HIV and ID Observations

From a local primary care provider comes this email:

Any chance you can look at my notes and scanned outside records from 6/22/2010 till today (including Nov 6 notation that details extensive past evaluation, including two previous ID consults) and labs? Briefly: 72 yr old woman with 6 episodes over the last 4 years of prolonged fever, malaise, normochromocytic, normochromic anemia, very high sed rate, negative cultures and scans. She has an upcoming rheum appt; I’m going to set up heme appt for consideration of bone marrow biopsy. Am I missing something?
Thanks in advance.
Nelson

(For the record, one stylistic part of this email to highlight — “Thanks in advance”. For some reason, I find “Thanks in advance” nettlesome, while a simple “Thanks”  or “Thank you” or even “Tx” all strike me as polite — and I like it. Why? What’s wrong with me? My wife thinks I’m way too sensitive, and should get a life.)

Ok, we’ve all been there. You get a curbside that is staggeringly complex, with a truckload of data already accumulated, and you, the ID doctor, are asked to review the chart and render an opinion without seeing the patient.

It’s obviously not that this is a stupid question — on the contrary, it’s completely understandable and quite appropriate that this PCP is asking for help on this challenging case.

It’s just that there are multiple reasons why this patient should actually be seen, interviewed, examined — you know, a “formal” consultation.

Why? Let me count the ways:

1. History. If there’s one thing ID doctors pride ourselves on, it’s getting the history right. For more on this, read here. If you don’t want to click the link, it’s a lengthy but I hope entertaining brag about how ID doctors take the best histories. Look, we have to boast about something.
2. Other specialist appointments. The patient has appointments set up with a rheumatologist and hematologist. What, are the ID doctors chopped liver? Given the duration and waxing/waning nature of the symptoms, the negative cultures, and the negative scans, the PCP is correct that a non-infectious diagnosis is more likely than an infection — but then why not schedule the ID appointment to take place after these two other brilliant specialists weigh in? (This is what I recommended, by the way.)
3. Medicolegal risk. Chart reviews of patients you have never seen or will never see are frowned upon by malpractice lawyers, who view this as establishing a doctor-patient relationship, increasing medicolegal risk. For more on this dicey subject, read here. Hey, I don’t make the rules.
4. Time and dollars. All that chart review takes time. And time is money, especially in our current payment structure. ID doctor’s RVUs per visit may pale in comparison to replacing someone’s knee or removing a mole or screening for colon cancer with a long scope with a light on its end, but what else can we do?

And it’s this last financial issue that could, and probably will, end up changing how ID (and other) doctors balance formal and curbside consultations.

Under Accountable Care Organizations (ACOs), groups of clinicians receive a lump sum to work together to provide the best care for their patients — and with the greatest efficiency. (Read: “Lowest cost.”) No more payment by RVU, and medical utilization is discouraged. My gut feeling is that I’d still want to see this patient, but perhaps instead I’d be encouraged to be part of a practice group panel to review all the outside records before she gets her specialty appointments.

So if ACOs don’t end up increasing the volume and complexity of curbside consults, I’d be shocked. Capitation in the 1990s, which had a similar (but not identical) structure to ACOs, triggered an increase in curbside consults, for obvious reasons.

The plus side of ACOs could be greater efficiency and more collaborative care. Let’s just hope that with greater demand for this sort of clinical work — informal, curbside consultation — there’s greater recognition of its value, both for patients and providers.