Tuesday, March 10, 2015

Dr. Orthochick: PM&R Consults

There's a remarkably dumb rule here that if you want to discharge a patient to an inpatient rehab facility (IPR), you have to order a Physical Medicine and Rehabilitation (PM&R) consult. I have no idea why that is because i know for a fact it is not a national rule.

Me: Ortho res returning a page
Case Manager: Hi, I'm calling about your patient in room 987, Ms. Jones. Physical therapy is recommending she go to IPR, so you need to call a PM&R consult.
Me: She had a hemipelvectomy. She can't get out of bed without two people helping her. I don't think she's going to be able to do inpatient rehab since usually you have to be able to do about 4 hours of therapy or so.
Case Manager: Physical therapy thinks she can do it
Me: But she doesn't want to go to rehab. She wants to go to a nursing home. She has about 6 months left to live.
Case Manager: You need to call a PM&R consult so I can get started with discharge planning to get her to a rehab facility
Me: I don't understand why I need to do that.

So I did and the PM&R doc said that not only would the patient not qualify for IPR, but, uh, she didn't want to go.

I figured the issue was put to rest, but I got paged again today:

Me: Ortho res returning a page
Case Manager: I'm calling about your patient in room 999, Ms. Smith. Physical therapy said she needs to go to a rehab facility, so you need to put in a consult for PM&R so I can get started on that.
Me: She's supposed to go home later today.
Case Manager: No, physical therapy said she needs rehab. So put in the consult.
Me: I spoke to her this morning and she feels very comfortable going home
Case Manager: I just spoke to her and she agrees she needs rehab. You need to put in a consult.

So I went to talk to the patient and she said that no, she didn't need rehab. She wanted physical therapy (fair enough), but she felt safe going home and didn't want to go to a rehab facility. Which I agree with. Except then I had the case manager and the physical therapist breathing down my neck until I finally ordered the stupid PM&R consult in the hopes that the PM&R doc would be more successful than me in convincing everyone that she didn't need it.

I really hate calling stupid consults. Mostly because I hate when people call me for stupid consults so I can sympathize with that one and I try not to do it. I'm not saying I've never called a stupid consult, but usually when I do it it's because my attending is making me. And it is really a waste of another doctor's time if I have to call a consult to get the case manager to stop telling me what to do.

Also, physical therapy and I do not always get along. They usually make discharge recommendations and that's fine, they see the patient mobilize more than I do, but sometimes I feel like they overstep their boundaries. Which is fine because sometimes I feel like everyone oversteps their boundaries, including me. And when I do it, I justify that i"m doing it in the best interest of the patient, which is probably how everyone justifies doing it, so whoever uses that argument generally wins the war. (just like the first person to say he/she is not comfortable doing something wins that war) Also, the physical therapists kind of hate me over at one of the hospitals because we got into, shall we say, a disagreement over a patient. They didn't think he was safe to go home, I personally walked him around the second floor with a walker and made him demonstrate foot-over-foot, pivot, stand to sit, sit to stand, off and on a toilet, and stairs...and then I decided he was safe to discharge and discharged him. They didn't like that one too much. And it was a case of me totally overstepping my boundaries. Which was, of course, in the patient's best interest (long story), but OK, I can see why they wouldn't be too impressed with that one.


  1. My favorite is when PT absolutely HAS to see the patient before they get discharged, and they do everything in their power to try and get out of doing it. There's one person in particular who will see there's family in the room and not even bother to talk to the patient because they are "busy." Hello. You're a health care provider. You can and should ask the family to leave if you need to do an eval. It's work. Get over it.

    (Which is to say I empathize with your dilemma.)

  2. "you need to call a PM&R consult” — Case Manager

    It’s great that non-MDs can tell MDs what is and is not necessary for medically-related issues.

  3. More like bullying?

  4. @NeuroTrumpet and latest Anonymous -- yes!!!!. >:(

  5. Congratulations Dr. Fizzy! Book of the Day!- The Devil Wears Scrubs.
    4.4/5 Stars. That says it all !
    On a different note, I clicked on the link for your tweet: Take a Bow, America: What Every U.S State is Best at: Hmm. North Dakota has a unique distinction, wouldn't you say?
    - Paul

    1. I clicked on it too. I hadn't realized how poor my geography was until I went to look for North Dakota :)

  6. I guess the state slogan for N. Dakota - "Legendary" will now take on a new meaning!

  7. As an acute care PT, I sympathize with you over the fact that Case Management/Social Work can be bullies. I often get talked down to or eyes rolled at me over making recommendations (that's the key word - recommendation!) because it'll make more work for some case managers to try to get a patient into SCIR or ACIR instead of letting the home health discharge planners take care of it.

    Also, I wish I had more physicians like you who would perform functional mobility with a patient if they disagreed with our recommendations! Most of ours will just put in a new PT/OT consult with a snarky comment about re-evaluating a patient.

  8. My favorite: Non-Physician hospital staff member: "Hospital policy requires that you order X for this patient because of Y and Z." Me (intern): "In my judgement, and the judgement of my attending who just saw the patient, X will not in any way be helpful for this patient." Nonphysician: "It is hospital policy, you have to order X." Me: "Since it is hospital policy and is already required, there is no reason for me to be ordering it." Nonphysician: "Ha-Ha-Ha . . .Oh, are you serious?"

  9. It’s great that non-MDs can tell MDs what is and is not necessary for medically-related issues.

    Agree 100%. I don't tolerate this at my hospital. I would report the CM for unprofessional behavior and document why the patient does not need PM&R consult.