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MaryO

A (Cushing's) Referral

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From http://doctorslife.blogspot.com/2008/09/referral.html

 

I referred a patient to my alma mater today.

 

And I have to say, it felt a bit weird. To be calling WFMC, to be faxing in the paperwork TO them, instead of WITH them.

 

It was a case of Cushing Syndrome. Always difficult, these cases, because lab results are often equivocal, and often contradictory. Case in mind, guy who previously had a normal 24 hour urine free cortisol. I did a 1 mg dexamethasone suppression test which was negative, yet close enough to being positive that it just didn't smell right. And so I repeated the urine studies which this time came back positive. And did a salivary cortisol, further confirmed by the 2-day low dose dexamethasone suppression test I did, with a nonsuppressed ACTH.563767.jpg His MRI showed a pituitary microadenoma. Presumptive diagnosis: Cushing Disease. Personally, I was confident enough of the diagnosis that I didn't think an IPSS (inferior petrosal sinus sampling) was necessary. But the neurosurgeon wanted that, and it's not something we have readily available here.

 

So, he's headed up to see if they feel he needs the IPSS, or if they are willing to operate on him based on the data I've collected thus far.It's a strange feeling sending the patient up. In a way, it's pride, telling the patient that if I was going to have pituitary surgery, it would be by one of WFMC's neurosurgeons' hands. And another, that near-gleeful feeling, reminiscing and telling the patient how the system there works, and the qwerks of some of the consultants there and helping choose a consultant and surgeon for them, based on what the patient wants. And yet, mild anxiety, sending a patient to your ex-mentors and teachers, not as a fellow of theirs anymore, but as a colleague, hoping that when they read your referral letter and see your patient, they go

"Ah, Dr. Vagus did a good job working him up. We taught him well."

And not

"What on God's green earth was that idiot doing?? This patient doesn't have Cushings!!"

I think they taught me well. I hope. We shall see when after they are done with their evaluation.

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Wow. I believe that after seeing what my PCP's peers said about her referring me to them for Cushing's.

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I thought that was interesting, from the doctor's point of view.

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I suspect that a great deal of why people have such a hard time with getting testing at the PCP level and the local endo level is because "they just don't want to go there" in making a referral if there a positive test results. In other words, if they have gotten the snide comments from the big U doctors of the same ilk that we get, one can assume that the local doctor isn't going to want to go down that path ever again. Which is why some geographical areas seem to be endo wastelands --- if the big U doc is a pill, everyone else down the food chain is going to be too.

 

I personally think that the best way to move the ball ahead in getting people to have access to local doctors is to focus efforts on the big U docs, and particularly not to allow them to get away with shoddy dxes (or refusal to dx). What that means, I think, is to make sure that the medical administration is made aware (not just the doc, cause they can blow it off), that a dx was made and proven when the original "big gun" blew that person off. It appears to me that the doctors are overly concerned that they will be liable for making a dx and sending someone to surgery inappropriately such that they lose sight of the very significant risks that attend refusing to make a dx and leaving someone untreated. I think that if you statistically compare those risks, the much more significant risk is in failing to DX.

 

I think we ought to go out of way to give this guy kudos for taking the risk of feeling foolish in favor of taking care of his patient.

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