Patient centered approach at clinics

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spimx

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Have y'all encountered a scenerio where in a clinic the doctor does not give the patient options? On multiple occasions nursing homes stand alone ER and clinics the doctor directs the patient exactly where to go and they must go my EMS, without options. Recently I pushed adenosine in a clinic and the NP directed the patient to the furthest possible ER that was also on diversion.

I respect my patients autonomy. Why are doctors and mostly NPs and PAs directing patients to specific ERs without options. I don't buy this ******** that continuity of the NP at the local clinic is important. I perform an assessment inform my patients and include them in their healthcare
 
There's a difference between not offering patients a choice of destinations and not providing options if requested.

There weren't many times when I volunteered to take EMS patients wherever they wanted to go. I felt part of my job was to pick the most appropriate facility for unstable or potentially unstable patients. If they objected, I'd accommodate their preferences when feasible. Is it possible the physicians, NPs and PAs you mentioned are doing the same?
 
mgr22 said:
There's a difference between not offering patients a choice of destinations and not providing options if requested.

There weren't many times when I volunteered to take EMS patients wherever they wanted to go. I felt part of my job was to pick the most appropriate facility for unstable or potentially unstable patients. If they objected, I'd accommodate their preferences when feasible. Is it possible the physicians, NPs and PAs you mentioned are doing the same?
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No not possible, they are choosing the destination based on the privilege's of the physician they work under, they send every patient to that hospital. We bypassed 3 hospitals, all very capable.
 
Since you know more…Why don’t you ask THEM?
 
spimx said:
No not possible, they are choosing the destination based on the privilege's of the physician they work under, they send every patient to that hospital. We bypassed 3 hospitals, all very capable.
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So, the patients are going to a hospital where their doctor has privileges. Do the patients object? Does the hospital not meet criteria for treating those conditions?
 
mgr22 said:
So, the patients are going to a hospital where their doctor has privileges. Do the patients object? Does the hospital not meet criteria for treating those conditions?
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Most patients don't even understand they have options, they will do whatever the doctor tells them to do unless they are given options. The hospital is suitable however like I said I bypassed 3 hospitals for a hospital on diversion twice the distance of the closest suitable hospital.
 
The same thing used to happen in San Marcos when a patient had a STEMI at CTMC and need to be transported for PCI, the patient is given no options and a Hospital is bypassed for an affiliated hospital 20 min further.
 
spimx said:
The same thing used to happen in San Marcos when a patient had a STEMI at CTMC and need to be transported for PCI, the patient is given no options and a Hospital is bypassed for an affiliated hospital 20 min further.
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So thus saving the pt from an insurance burden…

Your JOB is to drive the pt to the hospital, not suddenly decide you know what’s better for them.
 
CCCSD said:
So thus saving the pt from an insurance burden…

Your JOB is to drive the pt to the hospital, not suddenly decide you know what’s better for them
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A deputy chief should understand patient centered healthcare better that that. Unless I receive an order from my medical director my job is to be an advocate for my patient. Insurance has nothing to do with it. I'm talking about delaying patient care in a critical or life threatening scenerio. Respect for autonomy is also important. I am sorry for the community that you support if you can't understand these concepts.
 
spimx said:
A deputy chief should understand patient centered healthcare better that that. Unless I receive an order from my medical director my job is to be an advocate for my patient. Insurance has nothing to do with it. I'm talking about delaying patient care in a critical or life threatening scenerio. Respect for autonomy is also important. I am sorry for the community that you support if you can't understand these concepts.
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Don't confuse his forum rank with real world rank.
 
CCCSD said:
Your JOB is to drive the pt to the hospital, not suddenly decide you know what’s better for them.
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Sigh... I think we found the guy who refers to EMTs and paramedics as ambulance drivers...
 
Nothing is more frustrating than trying figure out a new patient who has never been to your hospital system's complex medical history at 2am on a Saturday morning and having to wait until 10am Monday when the competing hospital's medical records (that he/she has been admitted to 30x) or their PCP of 25 years opens because the patient was brought to the closest ED from the PCP office instead of 10 mins across town when it truly wasn't life threatening.

