – instead, you started this patient on iron. Then, you have her come back in one month and notice she isn’t responding to oral iron therapy.
She’s iron deficient. You gave her iron. It’s not working. What gives? Do you refer to hematology? Well, if you did, they would be pretty upset.
Did you get a history? Do you know why the patient is bleeding? Is it a bad diet, an absorption issue, or is there a bleed? The most common situation is a heavy menstrual cycle – this is a GYN problem not a hematology problem. What is a hematologist going to do about a heavy menses? It doesn’t matter how much iron is thrown at the patient – if she is losing more than she can absorb it won’t matter.
Moving on. Ok, you find out she has heavy menstrual bleeding, you place her on hormone therapy, and all is well.
You start her on iron once daily and have her come back in one month. Her hemoglobin is still at 10. Now do you refer?
I wouldn’t. Why not? If you were to refer – will the hematologist do anything differently that you can’t already do? At this point, not likely.
We need a better history. Is she taking her iron with calcium, on an empty stomach, or with her morning coffee? These are all things which will affect the absorption of iron.
Let’s say she’s not doing any of those things. Now what? Well, you can up her dose to twice daily or three times daily. Still worried? Have her take it with vitamin C – this helps increase iron absorption.
One month later she comes in. Let’s say she is still not responding. Now, is it time to refer? At this point, I would say so.
She has officially failed oral therapy. At this point she needs to be worked up for a bleed somewhere else or she needs to be given IV iron.
Either way, you can’t do an endoscopy and you can’t give IV iron therapy. You have officially exhausted your resources. This is the ideal time to refer.
What’s the problem you see here? A lack of experience can stop you at the very first step: giving iron without collecting an appropriate history. Many will get hung up here because the thought of asking those question would have never surfaced.
You don’t know, what you don’t know.
Ideally, you should refer this patient after the last step discussed. But, like I said, many won’t get there. So, what should you do?
YOU should refer this patient the second you don’t know what to do. But, before you refer to a specialist, ask a colleague for help. Sometimes all it takes is a different set of eyes on the case.
So, my final answer to your question: it depends.
Someone with more experience will be able to fix most things and will rarely have to refer. Someone without the same experience will need to ask for help much more often – but that is ok! There is zero shame in asking for help. Please don’t let your ego get in the way of this.
Asking for help shows that you are putting the patient first and how eager you are to learn. Asking for help also exposes you to a variety of different opinions which will accelerate the learning process.
I was forced into a sink or swim situation. Because I dealt with the uninsured so early in my career (and was a solo provider for a lot of the time) I had to force myself to stay up late and read, study more, and speak with various specialists.
This was probably not the most ideal situation, because looking back, I’m sure there were many I just didn’t care appropriately for due to my lack of knowledge. But, it forced me to think differently, so for that I am grateful.
I know this was a very long answer. But, I’m curious, when do you refer? Do you know when to say when? Shoot me a reply – I’d love to hear your thoughts!