Perspective is always important. For many patients with multiple chronic diseases their pre-hospital and ED care is often only a tiny portion of their interaction with healthcare. Balancing continuity of care vs need for urgent/emergency care in decision making is one part of being a good clinician.
 
silver said:
Nothing is more frustrating than trying figure out a new patient who has never been to your hospital system's complex medical history at 2am on a Saturday morning and having to wait until 10am Monday when the competing hospital's medical records (that he/she has been admitted to 30x) or their PCP of 25 years opens because the patient was brought to the closest ED from the PCP office instead of 10 mins across town when it truly wasn't life threatening.

Perspective is always important. For many patients with multiple chronic diseases their pre-hospital and ED care is often only a tiny portion of their interaction with healthcare. Balancing continuity of care vs need for urgent/emergency care in decision making is one part of being a good clinician.
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It's also a huge problem when their local PCP wants them to go an hour across town to a hospital they have privileges to and then later they have a life threatening medical emergency and now you are in conflict with the family that wants you to bypass the closest ER by 30min for the one their local PCP recommends.

I am only talking about critical or life threatening scenarios. I am fine to drive you all over creation if you are stable. Another issue is taking a unit out of service an hour longer than needs to be, in my area sometimes we bypass 3 hospitals and have a 4 hrs turn around.

The ethical thing to do for a doctor is provide patient centered care and include the patient in their healthcare. I don't understand the benefit of going to an ER that your PCP has privileges to, especially now days they are all np or pcp.
 
spimx said:
It's also a huge problem when their local PCP wants them to go an hour across town to a hospital they have privileges to and then later they have a life threatening medical emergency and now you are in conflict with the family that wants you to bypass the closest ER by 30min for the one their local PCP recommends.

I am only talking about critical or life threatening scenarios. I am fine to drive you all over creation if you are stable. Another issue is taking a unit out of service an hour longer than needs to be, in my area sometimes we bypass 3 hospitals and have a 4 hrs turn around.

The ethical thing to do for a doctor is provide patient centered care and include the patient in their healthcare. I don't understand the benefit of going to an ER that your PCP has privileges to, especially now days they are all np or pcp.
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Sounds like you've made up your mind...just going to say that because there's a sign that says 'hospital' in front of a building doesn't necessarily mean that's the best place to take a patient, especially if they're critical. Making up a little time on the initial transport may have a heavy price on long term recovery. Maybe 25 years ago, but not now. Subspecialist surgeons and proceduralists are not at every hospital because they are so specialized and some kinds of care have to be concentrated in order for the facility to be most efficient. Don't know if that's the case where you are, but it's not unusual.

Going to guess that there can be a lot of conversations between "providers", prior therapies/procedures etc. that you're not privy to and, odds are, everyone wants the patient to do as well as you do because they're going to see that patient again and you probably never will again.
 
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spimx said:
It's also a huge problem when their local PCP wants them to go an hour across town to a hospital they have privileges to and then later they have a life threatening medical emergency and now you are in conflict with the family that wants you to bypass the closest ER by 30min for the one their local PCP recommends.
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You keep saying "where they have privileges". But it seems much more likely that the reason the PCP is referring them to that hospital is probably because that facility is where they have seen providers and have all of their medical records. Unless the PCP who is referring them is also managing them in the hospital (which is really uncommon these days), then whether or not they have privileges there is irrelevant.

spimx said:
The ethical thing to do for a doctor is provide patient centered care and include the patient in their healthcare. I don't understand the benefit of going to an ER that your PCP has privileges to, especially now days they are all np or pcp.
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The ethical thing to do is make sure that the patient is referred to an appropriate facility, period. As has been mentioned, it is very likely that the most appropriate facility is one where the patient has previously received care, and not necessarily the closest facility that can provide the services that the patient needs. This is probably what is happening, and unless you have good reason to believe that patients are being coerced into going to a hospital they don't want to go to and which can't provide for their needs, then you really have no standing at all to claim than anything unethical is being done.

Honestly, it sounds like what is happening is that you don't really understand how patient referral and bed management works and are unhappy about having to drive patients farther than you think they need to go.
 
I work in a tourist area most of these people are from over 1000 miles away. They are sending people to the same place every time regardless of the pathology because it's an affiliated facility. How can you explain CTMC in San Marcos Texas sending a STEMI past a PCI facility for an extra 20 min to one that they are affiliated with. Patients don't know they are passing a cath lab on the highway unless you inform them.

Can anyone say that the patients should not be informed of their options before a facility is recommended? Our closest hospital is 35 min and longest trip is over an hour, these are not short trips where the difference in time is inconsequential. It's a problem of respect for autonomy that is exacerbated in the setting or rural EMS.
 
spimx said:
I work in a tourist area most of these people are from over 1000 miles away. They are sending people to the same place every time regardless of the pathology because it's an affiliated facility. How can you explain CTMC in San Marcos Texas sending a STEMI past a PCI facility for an extra 20 min to one that they are affiliated with. Patients don't know they are passing a cath lab on the highway unless you inform them.

Can anyone say that the patients should not be informed of their options before a facility is recommended? Our closest hospital is 35 min and longest trip is over an hour, these are not short trips where the difference in time is inconsequential. It's a problem of respect for autonomy that is exacerbated in the setting or rural EMS.
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If you show up to a PCP office or urgent care that is associated with "St. Theresa's Health System" and you need to go to the hospital for testing or a procedure, then yes, referral arrangements are going to be made to a hospital that is also associated with "St. Theresa's Health System". This is a universal practice and not isolated to your area. There are practical, logistical, and business reasons for this. It is very unlikely to have anything to do with the referring provider's "privileges".

It isn't an issue of patient autonomy unless, again, the patients are being coerced or lied to about their options. A referring physician has no ethical obligation to list every available destination option and the pros and cons of each, assuming the one that he does suggest is an appropriate facility.

If you are talking about scenarios where people in the midst of an anterior MI with hypotension and chest pain are sent all the way across town rather than the closest hospital with emergent PCI capabilities, then yes I'd agree that is problematic and you should probably report that to the appropriate authorities in your area. But the vast majority of PCI referrals are not emergent.
 
Carlos Danger said:
If you show up to a PCP office or urgent care that is associated with "St. Theresa's Health System" and you need to go to the hospital for testing or a procedure, then yes, referral arrangements are going to be made to a hospital that is also associated with "St. Theresa's Health System". This is a universal practice and not isolated to your area. There are practical, logistical, and business reasons for this. It is very unlikely to have anything to do with the referring provider's "privileges".

It isn't an issue of patient autonomy unless, again, the patients are being coerced or lied to about their options. A referring physician has no ethical obligation to list every available destination option and the pros and cons of each, assuming the one that he does suggest is an appropriate facility.

If you are talking about scenarios where people in the midst of an anterior MI with hypotension and chest pain are sent all the way across town rather than the closest hospital with emergent PCI capabilities, then yes I'd agree that is problematic and you should probably report that to the appropriate authorities in your area. But the vast majority of PCI referrals are not emergent.
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I'm sorry that I disagree with you. If they are calling 911 for an emergency the patient needs to be included in their own healthcare. I don't have an issue with the PCP recommending a destination the issue I have is with the PCP mandating a destination like the patient is under arrest and does not an option. This is not St. Theresa's Health System clinic and if they need a transfer they can wait for a private ambulance or go by personal vehicle.
 
Carlos Danger said:
But it seems much more likely that the reason the PCP is referring them to that hospital is probably because that facility is where they have seen providers and have all of their medical records.
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Don't all/most hospitals use the EPIC system, and can't a provider in one hospital look up records for the patient in front of them from other hospitals too?
spimx said:
the issue I have is with the PCP mandating a destination like the patient is under arrest and does not an option. This is not St. Theresa's Health System clinic and if they need a transfer they can wait for a private ambulance or go by personal vehicle.
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I mean, is the PCP really mandating the destination? or the the PCP telling the patient where they think they should go, and the patient listening to their PCP, who knows their history? Also, why would you have the patient wait for a private ambulance for a transfer (incurring another bill and delay in care), or having them go by POV? that doesn't sound like it's in the patient's best interest, esp when you have the vehicle with 2 trained providers and all the equipment that could be needed in case the patient deteriorates.

If anything, it sounds like you are mandating their destination, and placing your interests about the PCPs, and the patient's right to choose their destination
 
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